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Inhestern L, Brandt M, Driemeyer J, Denecke J, Johannsen J, Bergelt C. Experiences of Health Care and Psychosocial Needs in Parents of Children with Spinal Muscular Atrophy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5360. [PMID: 37047974 PMCID: PMC10094281 DOI: 10.3390/ijerph20075360] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 06/19/2023]
Abstract
Spinal muscular atrophy (SMA) is a neurodegenerative disorder that is characterized by progressive weakness, respiratory insufficiency, and dysphagia. Due to symptom burden and disease progress, its care management and impact on daily life can severely burden the families of affected children. The objectives of this study are (1) to explore the health care experiences and (2) to investigate the psychosocial needs of the parents of children with SMA. In total, 29 parents of patients with SMA participated in our study. All children received supportive therapy (e.g., physiotherapy) and most were dependent on medical equipment. Parents perceived the health care positively regarding team quality, communication and access to medical care. An assessment of the impact of the child's health on the family (e.g., stressors, burden, consequences) is not routinely integrated into care. On average, parents reported low to medium levels of psychosocial needs. Due to the complex health care needs of SMA patients, the health care experiences of parents can provide relevant information on care delivery. To enhance the inclusion of psychosocial and emotional issues, as well as family impact, into routine health care, health care providers should be sensitive towards parental needs for consistency in the health care team and emotional aspects and, if applicable, address them proactively.
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Affiliation(s)
- Laura Inhestern
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Maja Brandt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Joenna Driemeyer
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jonas Denecke
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jessika Johannsen
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Corinna Bergelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- Department of Medical Psychology, University Medicine Greifswald, 17475 Greifswald, Germany
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Stoesslein S, Gramm JD, Bender HU, Müller P, Rabenhorst D, Borasio GD, Führer M. "More life and more days"-patient and care characteristics in a specialized acute pediatric palliative care inpatient unit. Eur J Pediatr 2023; 182:1847-1855. [PMID: 36795188 PMCID: PMC10167193 DOI: 10.1007/s00431-023-04813-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/30/2022] [Accepted: 01/06/2023] [Indexed: 02/17/2023]
Abstract
UNLABELLED Only a few acute hospital inpatient units dedicated to pediatric palliative care (PPC) patients exist today. Clinical data on the patients and care provided at specialized acute PPC inpatient units (PPCUs) are scarce. This study aims at describing patient and care characteristics on our PPCU to learn about the complexity and relevance of inpatient PPC. A retrospective chart analysis was performed on the 8-bed PPCU of the Center for Pediatric Palliative Care of the Munich University Hospital, including demographic, clinical, and treatment characteristics (487 consecutive cases; 201 individual patients; 2016-2020). Data were analyzed descriptively; the chi-square test was used for comparisons. Patients' age (1-35.5 years, median: 4.8 years) and length of stay (1-186 days, median 11 days) varied widely. Thirty-eight percent of patients were admitted repeatedly (range 2-20 times). Most patients suffered from neurological diseases (38%) or congenital abnormalities (34%); oncological diseases were rare (7%). Patients' predominant acute symptoms were dyspnea (61%), pain (54%), and gastrointestinal symptoms (46%). Twenty percent of patients suffered from > 6 acute symptoms, 30% had respiratory support incl. invasive ventilation, 71% had a feeding tube, and 40% had full resuscitation code. In 78% of cases, patients were discharged home; 11% died on the unit. CONCLUSION This study shows the heterogeneity, high symptom burden, and medical complexity of the patients on the PPCU. The high dependency on life-sustaining medical technology points to the parallelism of life-prolonging and palliative treatments that is typical for PPC. Specialized PPCUs need to offer care at the intermediate care level in order to respond to the needs of patients and families. WHAT IS KNOWN • Pediatric patients in outpatient PPC or hospices present with a variety of clinical syndromes and different levels of complexity and care intensity. • There are many children with life-limiting conditions (LLC) in hospitals, but specialized PPC hospital units for these patients are rare and poorly described. WHAT IS NEW • Patients on a specialized PPC hospital unit show a high symptom burden and a high level of medical complexity, including dependency on medical technology and frequent full resuscitation code. • The PPC unit is mainly a place for pain and symptom management as well as crisis intervention, and needs to be able to offer treatment at the intermediate care level.
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Affiliation(s)
- Sophie Stoesslein
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Julia D Gramm
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Hans-Ulrich Bender
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.,Pediatric Palliative Care, Department of Pediatrics, Bern University Hospital, Bern, Switzerland
| | - Petra Müller
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Dorothee Rabenhorst
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.
