Advance Care Planning for Children With Rare Diseases: A Pilot RCT

BACKGROUND AND OBJECTIVE

Pediatric rare diseases are often life-limiting conditions and/or require constant caregiving. Investigators assessed the initial efficacy of the FAmily CEntered (FACE) pediatric advance care planning (pACP), FACE-Rare, intervention on families' quality of life.

METHODS

A pilot-phase, single-blinded, intent-to-treat, randomized controlled clinical trial enrolled families from 1 pediatric quaternary hospital between 2021 and 2023. Intervention families received 3 weekly 60-minute (FACE-Rare pACP) sessions: (1) Carer Support Needs Assessment Tool or Action Plan, (2) Carer Support Needs Assessment Tol Action Plan Review, and (3) Pediatric Next Steps: Respecting Choices pACP. Controls received treatment as usual (TAU). Outcome measures were Beck Anxiety Inventory, Family Appraisal of Caregiving, Functional Assessment of Chronic Illness Therapy (FACIT)-Spirituality, and health care utilization. Generalized mixed effect models with γ response assessed the intervention effect at 3-month follow-up.

RESULTS

Children (n = 21) were aged 1 to 10 years, 48% male, 24% Black; and 100% technology dependent. Primary family caregivers (n = 21) were aged 30 to 43 years, 19% male, 19% Black; and 27% household income below the Federal poverty level. Dyads underwent 1:1 randomization: 9 to FACE-Rare and 12 to TAU. TAU caregivers reported statistically lower meaning and peace than FACE-Rare caregivers (0.9, P = .03, confidence interval [CI]: 0.75-0.99). Black caregivers reported significantly less caregiver distress (0.7, P = .04, CI: 0.47-0.98) than non-Black caregivers. Poor families reported more anxiety (3.5, P = .002, CI: 1.62-7.94), more caregiver strain (1.2, P = .006, CI: 1.07-1.42); and less family well-being (0.8, P = .02, CI: 0.64-0.95).

CONCLUSIONS

FACE®-Rare was feasible, acceptable, safe, and demonstrated initial efficacy, providing greater feelings of meaning and peace to caregivers. Poverty impacted well-being. A multisite trial is needed to determine generalizability.

Exploring spirituality, religion and life philosophy among parents of children receiving palliative care: a qualitative study

BACKGROUND

Few studies have examined the spiritual environment of parents of children receiving palliative care in Southern European countries, which are mostly characterized by secularization (or the abandonment of traditional religiosity) and an increase of cultural and religious diversities resulting in a much broader spectrum of spiritual and religious beliefs. This study aimed to explore the parents' own spirituality, religiosity, and philosophy of life in coping with the care of their child with palliative needs.

METHODS

Qualitative interviews of 14 parents of children included in a palliative care program in a pediatric hospital in Barcelona, Spain. Inclusion criteria were parents of children who have been cared for the palliative care program for a minimum of 3 months and who displayed a willingness to talk about their personal experiences and gave written consent. Interviews were audio-recorded, transcribed by an independent service, and analyzed on a case-by-case basis using Interpretative Phenomenological Analysis.

RESULTS

The three domains identified were life philosophy, relational, and transcendent. Life philosophy included principles that guided parents' decision-making, and how the onset of their child's serious illness had promoted a change in their values. Relational was focused on how they perceived themselves (e.g. motherhood), others (e.g. one's own child exceptionality), and the way they believed others perceived and supported them (e.g. relatives, friends, and healthcare providers). The transcendent domain involved God-related concepts, divinity and divine intervention (e.g. a miracle as an interpretive framework for that which cannot be explained within scientific knowledge limitations).

CONCLUSIONS

Inflexible categories identifying parents as having a particular religious faith tradition are not sufficient to capture the interrelation of knowledges (ethical, religious, scientific) that each parent generates when faced with their child receiving palliative care. Clinicians should explore parents' spirituality in an individualized way that responds to the uniqueness of their experiential process.

The spiritual dimension of parenting a child with a life-limiting or life-threatening condition: A mixed-methods systematic review

BACKGROUND

Spirituality refers to the dynamic dimension of human life that relates to the way that persons experience meaning, purpose, and transcendence. The complex task of parenting a child with a life-limiting condition may raise existential questions, which are easily overlooked by healthcare professionals.

AIM

We explored how the spiritual dimension becomes manifest in parents of children in pediatric palliative care.

DESIGN

A mixed-methods systematic review was conducted, registered in Prospero (2021 CRD42021285318).

DATA SOURCES

PubMed, CINAHL, Embase, PsycInfo, and Cochrane were searched for articles published between January 1, 2015 and January 1, 2023. We included original empirical studies that reported on spirituality of parents of seriously ill children, from parents' perspectives.

RESULTS

Sixty-three studies were included: 22 North-American, 19 Asian, 13 European, 9 other. Studies varied in defining spirituality. We identified five different aspects of spirituality: religion, hope, parental identity, personal development, and feeling connected with others. All aspects could function as source of spirituality or cause of spiritual concern. Sources of spirituality helped parents to give meaning to their experiences and made them feel supported. However, parents also reported struggling with spiritual concerns. Several parents highlighted their need for professional support.

CONCLUSIONS

Although studies vary in defining spirituality, reports on spirituality focus on how parents connect to their faith, others, and themselves as parents. Healthcare professionals can support parents by paying attention to the spiritual process parents are going through. More research is needed into how healthcare professionals can support parents of seriously ill children in this process.

Face and content validity, acceptability, feasibility, and implementability of a novel outcome measure for children with life-limiting or life-threatening illness in three sub-Saharan African countries

BACKGROUND

The Children's Palliative Care Outcome Scale (C-POS) is the first measure developed for children with life-limiting and -threatening illness. It is essential to determine whether the measure addresses what matters to children, and if they can comprehend and respond to its items.

