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Peralta D, Nanduri N, Bansal S, Rent S, Brandon D, Pollak KI, Lemmon ME. Discussion of Spirituality in Family Conferences of Infants with Neurologic Conditions. J Pain Symptom Manage 2024:S0885-3924(24)01039-X. [PMID: 39326468 DOI: 10.1016/j.jpainsymman.2024.09.020] [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: 07/02/2024] [Revised: 09/10/2024] [Accepted: 09/12/2024] [Indexed: 09/28/2024]
Abstract
INTRODUCTION Spirituality serves as a mechanism to understand and cope with serious illness, yet little is known about how families and clinicians incorporate spirituality in pediatric family conferences. OBJECTIVES We sought to characterize the frequency and nature of spiritual statements in conferences between families and clinicians caring for infants with neurologic conditions. METHODS In this descriptive qualitative study, we used an existing dataset of audio-recorded, de-identified, transcribed family conferences of infants with neurologic conditions. Inclusion criteria for infants were 1) age < 1 year, 2) presence of a neurologic condition, and 3) planned conversation about neurologic prognosis or goals of care. We used a content analysis approach to code the data. RESULTS 68 family conferences were held for 24 infants and 36 parents. Most parents (n=32/36, 89%) self-identified as spiritual. References to spirituality occurred in the 32% of conferences (n=22/68). Spiritual discussion included 3 domains: 1) Spiritual beliefs and practices, 2) Spiritual support, and 3) Parent-child connection as sacred. Clinicians' responses to family member spiritual statements were inconsistent and included providing affirmation, exploring goals of care, and continuing discussion of clinical information. CONCLUSIONS Spirituality was discussed in approximately one-third of family conferences. Clinician engagement with spirituality discussion was variable. These findings highlight a need for training on when and how to discuss spirituality in conversations with families of seriously ill infants.
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Affiliation(s)
- Dana Peralta
- Department of Pediatrics, Duke University School of Medicine, Durham, NC.
| | | | - Simran Bansal
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Sharla Rent
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Global Health Institute, Duke University, Durham, NC
| | - Debra Brandon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke University School of Nursing, Durham, NC
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Cancer Prevention and Control, Duke Cancer Institute, Durham, NC
| | - Monica E Lemmon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
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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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Nanduri N, Bansal S, Treat L, Bogetz JF, Wusthoff CJ, Rent S, Lemmon ME. Promoting a neuropalliative care approach in fetal neurology. Semin Fetal Neonatal Med 2024; 29:101528. [PMID: 38664159 DOI: 10.1016/j.siny.2024.101528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024]
Affiliation(s)
| | - Simran Bansal
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Treuman Katz Center, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | | | - Sharla Rent
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA; Duke Global Health Institute, Durham, NC, USA
| | - Monica E Lemmon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
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Bernstein SM, Barks MC, Ubel PA, Weinfurt K, Barlet MH, Farley S, Jiao MG, Bansal S, Fisher K, Lemmon ME. Prognostic Discordance Among Parents and Physicians Caring for Infants with Neurologic Conditions. J Pediatr 2023; 263:113677. [PMID: 37611734 PMCID: PMC10841319 DOI: 10.1016/j.jpeds.2023.113677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/09/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE To determine the frequency, degree, and nature of prognostic discordance between parents and physicians caring for infants with neurologic conditions. STUDY DESIGN In this observational cohort study, we enrolled parents and physicians caring for infants with neurologic conditions in advance of a family conference. Parent-physician dyads completed a postconference survey targeting expected neurologic outcomes across 3 domains (motor, speech, and cognition) using a 6-point scale. Prognostic discordance was defined as a difference of ≥2 response options and was considered moderate (difference of 2-3 response options) or high (difference of 4-5 response options). Responses were categorized as differences in belief and/or differences in understanding using an existing paradigm. RESULTS Forty parent-physician dyads of 28 infants completed surveys. Parent-physician discordance about prognosis occurred in ≥1 domain in the majority of dyads (n = 28/40, 70%). Discordance was generally moderate in degree (n = 23/28, 82%) and occurred with similar frequency across all domains. Of parent-physician dyads with discordance, the majority contained a difference in understanding in at least 1 domain (n = 25/28, 89%), while a minority contained a difference of belief (n = 6/28, 21%). When discordance was present, parents were typically more optimistic in their predictions compared with physicians (n = 25/28, 89%). CONCLUSIONS Differing perceptions about the prognosis of critically ill infants are common and due to differences in both understanding and belief. These findings can be used to develop targeted interventions to improve prognostic communication.