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Saposnik G, Camacho A, Díaz-Abós P, Brañas-Pampillón M, Sánchez-Menéndez V, Cabello-Moruno R, Terzaghi M, Maurino J, Málaga I. Therapeutic Decision-Making Under Uncertainty in the Management of Spinal Muscular Atrophy: Results From DECISIONS-SMA Study. Neurol Ther 2022; 11:1209-1219. [PMID: 35657490 PMCID: PMC9338192 DOI: 10.1007/s40120-022-00366-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/13/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction There are many uncertainties about treatment selection and expectations regarding therapeutic goals and benefits in the new landscape of spinal muscular atrophy (SMA). Our aim was to assess treatment preferences and expectations of pediatric neurologists caring for patients with SMA. Methods DECISIONS-SMA is a non-interventional, cross-sectional pilot study that assessed pediatric neurologists with expertise in SMA from across Spain. Participants were presented with 11 simulated case scenarios of common encounters of patients with SMA type 1 and 2 to assess treatment initiation, escalation, or switches. We also asked for the expected benefit with new therapies for four simulated case scenarios. Participants completed a behavioral battery to address their tolerance to uncertainty and aversion to ambiguity. The primary outcome was therapeutic inertia (TI), defined as the number of simulated scenarios with lack of treatment initiation or escalation when warranted over the total (11) presented cases. Results A total of 35 participants completed the study. Participants’ mean (SD) expectation for achieving an improvement by starting a new therapy for SMA type 1 (case 1, a 5-month-old) and SMA type 2 (case 6, a 1-year-old) were both 59.6% (± 21.8), but declined to 20.2% (± 12.2) for a case scenario of a 16-year-old treatment-naïve patient with long-standing SMA type 2 with severe disability. The mean (SD) TI score was 4.2 (1.7), and 3.29 (1.5) for treatment initiation. Of a total 385 individual responses, TI was observed in 147 (38.2%) of treatment choices. The multivariable analysis showed that lower aversion to ambiguity (p = 0.019) and lower expectation of treatment response (p = 0.007) were associated with higher TI after adjustment for participants’ age and years of experience. Older age (p = 0.019), lower years of experience (p = 0.035), lower aversion to ambiguity (p = 0.015), and lower expectation of treatment benefits (p = 0.006) were associated with inertia for treatment initiation. Conclusions Pediatric neurologists managing patients with SMA were optimistic regarding treatment improvement in cases with early diagnosis, but had lower expectations when treatment delays and advanced patient age were present. Low aversion to ambiguity, low expectation of treatment benefits, and lower clinical experience were more likely to make suboptimal decisions, resulting in lack of treatment initiation, escalation, and TI. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00366-4.
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Affiliation(s)
- Gustavo Saposnik
- Clinical Outcomes and Decision Neuroscience Unit, Li Ka Shing Institute, University of Toronto, Toronto, Canada. .,Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Ana Camacho
- Division of Child Neurology, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | | | | | | | | | - María Terzaghi
- Clinical Outcomes and Decision Neuroscience Unit, Li Ka Shing Institute, University of Toronto, Toronto, Canada
| | | | - Ignacio Málaga
- Child Neurology Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
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Pechmann A, Langer T, Kirschner J. Parents' Perspectives on Diagnosis and Decision-Making regarding Ventilator Support in Children with SMA Type 1. Neuropediatrics 2022; 53:122-128. [PMID: 35196711 DOI: 10.1055/s-0042-1743439] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Spinal muscular atrophy (SMA) is a rare neuromuscular disorder with a broad clinical spectrum. The most severe phenotype-SMA type 1-is characterized by marked muscle weakness also affecting bulbar and respiratory function. Life expectancy of children with SMA type 1 is expected to be less than 2 years without ventilator support or disease-specific drug treatment. The aim of this study was to evaluate parents' perspectives on the process of decision-making regarding ventilator support in children with SMA type 1. Fourteen semi-structured interviews were performed with parents of children with SMA type 1 that decided either for or against ventilator support for their child. All children were diagnosed prior to the approval of SMA-specific drug treatment. Interviews were recorded and transcribed verbatim. Data analysis was performed using a qualitative content analysis approach according to Mayring. Parents experienced that they were not adequately informed about the disease and treatment options in first informed consent discussions. Especially regarding ventilator support, parents perceived that they were not offered ventilator support as an actual option for treatment. Regarding the decision of whether or not to offer ventilator support, parents reported that their attitude toward ventilator support and contact with other affected families or patient advocacy groups were more likely to influence the decision than the content of informed consent discussions with physicians. Our results underline the importance of an interdisciplinary team not only to provide parents with relevant information but also to consider the criteria of a patient-centered medicine.