AIM

To determine the face and content validity, comprehensiveness, comprehensibility, acceptability and feasibility, and implementability of the C-POS.

DESIGN

Mixed methods (1) Content validation: mapping C-POS items onto an evidence-based framework from prior evidence; (2) Comprehensiveness, comprehensibility, acceptability feasibility, and implementability: qualitative in-depth and cognitive interviews with a purposive sample of children and young people (n = 6), family caregivers (n = 16), and health workers (n = 12) recruited from tertiary facilities in Kenya, South Africa, and Uganda.

RESULTS

(1) C-POS content mapped on to palliative care domains for (a) children (i.e. physical (e.g. symptoms), social (e.g. play/socialize), psychological (e.g. happy)) and (b) families (i.e. psychological (e.g. worry), social (e.g. information), and help and advice). (2) C-POS items were well understood by children and their caregivers, acceptable, and relevant. Completion time was a median of 10 min, patients/caregivers and health workers reported that using the C-POS improved their communication with children and young people. Methodological and content issues included: (i) conceptual gap in the spiritual/existential domain; (ii) further consideration of developmental, age-appropriate items in the social and psychological domains, and (iii) linguistic complexity and difficulty in proxy rating.

CONCLUSION

C-POS items capture the core symptoms and concerns that matter to children and their families. C-POS is feasible, comprehensible, and acceptable for use in clinical settings; areas for further development and improvement are identified.

Family experiences with palliative care in freestanding paediatric hospices: a scoping review

BACKGROUND

Paediatric palliative care provides supportive care to children with life-threatening or life-limiting illnesses throughout the disease trajectory. Up to 42% of children receiving palliative care in Canada will die within a freestanding paediatric hospice or designated end-of-life care bed. Few studies have assessed families' experiences of this care within freestanding paediatric hospices.

OBJECTIVES

To find and describe literature relating to family experiences in paediatric hospice palliative care throughout the end-of-life care journey including grief and bereavement.

CRITERIA

Inclusion criteria: Children antepartum to 18 years or older if on paediatric palliative care service. Research conducted in freestanding paediatric hospices that focused on families' experiences and perceptions of end-of-life and grief and bereavement care. Full-text articles available in English.

EXCLUSION CRITERIA

Adult palliative and end-of-life care, respite care, palliative care provided in acute or community settings, professional perspectives, unexpected or sudden child death, pregnancy after loss.

SOURCES OF EVIDENCE

Academic Search Complete, CINAHL, Cochrane Database of Systematic Reviews, Embase, PsycINFO, PubMed and Web of Science databases were searched from database inception until the present. Grey literature was also searched for relevant results.

CHARTING METHODS

The scoping review was guided by recommendations from Arksey and O'Malley and Levac et al.

RESULTS

A total of 4250 papers were retrieved, of which 10 met the scoping review criteria. The majority of studies were conducted in the UK. Three major themes emerged: more supportive care for families including grief and bereavement support, the hospice experience itself and future research areas.

CONCLUSIONS

There is little literature that focuses specifically on the needs of families within freestanding paediatric hospices. Further examination of the themes identified above provides an opportunity for future research.

Grief Trajectories of Bereaved Parents of Adolescents and Young Adults With Advanced Cancer: A Qualitative Analysis Using Phenomenology

Different parents grieve differently. However, research directed at understanding the important contextual or individual factors that influence the path each bereaved parent takes is lacking. In this qualitative analysis we seek to understand the array of bereaved parent experiences more completely. By deeply diving into one parent dyad using interpretive phenomenology analysis and situating that story within the conventional content analysis of 13 other bereaved parents of adolescents and young adults (AYAs) who died from advanced cancer, we illustrate the roles of religion/spirituality, maintaining a connection, and fulfilling parental roles as elements of grief processing. Clinicians and investigators should consider similar individualized approaches to understanding and supporting the grief experiences of bereaved parents before and after the death of a child.

Parental Perspective in Paediatric Palliative Care: A Systematic Review of Literature Using the PRISMA Method

Research in Parental Perspectives are pivotal in gaining understanding of parents’ experiences, issues, concerns and attitude in pediatric palliative care which affects their decision making. However only a limited number of such studies have included the first-person perspective of Parents. The aim of this article is to understand the contribution of previous research on parental perspectives in pediatric palliative care through a systematic review of literature. Nine articles that met the inclusion criteria were accessed and seven key themes emerged; Psychological perspective, parental concerns, parental needs, parental attitude, spiritual perspective, cultural perspective and financial perspective. This review highlights requirement of more research into parental perspective if possible, covering all key aspects along with additional research in cultural perspective and development of validated tools, checklists and psychometric questionnaires for the assessment of these perspectives in various domains: spiritual, financial, psychological, cultural and social.

The role of religion and spirituality in caregiver decision-making about tracheostomy for children with medical complexity

Children with medical complexity (CMC) receive life-sustaining treatments such as tracheostomy. The objective of this paper is to explore the roles of religion and spirituality (R&S) of caregivers of children with medical complexity (CMC) in their decision to pursue tracheostomy for their children. We conducted 41 in-depth interviews of caregivers of CMC who had received tracheostomies in the prior 5 years. Four themes emerged: (1) Caregivers believed R&S to be powerful for their children's healing, and helped them cope with their children's illnesses; (2) Spirituality was an important factor for caregivers in the decision to pursue tracheostomy for their children; (3) Many caregivers did not discuss their spirituality with clinicians for a variety of reasons; (4) Clergy and hospital chaplains played a major supportive role overall; however, they did not play a significant role in the decision-making process. Our study shows the importance of R&S, and the roles of clergy and chaplains in pediatric tracheostomy decision-making.

