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HarnEnz Z, Vermilion P, Foster-Barber A, Treat L. Pediatric neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:157-184. [PMID: 36599507 DOI: 10.1016/b978-0-12-824535-4.00015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.
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Affiliation(s)
- Zoe HarnEnz
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Paul Vermilion
- Department of Medicine, University of Rochester, Rochester, NY, United States
| | - Audrey Foster-Barber
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States.
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Janisch M, Boehme K, Thiele S, Bock A, Kirschner J, Schara U, Walter MC, Nolte-Buchholtz S, von der Hagen M. Tasks and interfaces in primary and specialized palliative care for Duchenne muscular dystrophy - A patients' perspective. Neuromuscul Disord 2020; 30:975-985. [PMID: 33214012 DOI: 10.1016/j.nmd.2020.09.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/31/2020] [Accepted: 09/23/2020] [Indexed: 12/25/2022]
Abstract
In spite of the improvements in care and the emergence of disease-modifying treatments, Duchenne muscular dystrophy (DMD) remains a life-limiting disease of adolescence and (young) adulthood. Palliative care approaches and principles should be integrated from the point of diagnosis and implemented throughout the lifespan. A nationwide cross-sectional survey based on a mixed-method-design of qualitative and quantitative research approaches evaluated the structural implementation and perception of palliative care for DMD in Germany. Data analyses revealed that palliative care was predominantly provided at the primary care level by pediatricians, general practitioners and specialized multi-professional outpatient structures. The majority of patients did not utilize the scopes of specialized palliative structures. Simultaneously, insufficiently treated complex symptoms, emergent and elective hospitalizations and barriers in transitioning into adult care presented a considerable burden. A collaborative integrated model with a close cooperation of patients, families and care providers is proposed involving task areas and interfaces complementing primary and specialized palliative care (1) management of complex symptoms, (2) crisis support, (3) intermittent relief of the strain for caregivers, (4) coordination of care, (5) advance care planning and (6) end-of-life care. Specialized palliative care should be used as an "add-on" approach in time of need rather than as a prognosis or disease stage.
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Affiliation(s)
- Maria Janisch
- Pediatric Palliative Care Centre, Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - Kristin Boehme
- Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Simone Thiele
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University of Munich, Ziemssenstr. 1, 80336 Munich, Germany
| | - Annette Bock
- Social pediatric centre, Stiftung Kreuznacher Diakonie, Ringstraße 58, 55543 Bad Kreuznach, Bad Kreuznach, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Ulrike Schara
- Department of Neuropediatrics and Neuromuscular Centre for Children and Adolescents, Children's Hospital, University of Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Maggie C Walter
- Friedrich-Baur-Institute, Department of Neurology, Ludwig-Maximilians-University of Munich, Ziemssenstr. 1, 80336 Munich, Germany
| | - Silke Nolte-Buchholtz
- Pediatric Palliative Care Centre, Department of Pediatrics, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
| | - Maja von der Hagen
- Abteilung Neuropädiatrie, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany
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Oostendorp LJM, Rajapakse D, Kelly P, Crocker J, Dinsdale A, Fraser L, Bluebond-Langner M. Documentation of breakthrough pain in narrative clinical records of children with life-limiting conditions: Feasibility of a retrospective review. J Child Health Care 2019; 23:564-578. [PMID: 30463428 PMCID: PMC7323830 DOI: 10.1177/1367493518807312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
This study explored the feasibility of generating reliable information on the frequency, nature and management of breakthrough pain (BTP) in children with life-limiting conditions and life-threatening illnesses (LTIs) from narrative clinical records. In the absence of standardized ways for documenting BTP, we conducted a consensus exercise to develop a glossary of terms that could denote BTP in the records. Thirteen clinicians who contributed to the records reached consensus on 45 terms which could denote BTP, while emphasizing the importance of contextual information. The results of this approach together with guidance for improving the reliability of retrospective reviews informed a data extraction instrument. A pilot test of this instrument showed poor agreement between raters. Given the challenges encountered, we do not recommend a retrospective review of BTP using narrative records. This study highlighted challenges of data extraction for complex symptoms such as BTP from narrative clinical records. For both clinical and research purposes, the recording of complex symptoms such as BTP would benefit from clear criteria for applying definitions, a more structured format and the inclusion of validated assessment tools. This study also showed the value of consensus exercises in improving understanding and interpretation of clinical notes within a service.