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Affiliation(s)
- Astrid Pechmann
- Department of Neuropediatrics and Muscle Disorders, Faculty of Medicine, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Thorsten Langer
- Department of Neuropediatrics and Muscle Disorders, Faculty of Medicine, University Medical Center, University of Freiburg, Freiburg, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics and Muscle Disorders, Faculty of Medicine, University Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neuropediatrics, University Hospital Bonn, Bonn, Germany
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Saposnik G, Díaz-Abós P, Sánchez-Menéndez V, Álvarez C, Terzaghi M, Maurino J, Brañas-Pampillón M, Málaga I. Therapeutic decisions under uncertainty for spinal muscular atrophy: The DECISIONS-SMA study protocol. PLoS One 2022; 17:e0264006. [PMID: 35167619 PMCID: PMC8846509 DOI: 10.1371/journal.pone.0264006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/31/2022] [Indexed: 12/03/2022] Open
Abstract
Background The therapeutic landscape for spinal muscular atrophy has changed in the last few years, encompassing respiratory/motor function and life expectancy benefits. However, physicians still have the challenge of tailoring individuals’ treatment to therapeutic goals, disease progression, patient/caregiver’s preferences, and personal experience to achieve an optimal risk/benefit balance. This study aims to provide insight into the preferred treatment choices of pediatric neurologists managing spinal muscular atrophy in their daily practice and to recognize behavioral factors that may influence decision-making. Methods This is a noninterventional, cross-sectional pilot study involving 50 pediatric neurologists managing spinal muscular atrophy in Spain. We designed an online platform that contains 13 simulated case scenarios of common presentations of patients with spinal muscular atrophy. The primary study outcome will be treatment preferences according to the percentages of participants who select treatment initiation when recommended, switch therapies when there is evidence of disease progression, and select treatment discontinuation when disease progression puts patients outside treatment recommendation (11 case scenarios). Secondary outcomes include therapeutic inertia prevalence (11 case scenarios), herding phenomenon prevalence (2 case scenarios), care-related regret prevalence (specific questions) and intensity (10-item Regret Intensity Scale), occupational burnout prevalence (nonproprietary single-item measure), and risk preferences (uncertainty test and risk aversion assessment). Conclusions The study findings will contribute to better understand relevant factors associated with therapeutic decisions of pediatric neurologists in spinal muscular atrophy, identifying treatment preferences and evaluating the role of behavioral aspects such as therapeutic inertia, herding, regret, and workplace burnout.
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Affiliation(s)
- Gustavo Saposnik
- NeuroEconSolutions (Neuroeconsolutions.com), Toronto, Canada
- Clinical Outcomes & Decision Neuroscience Unit, Li Ka Shing Institute, University of Toronto, Toronto, ON, Canada
- Division of Neurology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | | | - María Terzaghi
- NeuroEconSolutions (Neuroeconsolutions.com), Toronto, Canada
- Clinical Outcomes & Decision Neuroscience Unit, Li Ka Shing Institute, University of Toronto, Toronto, ON, Canada
| | | | | | - Ignacio Málaga
- Department of Pediatric Neurology, Hospital Universitario Central de Asturias, Oviedo, Spain
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Boursange S, Araneda M, Stalens C, Desguerre I, Barnerias C, Nougues MC, Isapof A, Quijano-Roy S, Blu Genestine N, Ouillade L, Martinez Jalilie M, Castiglioni C, Boespflug-Tanguy O, Gargiulo M. Parents' dilemma: A therapeutic decision for children with spinal muscular atrophy (SMA) type 1. Front Pediatr 2022; 10:1062390. [PMID: 36619514 PMCID: PMC9811815 DOI: 10.3389/fped.2022.1062390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND SMA type 1 is a severe neurodegenerative disorder that, in the absence of curative treatment, leads to death before 1 year of age without ventilatory support. Three innovative therapies are available to increase life expectancy. PURPOSE (i) To increase knowledge about parents' experiences with their decision to have opted for an innovative therapy; (ii) to assess the middle-term psychological consequences in the parents' lives. METHODS We used an in-depth interview; a self-administrated questionnaire and self-report scales (BDI-II, STAI-Y, PSI-SF, SOC-13, PBA, DAS 16 and FICD). We compared parents hesitant before the decision to parents who were not-hesitant and the group of parents whose child was treated with gene therapy (GT) to parents whose child received another innovative therapy. MAIN RESULTS We included n = 18 parents of 13 children. Parent's mean age was 34.7 (±5.2), child's average age was 44.3 months (±38.0). Retrospectively, most parents felt involved by doctors in decision-making on treatment, they felt their point of view was considered and were satisfied with the effects of the treatment. The group of parents "non-hesitant" was more depressed (p < 0.001), more anxious (p = 0.022) and had higher parental stress (p = 0.026) than the group of "hesitant" parents; the group of "GT-treated" parents was more depressed (p = 0.036) than the group of parents with "other therapy". Qualitative data highlights revealed: the need to save the child's life at all costs; the fear of coping with end of life and palliative care, the high value of perceived physician confidence in the treatment, the hope that the child will acquire autonomy or be cured. At the time of the decision, no parents felt they fully understood all of the issues regarding therapy and the disease. CONCLUSION Hesitating before making a decision did not predispose parents to depression and anxiety. The narratives suggest that the parents faced a dilemma regarding their child's health in an urgent context. The decision was not final, and parents will continue to think about it throughout the care process.