Self-reinforcement: Coping strategies of Iranian mothers with preterm neonate during maternal role attainment in NICU; A qualitative study

INTRODUCTION

Having a preterm neonate in the neonatal intensive care unit (NICU) is one of the most stressful experience for parents. In facing these stressors, mothers need to find ways to adapt and control resources to maintain stability. The aim of this paper is to report coping strategies of mothers with preterm neonate during maternal role attainment in NICU.

METHODS

This paper reports a part of the findings of a grounded theory study that investigated how the mothers of preterm neonates go through maternal role attainment. The data were collected through in-depth semi-structured interviews with 12 mothers with preterm neonate admitted to the NICU and 5 nurses working in NICU. Data were analyzed according to Corbin and Strauss's (2015) approach using constant comparative analysis technique.

FINDINGS

Four themes, emerged from experiences of the participants, formed the concept of "Self-reinforcement" as the prominent strategy of mothers: "support seeking", "Spiritual getting in the mood", "Hope creation" and "Getting energy from the baby".

CONCLUSION

These findings showed that mothers use strategies to calm and support themselves and their neonates, and recognize that their lives had changed and need to adjust to their new circumstances.

What Do Parents Value Regarding Pediatric Palliative and Hospice Care in the Home Setting?

CONTEXT

Children with life-shortening serious illnesses and medically-complex care needs are often cared for by their families at home. Little, however, is known about what aspects of pediatric palliative and hospice care in the home setting (PPHC@Home) families value the most.

OBJECTIVES

To explore how parents rate and prioritize domains of PPHC@Home as the first phase of a larger study that developed a parent-reported measure of experiences with PPHC@Home.

METHODS

Twenty domains of high-value PPHC@Home, derived from the National Consensus Project's Guidelines for Quality Palliative Care, the literature, and a stakeholder panel, were evaluated. Using a discrete choice experiment, parents provided their ratings of the most and least valued PPHC@Home domains. We also explored potential differences in how subgroups of parents rated the domains.

RESULTS

Forty-seven parents participated. Overall, highest-rated domains included Physical aspects of care: Symptom management, Psychological/emotional aspects of care for the child, and Care coordination. Lowest-rated domains included Spiritual and religious aspects of care and Cultural aspects of care. In exploratory analyses, parents who had other children rated the Psychological/emotional aspects of care for the sibling(s) domain significantly higher than parents who did not have other children (P = 0.02). Furthermore, bereaved parents rated the Caregiversupportat the end of life domain significantly higher than parents who were currently caring for their child (P = 0.04). No other significant differences in domain ratings were observed.

CONCLUSION

Knowing what parents value most about PPHC@Home provides the foundation for further exploration and conversation about priority areas for resource allocation and care improvement efforts.

"Give them the door but don't push them through it": Family Attitudes Toward Physician-Led Spiritual Care in Pediatric Palliative Medicine

Little is known about pediatric caregivers' perceptions of religious or spiritual (R/S) care provided by physicians. We conducted a qualitative, semistructured interview study to understand perceptions of pediatric caregivers toward physician-led R/S care. Participants were 20 primary caregivers whose children were hospitalized and receiving palliative care services. Interviews were audio recorded, transcribed verbatim, and analyzed using constant comparative methods. Three recurrent themes emerged regarding physician-led R/S care: (1) Most caregivers view providing R/S care as a positive sign of physician empathy, while a minority (3/20) prefer to keep R/S and medical care separate, (2) many caregivers prefer R/S care from a physician with whom they have a close relationship and/or share a faith background, and (3) physicians should open the door, but allow families to lead conversations about R/S care. Caregivers have mixed perceptions on physicians engaging in R/S care; most prefer that families set the direction of R/S care for themselves and their loved ones. Physicians should be trained to evaluate families' spiritual backgrounds and needs in ways that respectfully open the door to these conversations.

Managing conversations with patients about death and dying

Caring for patients who are dying is both a challenging and demanding role. This is further intensified by the expectation that in addition to attending to physical issues, nurses are expected to manage the emotional and psychological aspects of the situation. The inconsistent nature of the care pathways between differing specialist services can often mean that open access to specialist services is not possible. As such, staff may find themselves inadvertently supplementing and often reinforcing interventions offered by specialist (psychological) services with little consideration given to capacity, experience and resources. As the most ‘consistently present’ professionals in such settings, it is important for nursing colleagues to be aware of the emotional and psychological themes common to patients who are dying. Thus, allowing patients access to supportive conversation with professionals as and when required, ameliorating unnecessary distress.

Challenges and Priorities for Pediatric Palliative Care Research in the U.S. and Similar Practice Settings: Report From a Pediatric Palliative Care Research Network Workshop

CONTEXT

To dramatically advance the evidence base for pediatric palliative care (PPC) interventions, practices, and programs in the U.S. and similar practice settings, the field needs to better understand the challenges and opportunities for rigorous scholarship.

OBJECTIVES

The Pediatric Palliative Care Research Network conducted a workshop to clarify challenges and identify key priorities.

METHODS

The workshop focused on PPC research topics and methods, including outcomes measurement, qualitative inquiry, analyses of big data, prospective collection of research data, case series and cohort studies, and intervention trials, with synthesizing summary and follow-up discussions. All attendees reviewed and approved the final report.

RESULTS

Five common challenges were identified: patient diversity and small population size; interdependencies and dynamic interactions between child, family members, and disease processes over time; outcomes and measurement; workforce and infrastructure limitations; and presumed burden of PPC research on participants. Seven priorities emerged: bolster training and development of PPC investigators; develop core resources; advance symptom measurement (and measurements of other exposures and outcomes); improve symptom management and quality of life interventions; improve communication, elicitation of goals of care, and decision making; understand family impact and facilitate or improve family adaptation and coping; and analyze and improve systems of care, policy, and education.