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Affiliation(s)
- Linda JM Oostendorp
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, University College London, London, UK
| | - Dilini Rajapakse
- Louis Dundas Centre for Oncology Outreach and Children’s Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Paula Kelly
- Louis Dundas Centre for Oncology Outreach and Children’s Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Joanna Crocker
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, University College London, London, UK,Health Experiences Institute, University of Oxford, London, UK
| | - Andrew Dinsdale
- Louis Dundas Centre for Oncology Outreach and Children’s Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children’s Palliative Care, UCL Institute of Child Health, University College London, London, UK,Myra Bluebond-Langner, UCL Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, Louis Dundas Centre for Children’s Palliative Care, 30 Guilford Street, London WC1N 1EH, UK.
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Beernaert K, Lövgren M, Jeppesen J, Werlauff U, Rahbek J, Sejersen T, Kreicbergs U. Parents' Experiences of Information and Decision Making in the Care of Their Child With Severe Spinal Muscular Atrophy: A Population Survey. J Child Neurol 2019; 34:210-215. [PMID: 30642225 DOI: 10.1177/0883073818822900] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study aims to assess the experiences and wishes of parents of children with severe spinal muscular atrophy regarding information and decision-making throughout the course of the illness. STUDY DESIGN A full population survey, conducted in 2015, among parents of children with severe spinal muscular atrophy who were born in Denmark between January 1, 2003, and December 31, 2013. We used a study-specific questionnaire with items about experiences and wishes concerning the provision of information about diagnosis, treatment, and end-of-life care. RESULTS Among the 47 parents that were identified, 34 parents of 21 children participated. Eleven of them were nonbereaved and 23 were bereaved parents. All parents stated that health care staff did not take any decisions without informing them. A proportion of parents indicated that they were not informed about what spinal muscular atrophy entails (32%), possible treatment options (18%), or the fact that their child would have a short life (26%) or that death was imminent (57%). Most of the bereaved parents who had wishes concerning how and where their child would pass away had their wishes fulfilled. CONCLUSIONS The study showed that health care staff did not take treatment decisions without parents being informed. However, there is room for improvement concerning information about what spinal muscular atrophy entails, treatment options, and prognosis. Possibilities of palliative care and advance care planning should be investigated for these parents, their child, and health care staff.
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Affiliation(s)
- Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universtiteit Brussel (VUB), Ghent, Belgium
| | - Malin Lövgren
- Ersta Sköndal Bräcke University College, Department of Health Care Sciences, Palliative Research Centre, Stockholm, Sweden.,Department of Women's and Children's Health, Paediatric Oncology and Haematology, Childhood Cancer Research Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Jørgen Jeppesen
- National Rehabilitation Centre for Neuromuscular Diseases, Aarhus, Denmark
| | - Ulla Werlauff
- National Rehabilitation Centre for Neuromuscular Diseases, Aarhus, Denmark
| | - Jes Rahbek
- National Rehabilitation Centre for Neuromuscular Diseases, Aarhus, Denmark
| | - Thomas Sejersen
- Department of Women's and Children's Health, Paediatric Neurology, Karolinska Institutet, Karolinska University Hospital, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Ulrika Kreicbergs
- Ersta Sköndal Bräcke University College, Department of Health Care Sciences, Palliative Research Centre, Stockholm, Sweden.,Department of Women's and Children's Health, Paediatric Oncology and Haematology, Childhood Cancer Research Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Abstract
Progressive neuromuscular disease requires increasing degrees of respiratory support to sustain life. Each step from intermittent to continuous-and noninvasive to invasive-ventilation requires thoughtful consideration based on the goals of the patient and family, and the inherent benefits and burdens of the treatment. Tracheostomy, in particular, should not be viewed as an inevitable next step when less permanent or invasive methods prove insufficient. Like other modes of respiratory support, tracheostomy may represent a bridge to recovery of pulmonary function, or a stabilizing action in the hope that novel therapies may prove beneficial. In other situations, tracheostomy represents a destination therapy, necessitating consideration of the implications of chronic mechanical ventilation. Institutional, social, and financial considerations may affect decisions related to tracheostomy, as may implicit bias regarding quality of life. The complexity of such care and decisions highlight the need for optimal palliative care throughout the patient's life.