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Affiliation(s)
- Sarah M Bernstein
- University of Utah School of Medicine, Salt Lake City, UT; Duke University Medical Center, Durham, NC.
| | - Mary C Barks
- Duke Margolis Center for Health Policy, Durham, NC
| | | | | | | | | | - Megan G Jiao
- Duke Margolis Center for Health Policy, Durham, NC
| | | | | | - Monica E Lemmon
- Duke University Medical Center, Durham, NC; Duke Margolis Center for Health Policy, Durham, NC
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Bansal S, Willis R, Barks MC, Pollak KI, Brandon D, Kaye EC, Lemmon ME. Supporting Disclosure of Unmet Mental Health Needs among Parents of Critically Ill Infants. J Pediatr 2023; 262:113596. [PMID: 37399922 PMCID: PMC10757990 DOI: 10.1016/j.jpeds.2023.113596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/11/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To characterize (1) the prevalence of mental health discussion and (2) facilitators of and barriers to parent disclosure of mental health needs to clinicians. STUDY DESIGN Parents of infants with neurologic conditions in neonatal and pediatric intensive care units participated in a longitudinal decision-making study from 2018 through 2020. Parents completed semi-structured interviews upon enrollment, within 1 week after a conference with providers, at discharge, and 6 months post-discharge. We used a conventional content analysis approach and NVIVO 12 to analyze data related to mental health. RESULTS We enrolled 61 parents (n = 40 mothers, n = 21 fathers) of 40 infants with neurologic conditions in the intensive care unit. In total, 123 interviews were conducted with 52 of these parents (n = 37 mothers, n = 15 fathers). Over two-thirds of parents (n = 35/52, 67%) discussed their mental health in a total of 61 interviews. We identified two key domains when approaching the data through the lens of mental health: (1) self-reported barriers to communicating mental health needs: parents shared uncertainty about the presence or benefit of support, a perceived lack of mental health resources and emotional support, and concerns about trust; (2) self-reported facilitators and benefits of communicating mental health needs: parents described the value of supportive team members, connecting to peer support, and speaking to a mental health professional or neutral third party. CONCLUSIONS Parents of critically ill infants are at high risk of unmet mental health needs. Our results highlight modifiable barriers and actionable facilitators to inform interventions to improve mental health support for parents of critically ill infants.
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Affiliation(s)
- Simran Bansal
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Rheaya Willis
- Department of Psychiatry, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - Mary C Barks
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Duke Cancer Institute, Durham, NC
| | - Debra Brandon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke University School of Nursing, Durham, NC
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Monica E Lemmon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.
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Bogetz JF, Lemmon ME. Affirming Perspectives About Quality-of-Life With Caregivers of Children With Severe Neurological Impairment. Pediatr Neurol 2023; 144:104-106. [PMID: 37216762 PMCID: PMC10330590 DOI: 10.1016/j.pediatrneurol.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/24/2023]
Affiliation(s)
- Jori F Bogetz
- Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington.
| | - Monica E Lemmon
- Division of Neurology, Department of Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, North Carolina; Duke University Medical Center, Durham, North Carolina
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Peralta D, Bogetz J, Lemmon ME. Seminars in Fetal & neonatal medicine: Palliative and end of life care in the NICU. Semin Fetal Neonatal Med 2023; 28:101457. [PMID: 37230860 PMCID: PMC10827319 DOI: 10.1016/j.siny.2023.101457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Dana Peralta
- Duke North Pavilion, 2400 Pratt Street, 8th Floor, DUMC 102509, Durham, NC 27710, USA.