CONCLUSION

These challenges and priorities identify key research areas that can guide individual investigators and research funders to advance the field.

Using a frame of reference for talking to patients about death and dying

Recent years have seen a recognition of the importance of talking openly to patients at the end of life about death and dying. This article aims to add to the existing body of literature on this subject. Conversations at the end of life can be difficult, particularly if the patient is experiencing mental distress alongside their terminal illness. A number of factors can disrupt a constructive and supportive conversation around death and dying. This article offers a frame of reference for nurses to consider when having such conversations.

Spiritual assessment and spiritual care offerings as a standard of care in pediatric oncology: A recommendation informed by a systematic review of the literature

Children with cancer and their families experience shifts in spiritual wellness from diagnosis through treatment and survivorship or bereavement. An interdisciplinary team conducted a systematic review of quantitative and qualitative research on spiritual assessments, interventions, and outcomes in childhood cancer following PRISMA guidelines using a PROSPERO registered protocol. Thirty-nine well-designed studies were included in the final analysis. The findings from this systematic review indicate the need for early spiritual assessment with offering of continued support for the spiritual functioning of children with cancer and their families as a standard of care.

The Influence of Parents' Religiosity or Spirituality on Decision Making for Their Critically Ill Child: An Integrative Review

Background: Religion and/or spirituality are important values for many parents of critically ill children; however, how religion and/or spirituality may influence which treatments parents accept or decline for their child, or how they respond to significant events during their child's illness treatment, remains unclear. Objective: To summarize the literature related to the influence of parents' religiosity or spirituality on decision making for their critically ill child. Design: Integrative review, using the Whittemore and Knafl approach. Setting/Subjects: Data were collected from studies identified through PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL plus), Embase, Scopus, and PsychInfo. Databases were searched to identify literature published between 1996 and 2016. Results: Twenty-four articles of variable methodological quality met inclusion criteria. Analysis generated three themes: parents' religiosity or spirituality as (1) guidance during decision making, (2) comfort and support during the decision-making process, and (3) a source of meaning, purpose, and connectedness in the experience of decision making. Conclusion: This review suggests that parents' religiosity and/or spirituality is an important and primarily positive influence on their decision making for a critically ill child.

Pediatric Palliative Care in the Multicultural Context: Findings From a Workshop Conference

CONTEXT

In our increasingly multicultural society, providing sensitive and respectful pediatric palliative care is vital.

OBJECTIVES

We held a one-day workshop conference with stakeholders and pediatric clinicians to identify suggestions for navigating conflict when cultural differences are present and for informing standard care delivery.

METHODS

Participants explored cases in one of four workshops focused on differences based on race/ethnicity, economic disparity, religion/spirituality, or family values. Each workshop was facilitated by two authors; separate transcriptionists recorded workshop discussions in real time. We used content analyses to qualitatively evaluate the texts and generate recommendations.

RESULTS

Participants included 142 individuals representing over six unique disciplines, 25 of the U.S., and three nations. Although the conference focused on pediatric palliative care, findings were broadly generalizable to most medical settings. Participants identified key reasons cultural differences may create tension and then provided frameworks for communication, training, and clinical care. Specifically, recommendations included phrases to navigate emotional conflict, broken trust, unfamiliar family values, and conflict. Suggested approaches to training and clinical care included the development of core competencies in communication, history taking, needs assessment, and emotional intelligence. Important opportunities for scholarship included qualitative studies exploring diverse patient and family experiences, quantitative studies examining health disparities, and randomized clinical trials testing interventions designed to improve community partnerships, communication, or child health outcomes.

CONCLUSION

Taken together, findings provide a foundation for collaboration between patients, families, and clinicians of all cultures.

The voices of Young New Zealanders Involved in Pediatric Palliative Care

The perspectives of young New Zealanders receiving pediatric palliative care (PPC) are not well understood. A qualitative study of the perceptions of 16 PPC patients and their siblings, aged 9 to 18, was conducted through audio and written diary accounts. Inductive thematic analysis revealed several concerns of participants, including special treatment that patients had received, spending time with their families, their feelings of being judged or discriminated against, their sense of being understood themselves and of understanding others, and mortality. A nonjudgemental, open approach is recommended when consulting with patients and their siblings in order to determine their needs.

Bio-psycho-social-spiritual needs of adolescents and young adults with life-threatening illnesses: Implications for social work practice

This paper explores the biopsychosocial and spiritual needs of adolescents and young adults (AYA) with life-threatening or terminal illnesses. AYA are situated between childhood and adulthood (ages 15-25) and have distinct biopsychosocial and spiritual needs unique to their developmental stage. Having a life-threatening or terminal illness directly challenges normal AYA developmental tasks and identity formation. AYA experience more troubling physical symptoms during the dying process compared to other age groups, which leads to significant psychological distress and an increased need for pharmacological treatments. In general, AYA desire to be fully informed and involved in the health care decision-making process, leading to ethical dilemmas when the AYA is a minor and their wishes differ from the wishes of their legal guardian(s). Social workers are especially well-equipped to serve this population due to aligning professional standards and ability to advocate for holistic care within interdisciplinary teams. Additional research is needed to tailor holistic interventions to meet the needs of this population.

Life-Limiting Conditions at a University Pediatric Tertiary Care Center: A Cross-Sectional Study

BACKGROUND

The increasing number of children with life-threatening and life-limiting conditions requires an individualized approach and additional supportive care in hospitals. However, these patients' characteristics and their prevalence in a pediatric tertiary hospital setting have not been systematically analyzed.

OBJECTIVE

This study aimed to determine the proportion of hospitalized children who are receiving care for life-threatening diseases with feasible curative treatments and for life-limiting diseases (LLDs) with inevitable premature death as opposed to care for acute or chronic diseases; additionally, it sought to compare patient characteristics, clinical features, and symptoms within these subgroups.

