Attitudes about palliative care: a comparison of pediatric critical care and oncology providers

Palliative Care Utilization Following Out-of-Hospital Cardiac Arrest in Pediatrics

OBJECTIVES:

Pediatric out-of-hospital cardiac arrest (OHCA) is associated with significant morbidity and mortality. Pediatric palliative care (PPC) services could provide an integral component of the comprehensive care necessary for these patients and their families. The main objectives of this study are to examine the utilization of PPC following OHCA and compare the differences in characteristics between children who received PPC with those who did not.

DESIGN:

Retrospective cohort study.

SETTING:

An urban, tertiary PICU.

PATIENTS:

Children less than 21 years old admitted from October 2009 to October 2019 with an admitting diagnosis of OHCA and minimum PICU length of stay (LOS) of 48 hours.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

Of the 283 patient charts reviewed, 118 patient encounters met inclusion criteria. Of those, 34 patients (28.8%) received a PPC consultation during hospitalization. Patients who received PPC had a longer PICU LOS (14.5 vs 4.0 d), a greater number of ventilator days (12.5 vs 4.0 d), and a larger proportion of do-not-resuscitate (DNR) statuses (41% vs 19%). When comparing the disposition of survivors, a greater proportion was discharged to rehab or nursing facilities (47% vs 28%), with no difference in mortality rates (53% vs 50%). In the multivariate logistic regression model, older age, longer LOS, and code status (DNR) were all associated with higher likelihood of PPC utilization. Data were analyzed using descriptive, Mann-Whitney U, and Fisher exact statistics.

CONCLUSIONS:

Our study demonstrates PPC services following OHCA are underutilized given the high degree of morbidity and mortality. The impact of automatic PPC consultation in all OHCA patients who survive beyond 48 hours should be explored further. Future studies are warranted to understand the benefits and barriers of PPC integration into standard postarrest care for patients and families.

When and Why Do Neonatal and Pediatric Critical Care Physicians Consult Palliative Care?

BACKGROUND

Parents of children admitted to neonatal and pediatric intensive care units (ICUs) are at increased risk of experiencing acute and post-traumatic stress disorder. The integration of palliative care may improve child and family outcomes, yet there remains a lack of information about indicators for specialty-level palliative care involvement in this setting.

OBJECTIVE

To describe neonatal and pediatric critical care physician perspectives on indicators for when and why to involve palliative care consultants.

METHODS

Semistructured interviews were conducted with 22 attending physicians from neonatal, pediatric, and cardiothoracic ICUs in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analyses.

RESULTS

We identified 2 themes related to the indicators for involving palliative care consultants: (1) palliative care expertise including support and bridging communication and (2) organizational factors influencing communication including competing priorities and fragmentation of care.

CONCLUSIONS

Palliative care was most beneficial for families at risk of experiencing communication problems that resulted from organizational factors, including those with long lengths of stay and medical complexity. The ability of palliative care consultants to bridge communication was limited by some of these same organizational factors. Physicians valued the involvement of palliative care consultants when they improved efficiency and promoted harmony. Given the increasing number of children with complex chronic conditions, it is important to support the capacity of ICU clinical teams to provide primary palliative care. We suggest comprehensive system changes and critical care physician training to include topics related to chronic illness and disability.

Providing Pediatric Palliative Care Education Using Problem-Based Learning

BACKGROUND

The Institute of Medicine and the American Academy of Pediatrics has called for improvement in education and training of pediatricians in pediatric palliative care (PPC). Given the shortage of PPC physicians and the immediate need for PPC medical education, this study reports the outcomes of a problem-based learning (PBL) module facilitated by academic general and subspecialty pediatric faculty (non-PPC specialists) to third year medical students. Objectives/Setting: To test the effectiveness of a PPC-PBL module on third year medical students' and pediatric faculty's declarative knowledge, attitudes toward, perceived exposure, and self-assessed competency in PPC objectives.

DESIGN

A PBL module was developed using three PPC learning objectives as a framework: define core concepts in palliative care; list the components of a total pain assessment; and describe key principles in establishing therapeutic relationships with patients. A PPC physician and nurse practitioner guided pediatric faculty on facilitating the PPC-PBL. In Part 1, students identified domains of palliative care for a child with refractory leukemia and self-assigned questions to research and present at the follow-up session. In Part 2, students were expected to develop a care plan demonstrating the three PPC objectives.

MEASUREMENTS

Measures included a knowledge exam and a survey instrument to assess secondary outcomes.

RESULTS

Students' declarative knowledge, perceived exposure, and self-assessed competency in all three PPC learning objectives improved significantly after the PPC-PBL, p = 0.002, p < 0.001, and p < 0.001, respectively. There were no significant differences in faculty knowledge test scores from baseline to follow-up, but scores were generally high (median >80%). Students and faculty rated palliative care education as "important or very important" at baseline and follow-up.

CONCLUSIONS

This study suggests that key concepts in PPC can be taught to medical students utilizing a PBL format and pediatric faculty resulting in improved knowledge and self-assessed competency in PPC.

Speaking a Different Language: A Qualitative Analysis Comparing Language of Palliative Care and Pediatric Intensive Care Unit Physicians

BACKGROUND

Family conferences in the pediatric intensive care unit (ICU) often include palliative care (PC) providers. We do not know how ICU communication differs when the PC team is present.

AIM

To compare language used by PC team and ICU physicians during family conferences.

DESIGN

A retrospective cohort review of ICU family conferences with and without the PC team.

SETTING

Forty-four bed pediatric ICU in a tertiary medical center.

PARTICIPANTS

Nine ICU physicians and 4 PC providers who participated in 18 audio-recorded family conferences.

RESULTS

Of the 9 transcripts without the PC team, we identified 526 ICU physician statements, generating 10 thematic categories. The most common themes were giving medical information and discussing medical options. Themes unique to ICU physicians included statements of hopelessness, insensitivity, and "health-care provider challenges." Among the 9 transcripts with the PC team, there were 280 statements, generating 10 thematic categories. Most commonly, the PC team offered statements of support, giving medical information, and quality of life. Both teams promoted family engagement by soliciting questions; however, the PC team was more likely to use open-ended questions, offer support, and discuss quality of life.

CONCLUSION

Pediatric ICU physicians spend more time giving medical information, whereas the PC team more commonly offers emotional support. The addition of the PC team to ICU family conferences may provide a balanced approach to communication.

Contributions of palliative care to pediatric patient care

OBJECTIVES

To provide an overview of pediatric palliative care (PPC) as it relates to children and families living with oncologic disease.

DATA SOURCES

Journal articles, clinical research reports, clinical guidelines, and national statistics.

CONCLUSION

As new treatment protocols become available, the need for simultaneous supportive PPC, including adequate pain and symptom management, is evident. Further research and PPC program development is necessary for adherence to the current recommendation that PPC should be initiated at the time of diagnosis and continue throughout the course of a child's disease.

IMPLICATIONS FOR NURSING PRACTICE

Palliative care nursing holds a specific role in the pediatric oncology setting. Registered nurses and advanced practice nurses should be adequately trained in PPC because they are in an optimal role to contribute to interdisciplinary PPC for pediatric oncology patients and their families.