| | - Jori Bogetz
- 1900 Ninth Ave, JMB-6, Seattle, WA 98101, 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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Barlet MH, Barks MC, Ubel PA, Davis JK, Pollak KI, Kaye EC, Weinfurt KP, Lemmon ME. Characterizing the Language Used to Discuss Death in Family Meetings for Critically Ill Infants. JAMA Netw Open 2022; 5:e2233722. [PMID: 36197666 PMCID: PMC9535532 DOI: 10.1001/jamanetworkopen.2022.33722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/09/2022] [Indexed: 12/03/2022] Open
Abstract
Importance Communication during conversations about death is critical; however, little is known about the language clinicians and families use to discuss death. Objective To characterize (1) the way death is discussed in family meetings between parents of critically ill infants and the clinical team and (2) how discussion of death differs between clinicians and family members. Design, Setting, and Participants This longitudinal qualitative study took place at a single academic hospital in the southeast US. Patients were enrolled from September 2018 to September 2020, and infants were followed up longitudinally throughout their hospitalization. Participants included families of infants with neurologic conditions who were hospitalized in the intensive care unit and had a planned family meeting to discuss neurologic prognosis or starting, not starting, or discontinuing life-sustaining treatment. Family meetings were recorded, transcribed, and deidentified before being screened for discussion of death. Main Outcomes and Measures The main outcome was the language used to reference death during family meetings between parents and clinicians. Conventional content analysis was used to analyze data. Results A total of 68 family meetings involving 36 parents of 24 infants were screened; 33 family meetings (49%) involving 20 parents (56%) and 13 infants (54%) included discussion of death. Most parents involved in discussion of death identified as the infant's mother (13 [65%]) and as Black (12 [60%]). Death was referenced 406 times throughout the family meetings (275 times by clinicians and 131 times by family members); the words die, death, dying, or stillborn were used 5% of the time by clinicians (13 of 275 references) and 15% of the time by family members (19 of 131 references). Four types of euphemisms used in place of die, death, dying, or stillborn were identified: (1) survival framing (eg, not live), (2) colloquialisms (eg, pass away), (3) medical jargon, including obscure technical terms (eg, code event) or talking around death with physiologic terms (eg, irrecoverable heart rate drop), and (4) pronouns without an antecedent (eg, it). The most common type of euphemism used by clinicians was medical jargon (118 of 275 references [43%]). The most common type of euphemism used by family members was colloquialism (44 of 131 references [34%]). Conclusions and Relevance In this qualitative study, the words die, death, dying, or stillborn were rarely used to refer to death in family meetings with clinicians. Families most often used colloquialisms to reference death, and clinicians most often used medical jargon. Future work should evaluate the effects of euphemisms on mutual understanding, shared decision-making, and clinician-family relationships.
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Affiliation(s)
| | - Mary C. Barks
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Peter A. Ubel
- Duke University School of Medicine, Durham, North Carolina
- Fuqua School of Business, Duke University, Durham, North Carolina
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - J. Kelly Davis
- Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Erica C. Kaye
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Monica E. Lemmon
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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Lemmon ME, Barks MC, Bernstein S, Davis JK, Jiao MG, Kaye EC, Glass HC, Brandon D, Ubel PA. Prognostic Discussion for Infants with Neurologic Conditions: Qualitative Analysis of Family Conferences. Ann Neurol 2022; 92:699-709. [PMID: 35866708 PMCID: PMC9600061 DOI: 10.1002/ana.26457] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We characterize the content and role of prognostic discussion for infants with neurologic conditions. METHODS In this descriptive qualitative study, we prospectively enrolled infants (age < 1 year) in the intensive care unit with a neurologic condition anticipated to have ≥1 family conference about prognosis or goals of care. We audiorecorded family conferences as they occurred. We used a rapid-cycle qualitative approach to identify and refine themes. RESULTS Forty infants and 61 parents were enrolled; 68 family conferences occurred for 24 infants. The majority of infant cases (n = 23/24, 96%) and conferences (n = 64/68, 94%) included discussion of neurologic prognosis. Common infant diagnoses included prematurity (n = 12, 52%), genetic conditions (n = 9, 35%), and brain malformations (n = 7, 30%). We identified 2 themes relating to the characterization of the infant's prognosis: (1) predictions of impairment and (2) rationale for prognostic predictions. We identified 3 themes characterizing the role of prognostic discussion: (1) aligning parent and clinician understanding of infant outcome, (2) influencing decision-making, and (3) preparing for life at home. We identified 2 themes characterizing discussion of prognostic uncertainty: (1) multilayered types of uncertainty and (2) holding space for hope alongside uncertainty. INTERPRETATION In this cohort of infants with neurologic conditions and their parents, we identified salient themes characterizing the content and role of discussion about neurologic outcome. Our findings highlight that prognostic discussion focuses on anticipated impairments, informs decision-making, and helps families prepare for home life. Future work should characterize whether these findings align with parent preferences for prognostic disclosure. ANN NEUROL 2022;92:699-709.
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Affiliation(s)
- Monica E Lemmon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Washington, DC, USA
| | - Mary C Barks
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Washington, DC, USA
| | - Sarah Bernstein
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - J Kelly Davis
- Duke-Margolis Center for Health Policy, Washington, DC, USA
| | - Megan G Jiao
- Duke-Margolis Center for Health Policy, Washington, DC, USA
| | - Erica C Kaye
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Hannah C Glass
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology and Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Debra Brandon
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke University School of Nursing, Durham, NC, USA
| | - Peter A Ubel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Fuqua School of Business and Sanford School of Public Policy, Duke University, Durham, NC, USA
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