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Affiliation(s)
- Sophie Boursange
- Université Paris Cité, Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt, France.,Université Paris Cité, Ecole Doctorale ED-261, "Cognition, Conduct and Human Behavior", Boulogne-Billancourt, France.,Institut de Myologie, Hôpital de la Pitié-Salpêtrière, APHP-Paris, France
| | | | - Caroline Stalens
- French Association against Myopathies (AFM), Public Health and Medical Research Department, Evry, France
| | - Isabelle Desguerre
- Centre de Référence des Maladies Neuromusculaires, Centre Nord-Est-Ile de France, Réseau National des Maladies Neuromusculaires, FILNEMUS, France.,European Reference Center Network (Euro-NMD ERN), Paris, France.,Pediatric Neurology Department, AP-HP Hôpital Necker Enfants Malades, Paris, France
| | - Christine Barnerias
- Centre de Référence des Maladies Neuromusculaires, Centre Nord-Est-Ile de France, Réseau National des Maladies Neuromusculaires, FILNEMUS, France.,European Reference Center Network (Euro-NMD ERN), Paris, France.,Pediatric Neurology Department, AP-HP Hôpital Necker Enfants Malades, Paris, France
| | - Marie-Christine Nougues
- Centre de Référence des Maladies Neuromusculaires, Centre Nord-Est-Ile de France, Réseau National des Maladies Neuromusculaires, FILNEMUS, France.,European Reference Center Network (Euro-NMD ERN), Paris, France.,Department of Paediatric Neurology, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Arnaud Isapof
- Centre de Référence des Maladies Neuromusculaires, Centre Nord-Est-Ile de France, Réseau National des Maladies Neuromusculaires, FILNEMUS, France.,European Reference Center Network (Euro-NMD ERN), Paris, France.,Department of Paediatric Neurology, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Susana Quijano-Roy
- Centre de Référence des Maladies Neuromusculaires, Centre Nord-Est-Ile de France, Réseau National des Maladies Neuromusculaires, FILNEMUS, France.,European Reference Center Network (Euro-NMD ERN), Paris, France.,APHP Université Paris Saclay, Neuromuscular Unit Pediatric Neurology and ICU Department, Raymond Poincarré Hospital, Garches, France
| | | | | | | | | | - Odile Boespflug-Tanguy
- Centre de Référence des Maladies Neuromusculaires, Centre Nord-Est-Ile de France, Réseau National des Maladies Neuromusculaires, FILNEMUS, France.,European Reference Center Network (Euro-NMD ERN), Paris, France.,I-Motion, Institute of Myology, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris, France.,Université Paris Cité, UMR 1141, Paris, France
| | - Marcela Gargiulo
- Université Paris Cité, Laboratoire de Psychologie Clinique, Psychopathologie, Psychanalyse, Boulogne-Billancourt, France.,Institut de Myologie, Hôpital de la Pitié-Salpêtrière, APHP-Paris, France
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Carr K, Hasson F, McIlfatrick S, Downing J. Parents' experiences of initiation of paediatric advance care planning discussions: a qualitative study. Eur J Pediatr 2022; 181:1185-1196. [PMID: 34783898 PMCID: PMC8897342 DOI: 10.1007/s00431-021-04314-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
Advance care planning enables parents to discuss their goal and wishes for the future treatment and care of their life-limited or life-threatened child. Whilst research has identified the barriers clinicians face to initiate such discussions, the views of the parents have received scant attention. This qualitative study, using reflexive thematic analysis, aimed to explore parents' experience of the initiation of their child's advance care planning discussions, to help provide an understanding to inform future practice. Single interviews were undertaken with 17 non-bereaved and bereaved parents. Parents reported they had engaged with future thinking but needed time before initiating this with clinicians. They identified the need for a trusted professional and time for private, thorough, non-judgemental discussion without feeling clinicians were 'giving up'. Parents reported that advance care planning discussions were not always aligned to the dynamics of family life. They felt that health professionals were responsible for initiating advance planning conversations according to the families' individual requirements. There was an apparent lack of standardised protocols to assist paediatric advance care planning discussion initiation.Conclusion: Initiating advance care planning is a complicated process that needs to be tailored to the specific parent and child situation. Health professionals need to appreciate that parents are key contributors to initiate engagement with advance care planning discussions but that they also require support and care, recognising this may facilitate the building of trust, identified as a key corner stone, of paediatric advance care planning initiation and engagement. What is Known: • In paediatric palliative care, parents are challenged with wanting to sustain hope whilst thinking and planning for their child's end of life. Paediatric advance care planning discussions are often delayed or avoided and triggered by physical deterioration. What is New: • Previous relationship with HCP not essential but parental trust of the HCP is fundamental to Paediatric advance care planning initiation engagement. To build mutual trust health professionals' approach needs to be professional, respectful and empathetic to the parent and child's situation. • Subtle paediatric advance care planning parent initiation preparation by HCP is often unnoticed by parents but may be the crux of empowering parents to initiate advance care planning conversations themselves as they need to feel a sense of regaining control before planning ahead.