DESIGN/SETTING/SUBJECTS

A cross-sectional survey of 208 patients was conducted at a large tertiary pediatric care center through standardized interviews with the responsible medical teams. Patient subgroups were defined as those with acute, chronic, life-threatening, or LLDs.

RESULTS

The comparisons of patient subgroups showed distinct differences and revealed that nearly half of all inpatients suffer from life-threatening (20%) or LLDs (27%), with a high proportion of rare diseases (82%). They experienced a high burden of symptoms in all parameters of clinical features, including high demand for medications and nursing care.

CONCLUSION

A substantial proportion of pediatric inpatients suffered from life-threatening or LLDs, as well as rare diseases, indicating a high burden of symptoms and a high need for additional care. The results suggest a substantial need to implement pediatric palliative care structures in tertiary care centers for patients in critical and terminal conditions.

Pediatric Palliative Care: A Five-Year Retrospective Chart Review Study

BACKGROUND

More children are living with serious illness. However, survival and complexity of illnesses have not been described.

OBJECTIVE

To describe types of illnesses, timing of referral, and time to death following referral to palliative care; to examine the associations between demographics and clinical characteristics and patient survival; and to examine whether average daily pain decreases after referral.

DESIGN

Retrospective chart review of all children ages 2-16 years referred to palliative care at one large children's hospital during the five-year study period from January 1, 2009, through December 31, 2013.

MEASUREMENTS

The primary outcome was patient survival and the main independent predictor was type of illness. Kaplan-Meier estimation was used to estimate patient survival time following referral, Cox proportional hazards regression was used to build predictive models based on gender, age, race, religion, and types of illnesses, and paired t-test compared the assessment of pain before and after referral.

RESULTS

The cohort consisted of 256 children. Survival experience did not differ significantly based on gender, age, race, or religion (p ≥ 0.05); however, survival did vary based on referring diagnosis (χ² = 40.3, df = 4, p < 0.001), particularly cancer. Forty-eight children with three days of pain assessments pre- and postreferral had significantly decreased pain postreferral (t(47) = 1.816, p < 0.05 one tailed), supporting our hypothesis.

DISCUSSION

Results provide important information on the complexity of disease processes for children referred to palliative care, types of illnesses referred, survival, and pain levels. Results reflect earlier referral to palliative care for most children and highlight the medical complexity especially for children with congenital and genetic diagnoses.

Aligning guidelines and medical practice: Literature review on pediatric palliative care guidelines

OBJECTIVE

Palliative care for children is becoming an important subspecialty of healthcare. Although concurrent administration of curative and palliative care is recommended, timely referral to pediatric palliative care (PPC) services remains problematic. This literature review aims to identify barriers and recommendations for proper implementation of palliative care for children through the looking glass of PPC guidelines.

METHOD

To identify studies on PPC guidelines, five databases were searched systematically between 1960 and 2015: Scopus, PubMed, PsycINFO, the Web of Science, and CINAHL. No restrictions were placed on the type of methodology employed in the studies.

RESULTS

Concerning barriers, most of the papers focused on gaps within medical practice and the lack of evidence-based research. Common recommendations therefore included: training and education of healthcare staff, formation of a multidisciplinary PPC team, research on the benefits of PPC, and raising awareness about PPC. A small number of publications reported on the absence of clear guidance in PPC documents regarding bereavement care, as well as on the difficulties and challenges involved in multidisciplinary care teams.

SIGNIFICANCE OF RESULTS

Our results indicate that a critical assessment of both the research guidelines and medical practice is required in order to promote timely implementation of PPC for pediatric patients.

Nurses' Experiences of Spiritual Communication with Seriously III Children

OBJECTIVE

The goal of this study was to explore nurse experiences in communication with children about spiritual topics in order to develop training in this area.

BACKGROUND

Although spiritual care is essential in pediatric palliative care, few providers receive training about communication with ill children about spirituality.

METHODS

Researchers developed a brief survey to prompt nurses to reflect on pediatric palliative care experiences that included spiritual discussions. Nurses attending training courses voluntarily submitted stories. Qualitative data were thematically analyzed by members of the research team, consisting of two researchers with expertise in palliative care, spirituality, and communication and two expert pediatric palliative care clinicians.

RESULTS

Nurses' spiritual conversations with children revealed that children question God and the reason for their illness, have a desire to talk about the afterlife as a way of understanding their limited lifespan, and to share descriptions of an afterlife, in these cases described as heaven. Nurses conveyed the importance of being present and engaging in spiritual communication with children.

DISCUSSION

Communication training is needed and should prepare providers to respond to a child's spiritual questioning, assist parents when the child initiates discussion about the afterlife, and help parent and child understand the spiritual meaning of their illness. Chaplains serve as spiritual care experts and can help train nurses to screen for spiritual distress, have greater competence in spiritual communication, and to collaborate with chaplains in care. Quality palliative care is incomplete without attention to spiritual care.

The needs of children with life-limiting conditions: A healthcare-provider-based model

Pediatric hospice and palliative care has progressed in recent years with the development of new programs and models of care. Missing from the empirical literature, however, is a model of the needs of children. The purpose of the present study was to develop an empirically based conceptual model of the needs of children with life-limiting conditions. Recognizing the value of both qualitative and quantitative data, concept mapping methodology was selected as an effective way to obtain data that reflected both the “big picture” and subtleties of pediatric endof-life needs. The seven-cluster concept map appeared best in terms of both interpretability and parsimony. This model includes the following clusters of needs: 1) pain, 2) decision making, 3) medical system access and quality, 4) dignity and respect, 5) family-oriented care, 6) spirituality, and 7) psychosocial issues. We believe that the development of a comprehensive model of the needs of such children is a step toward concrete, measurable, and effective support for children and their families.