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Affiliation(s)
- Robert Macauley
- Cambia Health Foundation Endowed Chair in Pediatric Palliative Care, Oregon Health and Science University, 707 SW Gaines Street, Mailcode CDRCP, Portland, OR 97239, United States.
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Abstract
It has long been recognized that patients with neurological conditions, and particularly pediatric neurology patients, are well suited for palliative care because they frequently have a high symptom burden and variable prognoses. In 1996, the American Academy of neurology formally recognized a need for neurologists to "understand and apply the principles of palliative medicine." Subsequently, some reviews have proposed a simultaneous care model in which palliative care is integrated for all neurology patients from the time of diagnosis. This article will review the current status of palliative care in pediatric neurology and discuss barriers to its integration.
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Affiliation(s)
- Ariel M Lyons-Warren
- 1 Department of Pediatrics, Section on Neurology, Baylor College of Medicine, Houston, TX, USA
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Yang BH, Mu PF, Wang WS. The experiences of families living with the anticipatory loss of a school-age child with spinal muscular atrophy - the parents' perspectives. J Clin Nurs 2016; 25:2648-57. [PMID: 27477332 DOI: 10.1111/jocn.13312] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2016] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To probe into parents' anticipatory loss of school-age children with Type I or II spinal muscular atrophy. BACKGROUND Spinal muscular atrophy is a rare disorder that causes death. Children die early due to either gradual atrophy or an infection of the lungs. Therefore, family members experience anticipatory loss, which causes grief before the actual loss. Family members feel physically and mentally exhausted, which results in a family crisis. Therefore, it is important to explore their experiences related to anticipatory loss to assist with the adjustment of the families to their circumstances. DESIGN This study applied a phenomenology method and purposive sampling. PARTICIPANTS The 19 parents who participated in this study were referred to us by two medical centers in Taiwan. Their average age was 32-49 years. METHODS Using in-depth interviews, this study explored parents' anticipatory loss. The interviews were recorded and transcribed. Meanings were extracted using Giorgi analysis, and precision was assessed according to Guba and Lincoln, which was treated as the evaluation standard. RESULTS Four themes were identified from the parents' interviews. The themes included enduring the helplessness and pressure of care, suffering due to the child's rare and unknown condition, loss of hope and a reinforcement of the parent-child attachment, and avoiding the pressure of death and enriching the child's life. CONCLUSIONS The research findings help nurses identify anticipatory loss among parents of school-age children with type I or II spinal muscular atrophy. They enhance health professionals' understanding of the panic that occurs in the society surrounding the families, family members' dynamic relationships, and the families' demands for care. RELEVANCE TO CLINICAL PRACTICE In an attempt to providing intersubjective empathy and support with family having a child with type I and II SMA, nurses may recognize relevant family reactions and enhancing their hope and parent-child attachment. Encourage family members and child go beyond the pressure of death and create customized care plans meeting families' emotional and medical needs.