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Affiliation(s)
- Karen Carr
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road , Newtownabbey, BT37 0QB, UK.
| | - Felicity Hasson
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road , Newtownabbey, BT37 0QB UK
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road , Newtownabbey, BT37 0QB UK
| | - Julia Downing
- International Children’s Palliative Care Network, Bristol, UK ,Makerere University Uganda, Kampala, Uganda
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Vig PS, Lim JY, Lee RWL, Huang H, Tan XH, Lim WQ, Lim MBXY, Lee ASI, Chiam M, Lim C, Baral VR, Krishna LKR. Parental bereavement - impact of death of neonates and children under 12 years on personhood of parents: a systematic scoping review. BMC Palliat Care 2021; 20:136. [PMID: 34481491 PMCID: PMC8418708 DOI: 10.1186/s12904-021-00831-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Losing a child tragically impacts the well-being and functioning of parents. With these effects extending beyond emotional, physical morbidity and compromising self-perceptions, appropriate, longitudinal, timely and personalised support is key to effective care of bereaved parents. However, in the absence of a comprehensive understanding of parental bereavement, effective support of bereaved parents remains suboptimal. To address this gap, we scrutinise prevailing data on the effects of a child's death, aged 0-12 years, through the lens of the Ring Theory of Personhood (RToP). METHODS To study prevailing accounts of bereaved parents following the death of a child, we adopt Krishna's Systematic Evidence Based Approach (SEBA) to structure our Systematic Scoping Review (SSR in SEBA). RESULTS Three thousand seventy-four abstracts were reviewed, 160 full text articles were evaluated, and 111 articles were included and analysed using thematic and content analysis. Four themes/categories were identified relating to the four rings of the RToP. Findings reveal that static concepts of protective and risk factors for grief are misplaced and that the support of healthcare professionals is key to assisting bereaved parents. CONCLUSION In the absence of consistent support of bereaved parents, this study highlights the need for effective training of healthcare professionals, beginning with an appreciation that every aspect of an individual parent's personhood is impacted by the loss of their child. Acknowledging grief as a complex, evolving and personalised process subjected to parental characteristics, settings, context and available support, this SSR in SEBA calls attention to effective nurturing of the relationship between parents and healthcare professionals, and suggests use of the RToP to assess and direct personalised, timely, specific support of parents in evolving conditions. We believe the findings of this review also call for further studies to support healthcare professionals as they journey with bereaved parents.
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Affiliation(s)
- Prachi Simran Vig
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Jia Yin Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Randal Wei Liang Lee
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Huixin Huang
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Xiu Hui Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Wei Qiang Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Marie Bernadette Xin Yi Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Alexia Sze Inn Lee
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Crystal Lim
- Medical Social Services, Singapore General Hospital, Outram Road, Block 3 Level 1, Singapore, 169608 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
| | - Vijayendra Ranjan Baral
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Division of Neonatal and Developmental Medicine, Singapore General Hospital, Outram Road, Block 5 Level 4, Singapore, 169608 Singapore
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
- Centre for Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597 Singapore
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436 Singapore
- Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA UK
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9
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Quality of Life Outcomes According to Differential Nusinersen Exposure in Pediatric Spinal Muscular Atrophy. CHILDREN-BASEL 2021; 8:children8070604. [PMID: 34356583 PMCID: PMC8305818 DOI: 10.3390/children8070604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 01/07/2023]
Abstract
The purpose of this study was to explore early changes in patient and family caregiver report of quality of life and family impact during the transitional period of nusinersen use. Communication; family relationships; physical, emotional, social, and cognitive functioning; and daily activities were measured using Pediatric Quality of Life modules (Family Impact Modules and both Patient and Proxy Neuromuscular-Specific Reports) pre- and post-nusinersen exposure. A total of 35 patients with SMA (15 Type 1, 14 Type 2, and 6 Type 3) were grouped according to nusinersen exposure. When analyzed as a whole cross-sectional clinical population, no significant differences were found between the initial and final surveys. Nusinersen therapy was associated with improved communication and emotional functioning in subsets of the population, particularly for patients on maintenance therapy for longer duration. Several unexpected potentially negative findings including increases in family resources and trends towards increases in worry warrant further consideration. Further research is warranted to explore the impact of novel pharmaceuticals on quality of life for children with SMA longitudinally to optimize clinical and psychosocial outcomes.
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10
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Edwards JD, Panitch HB, George M, Cirrilla AM, Grunstein E, Wolfe J, Nelson JE, Miller RL. Development and validation of a novel informational booklet for pediatric long-term ventilation decision support. Pediatr Pulmonol 2021; 56:1198-1204. [PMID: 33305899 PMCID: PMC8035285 DOI: 10.1002/ppul.25221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To provide accessible, uniform, comprehensive, and balanced information to families deciding whether to initiate long-term ventilation (LTV) for their child, we sought to develop and validate a novel informational resource. METHODS The Ottawa Decision Support Framework was followed. Previous interviews with 44 lay and 15 professional stakeholders and published literature provided content for a booklet. Iterative versions were cognitive tested with six parents facing decisions and five pediatric intensivists. Ten parents facing decisions evaluated the booklet using the Preparation for Decision Making Scale and reported their decisional conflict, which was juxtaposed to the conflict of 21 parents who did not read it, using the Decisional Conflict Scale. Twelve home ventilation program directors evaluated the booklet's clinical sensibility and sensitivity, using a self-designed six-item questionnaire. Data presented using summary statistics. RESULTS The illustrated booklet (6th-grade reading level) has nine topical sections on chronic respiratory failure and invasive and noninvasive LTV, including the option to forgo LTV. Ten parents who read the booklet rated it as helping "Quite a bit" or more on all items of the Preparation for Decision Making Scale and had seemingly less decisional conflict than 21 parents who did not. Twelve directors rated it highly for clinical sensibility and sensitivity. CONCLUSIONS The LTV booklet was rigorously developed and favorably evaluated. It offers a resource to improve patient/family knowledge, supplement shared decision-making, and reduce decisional conflict around LTV decisions. Future studies should validate it in other settings and further study its effectiveness.