Assessment of the Spiritual Needs of Primary Caregivers of Children with Life-Limiting Illnesses Is Valuable Yet Inconsistently Performed in the Hospital

BACKGROUND

Religion and spirituality influence how many patients and families experience illness, but knowledge of the level of spiritual care provided to caregivers of pediatric patients within the hospital is limited.

OBJECTIVE

We evaluated patient caregivers' perceptions of the extent to which their religious and spiritual (R/S) needs were assessed and addressed in the hospital.

METHODS

We surveyed primary caregivers of children referred to palliative care <1 year prior at an urban, pediatric academic medical center. Participants completed a structured questionnaire with quantitative and qualitative measures of the provision of spiritual care in the hospital. Nonparametric tests were used to compare various measures of perceived and desired R/S support.

RESULTS

The majority (16/24) of caregivers desired inquiry about R/S needs by the medical team. Fewer than half (12/25) had these needs assessed. No subjects were uncomfortable with questions regarding R/S needs. Only 35% (8/23) specifically wanted a physician to inquire about R/S needs. Subjects whose R/S needs were assessed perceived higher levels of support from the medical team (4.40 versus 3.08, p = 0.02). A significant correlation existed between number of hospital-based R/S resources used and reported R/S-related comfort (rs = 0.438, p = 0.043).

CONCLUSIONS

Assessment of R/S needs of caregivers of pediatric palliative care patients is performed less often than desired, even though it can improve perceptions of support from medical teams. Use of hospital-based R/S resources can increase spiritual comfort. Standardizing assessment of caregivers' R/S needs and referral to appropriate resources is a target for quality improvement in pediatric palliative medicine.

Parental beliefs and practice of spiritual methods for their sick children at a tertiary care hospital of Pakistan- a cross sectional questionnaire study

Background

Complementary and alternative medicine (CAM) comprises a variety of health care systems, practices, and products that are not usually thought to be part of allopathic medicine. This study investigated the parental beliefs and practices for use of spiritual methods in the treatment and early recovery of their children.

Methods

We performed a cross-sectional, descriptive study with convenience sampling of parents/caregivers of sick children who were admitted to the Children’s Hospital in Multan. A trained interviewer collected the data.

Results

A total of 1280 forms were analyzed. The majority of respondents were mothers (1053, 82.4 %), they resided in Multan (817, 63.8 %), and were not educated (754, 58.9 %). A total of 420 (32.8 %) respondents had a low socioeconomic background, 601 (47 %) were middle class, and 259 (20.2 %) were upper class. Grandmothers/mothers advised spiritual methods in the majority of respondents (605, 85.9 %). The parents used a variety of spiritual methods in 704 (55 %) children. Economic status and education showed an inverse relation with the use of CAM. A total of 809 (63.2 %) respondents believed that only a drug would heal the disease, while 575 (44.9 %) believed that spiritual methods have a 25 %–50 % role in healing. A total of 1269 (99.1 %) respondents believed that allopathic drugs are needed for healing, while only 0.9 % considered otherwise.

Conclusion

The majority of people believe that CAM is a contributory factor towards healing and does not interfere with allopathic treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-016-0986-3) contains supplementary material, which is available to authorized users.

Geographic access to hospice care for children with cancer in Tennessee, 2009 to 2011

The geographic interface between the need for and the supply of pediatric hospice may be critical in whether children with cancer access care. This study sought to describe the geographic distribution of pediatric hospice need and supply and identify areas lacking pediatric hospice care in Tennessee over a 3-year time period. Using ArcGIS, a series of maps were created. There was a consistent need for care among children with cancer across the state. Most urban areas were supplied by pediatric hospices, except the Knoxville area. Areas within the state were identified where the supply of pediatric hospice care declined, while the need for hospice care was unchanging. This study has important regulatory implications for clinicians practicing in certificate of need states such as Tennessee.

The parent perspective: "being a good parent" when making critical decisions in the PICU

OBJECTIVE

To identify factors important to parents making decisions for their critically ill child.

DESIGN

Prospective cross-sectional study.

SETTING

Single center, tertiary care PICU.

SUBJECTS

Parents making critical treatment decisions for their child.

INTERVENTION

One-on-one interviews that used the Good Parent Tool-2 open-ended question that asks parents to describe factors important for parenting their ill child and how clinicians could help them achieve their definition of "being a good parent" to their child. Parent responses were analyzed thematically. Parents also ranked themes in order of importance to them using the Good Parent Ranking Exercise.

MEASUREMENT AND MAIN RESULTS

Of 53 eligible parents, 43 (81%) participated. We identified nine themes through content analysis of the parent's narrative statements from the Good Parent Tool. Most commonly (60% of quotes) components of being a good parent described by parents included focusing on their child's quality of life, advocating for their child with the medical team, and putting their child's needs above their own. Themes key to parental decision making were similar regardless of parent race and socioeconomic status or child's clinical status. We identified nine clinician strategies identified by parents as helping them fulfill their parenting role, most commonly, parents wanted to be kept informed (32% of quotes). Using the Good Parent Ranking Exercise, fathers ranked making informed medical decisions as most important, whereas mothers ranked focusing on the child's health and putting their child's needs above their own as most important. However, mothers who were not part of a couple ranked making informed medical decisions as most important.

CONCLUSION

These findings suggest a range of themes important for parents to "be a good parent" to their child while making critical decisions. Further studies need to explore whether clinician's knowledge of the parent's most valued factor can improve family-centered care.

Spiritual care of the child with cancer at the end of life: a concept analysis

AIM

The aim of this paper is to report an analysis of the concept of spiritual care of a child with cancer at the end of life.

BACKGROUND

Spirituality is a vital dimension of a child's experience at the end of life; providing comfort; support; and a sense of connection. Spiritual care is paramount to address the substantial spiritual distress that may develop.

