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Craig AK, Munoz-Blanco S, Pilon B, Lemmon M. Communicating with Parents About Therapeutic Hypothermia and Hypoxic Ischemic Encephalopathy: Integrating a Palliative Care Approach into Practice. Clin Perinatol 2024; 51:711-724. [PMID: 39095105 DOI: 10.1016/j.clp.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
Parents of newborns with hypoxic ischemic encephalopathy (HIE) can face communication challenges in the neonatal intensive care unit. Both specialty palliative care and primary palliative care trained clinicians can assist parents as they navigate traumatic experiences and uncertain prognoses. Using evidence-based frameworks, the authors provide samples of how to communicate with parents and promote parent well-being across the care trajectory. The authors demonstrate how to involve parents in a shared decision-making process and give special consideration to the complexities of hospital discharge and the transition home. Sustained investment to guide the development of effective communication skills is crucial to support families of infants with HIE.
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Affiliation(s)
- Alexa K Craig
- Division of Pediatric Neurology, Department of Pediatrics, The Barbara Bush Children's Hospital at Maine Medical Center, Portland; Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA.
| | - Sara Munoz-Blanco
- Department of Pediatrics, Johns Hopkins School of Medicine; Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins Children's Center, 1800 Orleans Street, Baltimore, MD 21287, USA; Division of Pediatric Palliative Care, Department of Pediatrics, Johns Hopkins Children's Center, 1800 Orleans Street, Baltimore, MD 21287, USA
| | | | - Monica Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University School of Medicine, DUMC 3936, Durham 27710, USA; Division of Pediatric Neurology and Developmental Medicine, Department of Population Health Sciences, Duke University School of Medicine, DUMC 3936, Durham 27710, USA
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Lemmon ME, Barks MC, Bansal S, Bernstein S, Kaye EC, Glass HC, Ubel PA, Brandon D, Pollak KI. The ALIGN Framework: A Parent-Informed Approach to Prognostic Communication for Infants With Neurologic Conditions. Neurology 2023; 100:e800-e807. [PMID: 36456199 PMCID: PMC9984217 DOI: 10.1212/wnl.0000000000201600] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/07/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Clinicians often communicate complex, uncertain, and distressing information about neurologic prognosis to parents of critically ill infants. Although communication tools have been developed in other disciplines and settings, none address the unique needs of the neonatal and pediatric neurology context. We aimed to develop a parent-informed framework to guide clinicians in communicating information about neurologic prognosis. METHODS Parents of infants with neurologic conditions in the intensive care unit were enrolled in a longitudinal study of shared decision-making from 2018 to 2020. Parents completed semistructured interviews following recorded family meetings with the health care team, at hospital discharge, and 6 months after discharge. All interviews targeted information about parent preferences for prognostic disclosure. We analyzed the data using a conventional content analysis approach. Two study team members independently coded all interview transcripts, and discrepancies were resolved in consensus. We used NVIVO 12 qualitative software to index and organize codes. RESULTS Fifty-two parents of 37 infants completed 123 interviews. Parents were predominantly mothers (n = 37/52, 71%) with a median age of 31 (range 19-46) years. Half were Black (n = 26/52, 50%), and a minority reported Hispanic ethnicity (n = 2/52, 4%). Inductive analysis resulted in the emergence of 5 phases of prognostic communication (Approach, Learn, Inform, Give support, and Next steps: ALIGN): (1) Approach: parents appreciated receiving consistent information about their child's neurologic outcome from clinicians who knew their child well. (2) Learn: parents valued when clinicians asked them how they preferred receiving information and what they already knew about their child's outcome prior to information delivery. (3) Inform: parents valued honest, thorough, and balanced information that disclosed prognostic uncertainty and acknowledged room for hope. (4) Give support: parents valued empathic communication and appreciated clinicians who offered real-time emotional support. (5) Next steps: parents appreciated clinicians who connected them to resources, including peer support. DISCUSSION The ALIGN framework offers a novel, parent-informed strategy to effectively communicate neurologic prognosis. Although ALIGN represents key elements of a conversation about prognosis, each clinician can adapt this framework to their own approach. Future work will assess the effectiveness of this framework on communication quality and prognostic understanding.
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Affiliation(s)
- Monica E Lemmon
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC.
| | - Mary C Barks
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Simran Bansal
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Sarah Bernstein
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Erica C Kaye
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Hannah C Glass
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Peter A Ubel
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Debra Brandon
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
| | - Kathryn I Pollak
- From the Departments of Pediatrics (M.E.L., M.C.B., S. Bansal, S. Bernstein), Population Health Sciences (M.E.L., K.I.P.), Duke University School of Medicine, Durham, NC; University of Utah School of Medicine (S. Bernstein), Salt Lack City; Department of Oncology (E.C.K.), St. Jude Children's Research Hospital, Memphis, TN; Departments of Neurology and Pediatrics (E.C.K.), UCSF Benioff Children's Hospital and Department of Epidemiology & Biostatistics (H.C.G.), University of California, San Francisco; Fuqua School of Business and Sanford School of Public Policy (P.A.U.), Duke University, Durham; and Duke University School of Nursing (D.B.), Durham; Cancer Prevention and Control (KIP), Duke Cancer Institute, Durham, NC
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Taylor LP, Besbris JM, Graf WD, Rubin MA, Cruz-Flores S, Epstein LG. Clinical Guidance in Neuropalliative Care: An AAN Position Statement. Neurology 2022; 98:409-416. [PMID: 35256519 DOI: 10.1212/wnl.0000000000200063] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lynne P Taylor
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL.
| | - Jessica M Besbris
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - William D Graf
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Michael A Rubin
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Salvador Cruz-Flores
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
| | - Leon G Epstein
- From the Department of Neurology (L.P.T.), University of Washington, Seattle; Department of Supportive Care Medicine and Neurology (J.M.B.), Cedars-Sinai Medical Center, Los Angeles, CA; Department of Pediatrics (Division of Neurology) (W.D.G.), Connecticut Children's, University of Connecticut, Farmington; Department of Neurology (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Department of Neurology (S.C.C.-F.), Texas Tech University Center, El Paso; and Department of Pediatrics and Neurology (L.G.E.), Northwestern University School of Medicine, Chicago, IL
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