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Affiliation(s)
- Jeffrey D Edwards
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Valegos College of Physicians and Surgeons, New York, New York, USA
| | - Howard B Panitch
- Division of Pulmonary Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maureen George
- Columbia University School of Nursing, New York, New York, USA
| | - Anne-Marie Cirrilla
- Department of Care Coordination/Social Work, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Eli Grunstein
- Division of Pediatric Otolaryngology, Columbia University Valegos College of Physicians and Surgeons, New York, New York, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Judith E Nelson
- Critical Care Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, USA.,Palliative Medicine Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York, USA
| | - Rachel L Miller
- Division of Clinical Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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11
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Willems J, Farin-Glattacker E, Langer T. Evaluation of a Case Management to Support Families With Children Diagnosed With Spinal Muscular Atrophy-Protocol of a Controlled Mixed-Methods Study. Front Pediatr 2021; 9:614512. [PMID: 34414138 PMCID: PMC8369478 DOI: 10.3389/fped.2021.614512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 07/12/2021] [Indexed: 01/02/2023] Open
Abstract
Background: Spinal muscular atrophy (SMA) is a rare neuromuscular disease characterized by degeneration of the anterior horn cells in the spinal cord, resulting in muscle atrophy, and proximal muscle weakness. SMA presents with a wide range of symptoms requiring multiple clinical specialists and therapists. Integrating care between disciplines can be challenging due to the dynamic course of the disease, and great distances between specialist centers and local providers. Insufficient care integration can lead to suboptimal quality of care and more difficulties for patients and families. This study aims to improve care integration through a Case Management intervention, and taking a mixed-methods approach, to evaluate its impact. Methods: An exploratory, controlled, two-armed study with baseline, post- and follow-up measurement and process evaluation is conducted to evaluate our intervention compared to usual care. Through a multi-perspective state analysis, we investigate the experiences of caregivers and healthcare providers concerning the actual healthcare quality of patients with SMA I and II. Semi-structured interviews and care diaries are used. We apply that data to conceive a tailored Case Management intervention supplemented by a digital platform. The intervention's effect is examined in comparison to a control group taking a mixed-methods approach. As primary endpoints, we investigate the caregivers' health-related quality of life and the quality of care integration. Secondary endpoints are the use of healthcare services (patients and caregivers) and costs. We assess the process quality from the perspectives of caregivers and healthcare providers through semi-structured interviews. Discussion: This is an exploratory, controlled study to assess the impact of a tailored Case Management intervention to improve the care of patients with SMA I and II. After the evaluation, results on feasibility, expected effect sizes, and process quality will be available. On this basis, future randomized controlled trials can be planned. If demonstrated beneficial, the experience gained within this study may also be valuable for care strategies in other regions and other (non-pediatric) patient groups with rare diseases and/or chronic, complex conditions. Clinical Trial registration:https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00018778, identifier: DRKS00018778.
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Affiliation(s)
- Jana Willems
- Section of Healthcare Research and Rehabilitation Research, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Erik Farin-Glattacker
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thorsten Langer
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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12
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Chabrol B, Desguerre I. Ethical aspects in the care of a child with infantile spinal muscular atrophy (SMA). Arch Pediatr 2020; 27:7S50-7S53. [PMID: 33357599 DOI: 10.1016/s0929-693x(20)30278-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The pediatrician has a privileged relationship with a child with infantile spinal muscular atrophy (SMA). At all times, he/she must be the child's mentor, promoting a comprehensive approach and support in order to ensure the best possible solution for the patient's autonomy. In all circumstances, an ethical stance is essential. After a reminder on the notions of ethics of care, we will address various ethical questions encountered through three critical situations during the care of a child with infantile spinal muscular atrophy: the announcement of the diagnosis, the transmission of information on innovative therapies, and palliative care and end-of-life support. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
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Affiliation(s)
- B Chabrol
- Centre de référence des maladies neuromusculaires de l'Enfant, Neuromuscular Commission of French Society of Pediatric Neurology, Filière FINELMUS, Hôpital d'Enfants, CHU Timone, 13385 Marseille cedex 5.