DESIGN

Rodgers' method of evolutionary concept analysis guided the review process.

DATA SOURCES

The literature search was not limited by start date and literature through the end of 2012 was included. English, peer-reviewed texts in the databases CINAHL, ATLA and PubMed were included.

METHODS

Critical analysis of the literature identified surrogate terms, related concepts, attributes, antecedents and consequences.

RESULTS

The analysis identified six attributes: assessing spiritual needs; assisting the child to express feelings; guiding the child in strengthening relationships; helping the child to be remembered; assisting the child to find meaning; and aiding the child to find hope. Antecedents include existential questions and spiritual distress. Consequences include a peaceful death, spiritual growth, a relationship of trust and enhanced end-of-life care.

CONCLUSION

Spiritual care is a vital aspect of holistic nursing care; however, gaps in knowledge and practice prevent children from receiving adequate spiritual care at the end of life. Nurses would benefit from increased awareness, skills and knowledge about spiritual care. Research is needed to identify interventions that exert the greatest effect on patient care outcomes.

Understanding Pediatric Palliative Care

Advancing pediatric palliative care is desperately needed to support the physical, emotional, cultural, spiritual, and psychosocial needs of children and families who live with life-threatening illnesses. Although educational resources and standards of practice related to this topic have been developed, dissemination and implementation of programs have been slow to progress. The purpose of this case study is to present the lived experiences of an adolescent with leukemia and his family to illustrate how health care providers may benefit from receiving enhanced palliative and end-of-life care education.

Palliative care for children with cancer

Over the past two decades, paediatric palliative care has emerged as both a primary approach and as its own medical subspecialty, the overall aim of which is to ease suffering for children with life-threatening illness and their families through a concurrent model of care. However, most discussions have been focused on the transition to palliative care when no realistic hope for cure exists. We believe that, because the course of cancer is so unpredictable, this idea is misleading. Indeed, palliative care is increasingly being recognized as being about not just how to cope with the process of dying, but also about how to engage in living when faced with a life-threatening illness. This article will examine our current understanding of several areas of palliative care, with the ultimate message that palliative care is simply a novel term for the total care of a child and family, an approach that should be applied consistently and concurrently regardless of disease status. By improving familiarity with palliative care and building relationships with palliative care specialists, the paediatric oncology clinician will ensure that the best care possible for children and families is provided, regardless of outcome.

Trends in services among pediatric hospice providers during 2002 to 2008

The medical complexities involved in caring for children at end of life have increased during the past few decades. This study sought to understand what hospice services were offered for these children and to examine service trends among pediatric hospice providers over a 7-year (2002-2008) timeframe. The number of core hospice services diminished in 2003 (IRR = 0.873, 95% CI [0.795,0.971]) and 2004 (IRR = 0.889, 95% CI [0.793, 0.995]); however, by 2008 there was an increase in offering core (IRR = 1.130, 95% CI [1.038,1.230]), noncore (IRR = 1.117, 95% CI [1.013,1.231]), and other hospice (IRR = 1.117, 95% CI [1.005,1.583]) services among pediatric providers. These findings highlight the importance of family-clinician communication about needed services prior to admitting children to hospice care.

Music therapy in pediatric palliative care: family-centered care to enhance quality of life

Research into the value of music therapy in pediatric palliative care (PPC) has identified quality of life as one area of improvement for families caring for a child in the terminal stages of a life-threatening illness. This small-scale investigation collected data in a multisite, international study including Minnesota, USA, and Melbourne, Australia. An exploratory mixed method design used the qualitative data collected through interviews with parents to interpret results from the PedsQL Family Impact Module of overall parental quality of life. Parents described music therapy as resulting in physical improvements of their child by providing comfort and stimulation. They also valued the positive experiences shared by the family in music therapy sessions that were strength oriented and family centered. This highlighted the physical and communication scales within the PedsQL Family Impact Module, where minimal improvements were achieved in contrast to some strong results suggesting diminished quality of life in cognitive and daily activity domains. Despite the significant challenges faced by parents during this difficult time, parents described many positive experiences in music therapy, and the overall score for half of the parents in the study did not diminish. The value of music therapy as a service that addresses the family-centered agenda of PPC is endorsed by this study.

How parents of children receiving pediatric palliative care use religion, spirituality, or life philosophy in tough times

BACKGROUND

How parents of children with life threatening conditions draw upon religion, spirituality, or life philosophy is not empirically well described.

METHODS

Participants were parents of children who had enrolled in a prospective cohort study on parental decision-making for children receiving pediatric palliative care. Sixty-four (88%) of the 73 parents interviewed were asked an open-ended question on how religion, spirituality, or life philosophy (RSLP) was helpful in difficult times. Responses were coded and thematically organized utilizing qualitative data analysis methods. Any discrepancies amongst coders regarding codes or themes were resolved through discussion that reached consensus.

RESULTS

Most parents of children receiving palliative care felt that RSLP was important in helping them deal with tough times, and most parents reported either participation in formal religious communities, or a sense of personal spirituality. A minority of parents, however, did not wish to discuss the topic at all. For those who described their RSLP, their beliefs and practices were associated with qualities of their overall outlook on life, questions of goodness and human capacity, or that "everything happens for a reason." RSLP was also important in defining the child's value and beliefs about the child's afterlife. Prayer and reading the bible were important spiritual practices in this population, and parents felt that these practices influenced their perspectives on the medical circumstances and decision-making, and their locus of control. From religious participation and practices, parents felt they received support from both their spiritual communities and from God, peace and comfort, and moral guidance. Some parents, however, also reported questioning their faith, feelings of anger and blame towards God, and rejecting religious beliefs or communities.

CONCLUSIONS

RSLP play a diverse and important role in the lives of most, but not all, parents whose children are receiving pediatric palliative care.