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Affiliation(s)
- Bao-Huan Yang
- School of Nursing, Chang Gung University of Science and Technology, Guishan District, Taoyuan City, Taiwan
| | - Pei-Fan Mu
- Institute of Clinical Nursing, National Yang-Ming University, Taipei City, Taiwan. .,Taiwan Joanna Briggis Collaborating Center, National Yang-Ming University, Taipei City, Taiwan. .,School of Nursing, National Defense Medical Center, Taipei City, Taiwan.
| | - Wen-Sheng Wang
- Department of Philosophy, National Chengchi University, Wenshan District, Taipei City, Taiwan
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Thrane SE, Maurer SH, Ren D, Danford CA, Cohen SM. Reiki Therapy for Symptom Management in Children Receiving Palliative Care: A Pilot Study. Am J Hosp Palliat Care 2016; 34:373-379. [PMID: 26858170 DOI: 10.1177/1049909116630973] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pain may be reported in one-half to three-fourths of children with cancer and other terminal conditions and anxiety in about one-third of them. Pharmacologic methods do not always give satisfactory symptom relief. Complementary therapies such as Reiki may help children manage symptoms. OBJECTIVE This pre-post mixed-methods single group pilot study examined feasibility, acceptability, and the outcomes of pain, anxiety, and relaxation using Reiki therapy with children receiving palliative care. METHODS A convenience sample of children ages 7 to 16 and their parents were recruited from a palliative care service. Two 24-minute Reiki sessions were completed at the children's home. Paired t tests or Wilcoxon signed-rank tests were calculated to compare change from pre to post for outcome variables. Significance was set at P < .10. Cohen d effect sizes were calculated. RESULTS The final sample included 8 verbal and 8 nonverbal children, 16 mothers, and 1 nurse. All mean scores for outcome variables decreased from pre- to posttreatment for both sessions. Significant decreases for pain for treatment 1 in nonverbal children ( P = .063) and for respiratory rate for treatment 2 in verbal children ( P = .009). Cohen d effect sizes were medium to large for most outcome measures. DISCUSSION Decreased mean scores for outcome measures indicate that Reiki therapy did decrease pain, anxiety, heart, and respiratory rates, but small sample size deterred statistical significance. This preliminary work suggests that complementary methods of treatment such as Reiki may be beneficial to support traditional methods to manage pain and anxiety in children receiving palliative care.
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Affiliation(s)
- Susan E Thrane
- 1 College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Scott H Maurer
- 2 Palliative Care, Hematology/Oncology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dianxu Ren
- 3 School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Susan M Cohen
- 3 School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
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Pediatric palliative care: current evidence and evidence gaps. J Pediatr 2015; 166:1536-40.e1. [PMID: 25799195 DOI: 10.1016/j.jpeds.2015.02.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/30/2015] [Accepted: 02/06/2015] [Indexed: 11/23/2022]
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10
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Kang SC, Hwang SJ, Wang WS. Investigations of the pediatric hospice care in Taiwan: 2005 to 2010. Am J Hosp Palliat Care 2014; 31:480-4. [PMID: 23739240 DOI: 10.1177/1049909113492007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The utilization of pediatric hospice care remains unclear in Taiwan. METHODS Data were analyzed from the claims of hospice admissions in patients aged 18 years or younger using the National Health Insurance Research Database from 2005 to 2010. RESULTS A total of 91 patients and 136 admissions were enrolled (male-female = 50:41; mean 11.6 years old). In all, 62 patients were admitted once, including 47 patients who died. All the patients had cancer, with brain cancer (40.7%) accounting the most . Among acute comorbidities, neurological complications (16.2%) were mostly accounted. Family physicians provided most (64.7%) of the hospice services. Hospice stay ≤3 days correlated positively with death in hospices (odds ratio = 2.922, 95% confidence interval = 1.268-6.730). CONCLUSIONS Pediatric hospice care revealed characteristics different from adults. Underlying late referrals were prevalent. There is space to promote the utilization of hospices for terminally ill pediatric patients.