| | - I Desguerre
- Centre de référence des maladies neuromusculaires de l'Enfant, Neuromuscular Commission of French Society of Pediatric Neurology, Filière FINELMUS, Hôpital Necker, rue de Sèvres, 75015 Paris
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13
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Kiefer P, Kirschner J, Pechmann A, Langer T. Experiences of caregivers of children with spinal muscular atrophy participating in the expanded access program for nusinersen: a longitudinal qualitative study. Orphanet J Rare Dis 2020; 15:194. [PMID: 32727502 PMCID: PMC7391692 DOI: 10.1186/s13023-020-01477-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 07/21/2020] [Indexed: 11/22/2022] Open
Abstract
Background Expanded access programs (EAPs) allow patients with serious, life-threatening conditions access to drugs prior to their formal approval. Despite the possible benefits for patients, EAPs present several challenges, including uncertainty regarding a drug’s efficacy and safety as well as inequities regarding access to treatment. Although the number of EAPs is growing, the experience of patients participating in EAPs has not yet been studied. In Germany, an EAP for the treatment of Spinal Muscular Atrophy (SMA) with nusinersen ran from December 2016 to May 2017). SMA is a rare, progressive neuromuscular disorder characterized by muscle atrophy and proximal muscle weakness. Insights into patients’ and caregivers’ experiences could help to improve future EAPs. Results We conducted a prospective study using semi-structured interviews with caregivers of children with Spinal Muscular Atrophy (SMA) Type 1who participated in the nusinersen EAP in Germany. Interviews were transcribed verbatim and analyzed using an inductive approach according to the principles of content analysis. Eight families participated in the study. Their children were between 2 and 28 months old. Six children received non-invasive ventilation. Participation in the EAP marked an important turning point in the caregivers’ experiences. Their perspective changed from a severely limited life expectancy and a palliative approach to a more optimistic view including hopes for a longer life and positive development of their children. However, participating in the EAP was also challenging for caregivers in several ways. Lack of information regarding the launch of the program and the enrollment procedures caused significant uncertainty and stress among caregivers prior to the actual treatment. Further, concerns persisted that nusinersen could not be approved or that the child could be excluded due to an insufficient treatment response. Good communication and trusting relationships with medical and non-medical staff at the hospital helped caregivers cope with the uncertainties associated with the treatment. Conclusion From the caregivers’ perspective, there was no alternative to participating in the EAP for nusinersen. All participants were positive regarding their decision to participate. However, this study suggests that developing procedures to increase speed and transparency and to ensure fairness could help to further improve the system of EAPs as a way to provide urgently needed care to highly vulnerable patients.
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Affiliation(s)
- Petra Kiefer
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany.,Department of Neuropediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Astrid Pechmann
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany
| | - Thorsten Langer
- Department of Neuropediatrics and Muscle Disorders, Center for Pediatrics, Faculty of Medicine, University of Freiburg, Mathildenstr. 1, 79106, Freiburg, Germany.
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14
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Weaver MS, Hanna R, Hetzel S, Patterson K, Yuroff A, Sund S, Schultz M, Schroth M, Halanski MA. A Prospective, Crossover Survey Study of Child- and Proxy-Reported Quality of Life According to Spinal Muscular Atrophy Type and Medical Interventions. J Child Neurol 2020; 35:322-330. [PMID: 32009500 DOI: 10.1177/0883073819900463] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Spinal muscular atrophy is an autosomal-recessive, progressive neuromuscular disease associated with extensive morbidity. Children with spinal muscular atrophy have potentially increased life spans due to improved nutrition, respiratory support, and novel pharmaceuticals. OBJECTIVES To report on the quality of life and family experience for children with spinal muscular atrophy with attentiveness to patient- and proxy-concordance and to stratify quality of life reports by spinal muscular atrophy type and medical interventions. METHODS A prospective, crossover survey study inclusive of 58 children (26 spinal muscular atrophy type I, 23 type II, 9 type III) and their family caregivers at a free-standing Midwestern children's hospital. Twenty-eight families completed the 25-item PedsQL 3.0 Neuromuscular Module. Forty-four participants completed the 36-item PedsQL Family Impact Module and 47 completed the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) questionnaire. RESULTS The PedsQL Family Impact Module demonstrated significant differences between spinal muscular atrophy types I and II in functioning domains including physical, emotional, social, and family relations (P < .03). Child self-report and proxy report surveys demonstrated significant differences between spinal muscular atrophy types in the communication domains (P < .003). Children self-reported their quality of life higher than proxy report of child quality of life. Gastrostomy tube (P = .001) and ventilation support (P = .029) impacted proxy-reported quality of life perspectives, whereas nusinersen use did not. Spinal surgery was associated with improved parental quality of life and family impact (P < .03). CONCLUSIONS The measurement and monitoring of quality of life for children with spinal muscular atrophy and their families represents an implementable priority for care teams.