Health Care Reform and Concurrent Curative Care for Terminally Ill Children: A Policy Analysis

Within the Patient Protection and Affordable Care Act of 2010 or health care reform, is a relatively small provision about concurrent curative care that significantly affects terminally ill children. Effective on March 23, 2010, terminally ill children, who are enrolled in a Medicaid or state Children's Health Insurance Plans (CHIP) hospice benefit, may concurrently receive curative care related to their terminal health condition. The purpose of this article was to conduct a policy analysis of the concurrent curative care legislation by examining the intended goals of the policy to improve access to care and enhance quality of end of life care for terminally ill children. In addition, the policy analysis explored the political feasibility of implementing concurrent curative care at the state-level. Based on this policy analysis, the federal policy of concurrent curative care for children would generally achieve its intended goals. However, important policy omissions focus attention on the need for further federal end of life care legislation for children. These findings have implications nurses.

The effect of an educational session on pediatric nurses' perspectives toward providing spiritual care

This study evaluated the effect of a spiritual education session on pediatric nurses' perspectives toward providing spiritual care. A one-group pretest and posttest design was used to evaluate the effectiveness of the educational session. Participants consisted of 41 pediatric and neonatal nurses that worked in a large university-affiliated children's hospital. Findings confirmed that the spiritual education session had a positive effect on nurses' perspectives toward providing spiritual care. In addition, a positive correlation was identified between the pediatric nurses' perception of their own spirituality and their perspective toward providing care.

Addressing children's beliefs through Fowler's stages of faith

Knowledge of child development, including faith development, is important in providing holistic care to the child. Pediatric nurses and nurse practitioners may be inadequately prepared to meet the spiritual needs of children in developmentally appropriate ways. This article demonstrates why it is necessary to asses a child's or an adolescent's religious and spiritual beliefs and when and how a nurse intervenes. Modeled here is one way in which pediatric nurses can effectively combine their knowledge of child development and Fowler's theory of faith development to address the child and adolescent's spiritual needs.

Neonatal end-of-life spiritual support care

The death of an infant is a profound loss that may complicate, disrupt, or end relationships between parents; and lead to maladaptive grieving, long-term decreased quality of life, and symptoms related to psychological morbidity. Facing neonatal loss is frequently experienced as traumatic assault on parents' spiritual and existential world of meaning. This article highlights the importance of supporting parents through loss by providing comprehensive care that focuses not only on the neonate's physical needs, but also addresses parents' and families' spiritual, religious, and existential needs. Our objective is to increase practitioners' awareness of spiritual and existential distress and to provide strategies to address such needs, particularly at the end of life.

The spirit of palliative practice: A qualitative inquiry into the spiritual journey of palliative care physicians

Objective:

Much is known about the important role of spirituality in the delivery of multidimensional care for patients at the end of life. Establishing a strong physician–patient relationship in a palliative context requires physicians to have the self-awareness essential to establishing shared meaning and relationships with their patients. However, little is known about this phenomenon and therefore, this study seeks a greater understanding of physician spirituality and how caring for the terminally ill influences this inner aspect.

Method:

A qualitative descriptive study was used involving face-to-face interviews with six practicing palliative care physicians.

Results:

Conceptualized as a separate entity from religion, spirituality was described by participants as a notion relating to meaning, personal discovery, self-reflection, support, connectedness, and guidance. Spirituality and the delivery of care for the terminally ill appeared to be interrelated in a dynamic relationship where a physician's spiritual growth occurred as a result of patient interaction and that spiritual growth, in turn, was essential for providing compassionate care for the palliative patient. Spirituality also served as an influential force for physicians to engage in self-care practices.

Significance of results:

With spirituality as a pervasive force not only in the lives of palliative care patients, but also in those of healthcare providers, it may prove to be beneficial to use this information to guide future practice in training and education for palliative physicians in both the spiritual care of patients and in practitioner self care.

Pediatric palliative care

Palliative care has always been a part of the care of children. It includes any intervention that focuses on relieving suffering, slowing the progression of disease, and improving quality of life at any stage of disease. In addition, for even the child with the most unpredictable disease, there are predictable times in this child's life when the child, family, and care team will be suffering in ways that can be mitigated by specific interventions. Rather than defining pediatric palliative care in terms of a patient base, severity of disease, or even a general philosophy of care, palliative care can best be understood as a specific set of tasks directed at mitigating suffering. By understanding these tasks; learning to identify predictable times and settings of suffering; and learning to collaborate with multidisciplinary specialists, use communication skills, and identify clinical resources, the pediatrician can more effectively support children with life-threatening illnesses and their families. In this article, we define palliative care as a focus of care integrated in all phases of life and as a set of interventions aimed at easing suffering associated with life-threatening conditions. We detail an approach to these interventions and discuss how they can be implemented by the pediatrician with the support of specialists in hospice and palliative medicine. We discuss common and predictable times of suffering when these interventions become effective ways to treat suffering and improve quality of life. Finally, we discuss those situations that pediatricians most commonly and intensely interface with palliative care-the care of the child with complex, chronic conditions and severe neurologic impairment (SNI).

Longing: the lived experience of spirituality in adolescents with Duchenne muscular dystrophy

Although much has been written regarding ill adolescents, research has not described their spiritual response. The purpose of this descriptive phenomenological study was to describe the lived experiences of spirituality in adolescents with Duchenne muscular dystrophy using van Manen's phenomenological method. Findings from nine teens showed that the essential theme of spirituality was "longing," the strong desire for something unattainable. Consistent with Reed's (1992) paradigm for understanding spirituality, participants mediated their longing through "Connecting with others, self, and beyond self." These findings support the need for nursing to assess spirituality in teens and determine developmentally appropriate interventions to ameliorate longing.