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Affiliation(s)
- Shih-Chao Kang
- Division of Family Medicine, National Yang-Ming University Hospital, Yilan, Taiwan, Republic of China Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, Republic of China
| | - Shinn-Jang Hwang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, Republic of China Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Wei-Shu Wang
- Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan, Republic of China Department of Oncology and Hematology and Deputy Administrator's Office, National Yang-Ming University Hospital, Yilan, Taiwan, Republic of China
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Steele R, Siden H, Cadell S, Davies B, Andrews G, Feichtinger L, Singh M, Spicer S, Goez H, Davies D, Rapoport A, Vadeboncoeur C, Liben S, Gregoire MC, Schwantes S, Friedrichsdorf SJ. Charting the territory: symptoms and functional assessment in children with progressive, non-curable conditions. Arch Dis Child 2014; 99:754-62. [PMID: 24833792 DOI: 10.1136/archdischild-2013-305246] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Children with progressive, non-curable genetic, metabolic, or neurological conditions require specialised care to enhance their quality of life. Prevention and relief of physical symptoms for these children needs to begin at diagnosis, yet, little is known about their patterns of symptoms and functional abilities. AIM To describe these children's symptoms, as well as how the children's condition affects them physically. DESIGN Cross-sectional, baseline results from an observational, longitudinal study, Charting the Territory, that followed 275 children and their families. SETTING/PARTICIPANTS Seven tertiary care children's hospitals in Canada, 2 in the USA. Families were eligible based on the child's condition. A total of 275 children from 258 families participated. RESULTS The 3 most common symptoms in these children were pain, sleep problems, and feeding difficulties; on average, they had 3.2 symptoms of concern. There was a pattern of under-reporting of children's symptoms for clinicians compared with parents. Regardless of use of associated medications, pain, feeding and constipation symptoms were often frequent and distressing. Children with a G/J tube had a higher total number of symptoms, and respiratory problems, pain, feeding difficulties and constipation were more likely to occur. They also tended to have frequent and distressing symptoms, and to need extensive mobility modifications which, in turn, were associated with higher numbers of symptoms. CONCLUSIONS These children experience multiple symptoms that have been previously documented individually, but not collectively. Effective interventions are needed to reduce their symptom burden. Future longitudinal analyses will examine which disease-modifying interventions improve, or do not improve, symptom burden.
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Affiliation(s)
- Rose Steele
- School of Nursing, Faculty of Health, York University, Toronto, Ontario, Canada
| | - Harold Siden
- Department of Paediatrics, University of British Columbia; Canuck Place Children's Hospice, Vancouver, British Columbia, Canada Developmental Neuroscience and Child Health, Child & Family Research Institute, Vancouver, British Columbia, Canada
| | - Susan Cadell
- School of Social Work, Renison University College-University of Waterloo, Waterloo, Ontario, Canada
| | - Betty Davies
- School of Nursing, University of Victoria, Victoria, British Columbia, Canada
| | - Gail Andrews
- Developmental Neuroscience and Child Health, Child & Family Research Institute, Vancouver, British Columbia, Canada
| | - Leanne Feichtinger
- Developmental Neuroscience and Child Health, Child & Family Research Institute, Vancouver, British Columbia, Canada
| | - Mina Singh
- School of Nursing, Faculty of Health, York University, Toronto, Ontario, Canada
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Martínez Carrasco C, Cols Roig M, Salcedo Posadas A, Sardon Prado O, Asensio de la Cruz O, Torrent Vernetta A. [Respiratory treatments in neuromuscular disease]. An Pediatr (Barc) 2014; 81:259.e1-9. [PMID: 24890888 DOI: 10.1016/j.anpedi.2014.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 03/25/2014] [Accepted: 04/07/2014] [Indexed: 11/29/2022] Open
Abstract
In a previous article, a review was presented of the respiratory pathophysiology of the patient with neuromuscular disease, as well as their clinical evaluation and the major complications causing pulmonary deterioration. This article presents the respiratory treatments required to preserve lung function in neuromuscular disease as long as possible, as well as in special situations (respiratory infections, spinal curvature surgery, etc.). Special emphasis is made on the use of non-invasive ventilation, which is changing the natural history of many of these diseases. The increase in survival and life expectancy of these children means that they can continue their clinical care in adult units. The transition from pediatric care must be an active, timely and progressive process. It may be slightly stressful for the patient before the adaptation to this new environment, with multidisciplinary care always being maintained.