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Affiliation(s)
- Meaghann S Weaver
- Children's Hospital of Omaha, University of Nebraska Medical Center, Omaha, NE, USA
| | - Rewais Hanna
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Scott Hetzel
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Karen Patterson
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Alice Yuroff
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Sarah Sund
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | | | | | - Matthew A Halanski
- Children's Hospital of Omaha, University of Nebraska Medical Center, Omaha, NE, USA
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15
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Hully M, Barnerias C, Chabalier D, Le Guen S, Germa V, Deladriere E, Vanhulle C, Cuisset JM, Chabrol B, Cances C, Vuillerot C, Espil C, Mayer M, Nougues MC, Sabouraud P, Lefranc J, Laugel V, Rivier F, Louvier UW, Durigneux J, Napuri S, Sarret C, Renouil M, Masurel A, Viallard ML, Desguerre I. Palliative Care in SMA Type 1: A Prospective Multicenter French Study Based on Parents' Reports. Front Pediatr 2020; 8:4. [PMID: 32133329 PMCID: PMC7039815 DOI: 10.3389/fped.2020.00004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/07/2020] [Indexed: 01/30/2023] Open
Abstract
Spinal muscular atrophy type 1 (SMA-1) is a severe neurodegenerative disorder, which in the absence of curative treatment, leads to death before 1 year of age in most cases. Caring for these short-lived and severely impaired infants requires palliative management. New drugs (nusinersen) have recently been developed that may modify SMA-1 natural history and thus raise ethical concerns about the appropriate level of care for patients. The national Hospital Clinical Research Program (PHRC) called "Assessment of clinical practices of palliative care in children with Spinal Muscular Atrophy Type 1 (SMA-1)" was a multicenter prospective study conducted in France between 2012 and 2016 to report palliative practices in SMA-1 in real life through prospective caregivers' reports about their infants' management. Thirty-nine patients were included in the prospective PHRC (17 centers). We also studied retrospective data regarding management of 43 other SMA-1 patients (18 centers) over the same period, including seven treated with nusinersen, in comparison with historical data from 222 patients previously published over two periods of 10 years (1989-2009). In the latest period studied, median age at diagnosis was 3 months [0.6-10.4]. Seventy-seven patients died at a median 6 months of age[1-27]: 32% at home and 8% in an intensive care unit. Eighty-five percent of patients received enteral nutrition, some through a gastrostomy (6%). Sixteen percent had a non-invasive ventilation (NIV). Seventy-seven percent received sedative treatment at the time of death. Over time, palliative management occurred more frequently at home with increased levels of technical supportive care (enteral nutrition, oxygenotherapy, and analgesic and sedative treatments). No statistical difference was found between the prospective and retrospective patients for the last period. However, significant differences were found between patients treated with nusinersen vs. those untreated. Our data confirm that palliative care is essential in management of SMA-1 patients and that parents are extensively involved in everyday patient care. Our data suggest that nusinersen treatment was accompanied by significantly more invasive supportive care, indicating that a re-examination of standard clinical practices should explicitly consider what treatment pathways are in infants' and caregivers' best interest. This study was registered on clinicaltrials.gov under the reference NCT01862042 (https://clinicaltrials.gov/ct2/show/study/NCT01862042?cond=SMA1&rank=8).
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Affiliation(s)
- Marie Hully
- Pediatric Neurology Department, Necker-Enfants Malades Hospital, APHP, Paris, France.,Physical Rehabilitation Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Christine Barnerias
- Pediatric Neurology Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Delphine Chabalier
- Pediatric Neurology Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Sophie Le Guen
- Clinical Research Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Virginie Germa
- Physical Rehabilitation Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | - Elodie Deladriere
- Physical Rehabilitation Department, Necker-Enfants Malades Hospital, APHP, Paris, France
| | | | - Jean-Marie Cuisset
- Pediatric Neurology Department and Neuromuscular Diseases Reference Center, CHU, Lille, France
| | - Brigitte Chabrol
- Pediatric Neurology Department, La Timone Hospital, APHM, Marseille, France
| | - Claude Cances
- Pediatric Neurology Department, Enfants Hospital, Toulouse, France
| | - Carole Vuillerot
- Pediatric Physical Rehabilitation Department, Femme Mère Enfants Hospital, Bron, France
| | - Caroline Espil
- Pediatric Neurology Department, Pellegrin Hospital, Bordeaux, France
| | - Michele Mayer
- Pediatric Neurology Department, Armand Trousseau Hospital, APHP, Paris, France
| | | | | | - Jeremie Lefranc
- Pediatric Neurology Department, Morvan Hospital, Brest, France
| | - Vincent Laugel
- Pediatric Neurology Department, Hautepierre Hospital, Strasbourg, France
| | - Francois Rivier
- Pediatric Neurology Department & Neuromuscular Diseases Reference Center AOC, CHU Montpellier, PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Ulrike Walther Louvier
- Pediatric Neurology Department & Neuromuscular Diseases Reference Center AOC, CHU Montpellier, Montpellier, France
| | - Julien Durigneux
- Pediatric Neurology Department, University Hospital, Angers, France
| | - Sylvia Napuri
- Pediatric Department, South Hospital, Rennes, France
| | - Catherine Sarret
- Pediatric Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Michel Renouil
- Pediatric Department, St-Pierre Hospital, Saint-Denis, France
| | - Alice Masurel
- Genetic Department, Children Hospital, CHU Dijon, Dijon, France
| | - Marcel-Louis Viallard
- Palliative Care Team, Necker-Enfants Malades Hospital, APHP, Paris, France.,Research Team "ETRES", UMR des Cordeliers, Université de Paris, Paris, France
| | - Isabelle Desguerre
- Pediatric Neurology Department, Necker-Enfants Malades Hospital, APHP, Paris, France
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