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Affiliation(s)
- C Martínez Carrasco
- Sección de Neumología Pediátrica, Hospital Universitario La Paz, Madrid, España.
| | - M Cols Roig
- Sección de Neumología Pediátrica, Hospital Sant Joan de Déu, Barcelona, España
| | - A Salcedo Posadas
- Sección de Neumología Pediátrica, Hospital Universitario Gregorio Marañón, Madrid, España
| | - O Sardon Prado
- Sección de Neumología Pediátrica, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - O Asensio de la Cruz
- Sección de Neumología Pediátrica, Hospital de Sabadell, Corporació Sanitària i Universitària Parc Taulí, Sabadell, Barcelona, España
| | - A Torrent Vernetta
- Sección de Neumología Pediátrica, Hospital Universitario Vall d'Hebron, Barcelona, España
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Abstract
OBJECTIVE Our aim was to describe the clinical evolution and needs of children with spinal muscular atrophy type I treated in a domiciliary palliative care program. METHOD We undertook a retrospective chart review of nine consecutive patients. Descriptions of the clinical and demographic profile of children with spinal muscular atrophy (SMA) type I were referred to a pediatric palliative care team (PPCT). RESULTS Six males and three females were admitted to the PPCT, all before six months of age, except for one afflicted with SMA type I with respiratory distress. The median time of attention was 57 days (range 1-150). The domiciliary attention mainly consisted of respiratory care. The patient with SMA type I with respiratory distress required domiciliary mechanical ventilation by tracheotomy. In all cases, a nasogastric tube (NT) was indicated. As end-of-life care, eight required morphine to manage the dyspnea, four received it only by enteral (oral or NT) administration, and four received it first by enteral administration with continuous subcutaneous infusion (CSI) later. Three of the four patients with CSI also received benzodiazepines. While they were attended by the PPCT, none required hospital admission. All the patients died at home except for the one attended to for just one day. SIGNIFICANCE OF RESULTS Domiciliary care for these patients is possible. The respiratory morbidity and its management are the main issues. Application of an NT is useful to maintain nutritional balance. Morphine administration is necessary to manage the dyspnea. Palliative sedation is not always necessary.
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Feudtner C, Womer J, Augustin R, Remke S, Wolfe J, Friebert S, Weissman D. Pediatric palliative care programs in children's hospitals: a cross-sectional national survey. Pediatrics 2013; 132:1063-70. [PMID: 24190689 DOI: 10.1542/peds.2013-1286] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric palliative care (PPC) programs facilitate the provision of comprehensive care to seriously ill children. Over the past 10 years many such programs have been initiated by children's hospitals, but little is known about their number, staff composition, services offered, sources of support, or national distribution. METHODS In the summer of 2012, we surveyed 226 hospitals as identified by the National Association of Children's Hospitals and Related Institutions. The survey instrument gathered data about whether their institution had a PPC program, and for hospitals with programs, it asked for a wide range of information including staffing, patient age range, services provided, and financial support. RESULTS Of the 162 hospitals that provided data (71.7% response rate), 69% reported having a PPC program. The rate of new program creation peaked in 2008, with 12 new programs created that year, and 10 new programs in 2011. Most programs offer only inpatient services, and most only during the work week. The number of consults per year varied substantially across programs, and was positively associated with hospital bed size and number of funded staff members. PPC programs report a high level of dependence on hospital funding. CONCLUSIONS PPC programs are becoming common in children's hospitals throughout the United States yet with marked variation in how these programs are staffed, the level of funding for staff effort to provide PPC, and the number of consultations performed annually. Guidelines for PPC team composition, funding, and consultation standards may be warranted to ensure the highest quality of PPC.
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Affiliation(s)
- Chris Feudtner
- CHOP North, Room 1523, The Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 10194.
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Up against the System: A Case Study of Young Adult Perspectives Transitioning from Pediatric Palliative Care. Nurs Res Pract 2013; 2013:286751. [PMID: 23997951 PMCID: PMC3753759 DOI: 10.1155/2013/286751] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 06/28/2013] [Indexed: 11/20/2022] Open
Abstract
Advances in pediatric care have not provided the interdisciplinary support services required by those young adults with pediatric life-threatening conditions (pedLTCs) who live beyond childhood but have limited expectations to live past early adulthood. These young adults, the first generation to live into adulthood, face multiple challenges transitioning from a plethora of pediatric palliative services to scant adult health services. In a case study, using an innovative bulletin board focus group, we describe the complex interplay of the health, education, and social service sectors in this transition. Our descriptions include system deficits and strengths and the young adults' resilience and coping strategies to overcome those deficits and move forward with their lives. Young adults with pedLTC need knowledgeable providers, coordinated and accessible services, being respected and valued, and services and supports that promote independence. We recommend implementation of multidisciplinary solutions that are focused on young adult priorities to ensure seamless access to resources to support these young adults' health, educational, vocational, and social goals. The input and voice of young adults in the development of these services are imperative to ensure that multisystem services support their needs and life goals.
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Berry JG, Toomey SL, Zaslavsky AM, Jha AK, Nakamura MM, Klein DJ, Feng JY, Shulman S, Chiang VW, Kaplan W, Hall M, Schuster MA. Pediatric readmission prevalence and variability across hospitals. JAMA 2013; 309:372-80. [PMID: 23340639 PMCID: PMC3640861 DOI: 10.1001/jama.2012.188351] [Citation(s) in RCA: 332] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Readmission rates are used as an indicator of the quality of care that patients receive during a hospital admission and after discharge. OBJECTIVE To determine the prevalence of pediatric readmissions and the magnitude of variation in pediatric readmission rates across hospitals. DESIGN, SETTING, AND PATIENTS We analyzed 568,845 admissions at 72 children's hospitals between July 1, 2009, and June 30, 2010, in the National Association of Children's Hospitals and Related Institutions Case Mix Comparative data set. We estimated hierarchical regression models for 30-day readmission rates by hospital, accounting for age and Chronic Condition Indicators. Hospitals with adjusted readmission rates that were 1 SD above and below the mean were defined as having "high" and "low" rates, respectively. MAIN OUTCOME MEASURES Thirty-day unplanned readmissions following admission for any diagnosis and for the 10 admission diagnoses with the highest readmission prevalence. Planned readmissions were identified with procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. RESULTS The 30-day unadjusted readmission rate for all hospitalized children was 6.5% (n = 36,734). Adjusted rates were 28.6% greater in hospitals with high vs low readmission rates (7.2% [95% CI, 7.1%-7.2%] vs 5.6% [95% CI, 5.6%-5.6%]). For the 10 admission diagnoses with the highest readmission prevalence, the adjusted rates were 17.0% to 66.0% greater in hospitals with high vs low readmission rates. For example, sickle cell rates were 20.1% (95% CI, 20.0%-20.3%) vs 12.7% (95% CI, 12.6%-12.8%) in high vs low hospitals, respectively. CONCLUSIONS AND RELEVANCE Among patients admitted to acute care pediatric hospitals, the rate of unplanned readmissions at 30 days was 6.5%. There was significant variability in readmission rates across conditions and hospitals. These data may be useful for hospitals' quality improvement efforts.
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Affiliation(s)
- Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA.
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