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Malhotra C, Huynh VA, Shafiq M, Batcagan-Abueg APM. Advance care planning and caregiver outcomes: intervention efficacy - systematic review. BMJ Support Palliat Care 2024; 13:e537-e546. [PMID: 35788465 DOI: 10.1136/spcare-2021-003488] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 06/13/2022] [Indexed: 11/04/2022]
Abstract
CONTEXT Caregivers make difficult end-of-life (EOL) decisions for patients, often adversely affecting their own psychological health. Understanding whether advance care planning (ACP) interventions benefit caregivers can enable healthcare systems to use these approaches to better support them. OBJECTIVE We conducted a systematic review and meta-analysis to identify and quantify the impacts of ACP interventions on caregiver outcomes. METHODS We searched MEDLINE, Embase and Cochrane databases for English-language randomised or cluster randomised controlled trials (RCTs) published until May 2021. Two reviewers independently assessed methodological quality using the Physiotherapy Evidence-Based Database Scale. We conducted a narrative synthesis for each outcome. Difference between arms with a p value of <0.05 was considered statistically significant. RESULTS Of the 3487 titles reviewed, 35 RCTs met eligibility; 68.6% were rated high quality. Included RCTs were heterogeneous in intervention characteristics, setting and disease. Meta-analysis of 17 RCTs showed that ACP had large and significant improvement in congruence in EOL care preferences between caregivers and patients (standardised mean difference 0.73, 95% CI 0.42 to 1.05). The effect of ACP on this outcome, however, declined over time. We also found some evidence that ACP improved bereavement outcomes (three of four RCTs), satisfaction with care quality/communication (four of the six RCTs), reduced decisional conflict (two of the two RCTs) and burden (one RCT). No study showed that mental health of caregivers were adversely affected. CONCLUSION The review provides most comprehensive evidence about the efficacy of ACP on caregiver outcomes. Findings suggest some evidence of benefit of ACP on caregiver outcomes.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Vinh Anh Huynh
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
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Stone A, Perre T, Young Y. Exploring Five Wishes and End-of-Life Care Planning in Young Adults. Am J Hosp Palliat Care 2023; 40:1297-1302. [PMID: 36789632 DOI: 10.1177/10499091231158081] [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: 02/16/2023] Open
Abstract
INTRODUCTION Our study aims to (1) examine the perspectives of young adults toward Five Wishes, and (2) measure their preferences related to personal, emotional, spiritual, and medical choices in end-of-life care planning. METHODS Data were collected using a structured survey questionnaire and Five Wishes. Participants include graduate students (n = 30) attending a university in New York State. Bivariate summary statistics were performed to address the study aims. RESULTS The average age of the participants was 24 years old; 60% were female, 60% White, and 27% Black. In the case of permanent and severe brain damage without the expectation to wake up or recover, 63% of the participants do not want life-support treatment. In the event of a coma without expectation to wake up or recover, 53% do not want life-support treatment. When close to death, 80% want to have religious or spiritual readings and well-loved - poems read aloud. CONCLUSION Young adults are capable of making their own decisions about appointing a health care proxy and making choices for their personal, emotional, spiritual, and medical care for the future. The present findings intend to make contributions to the research pertaining to end-of-life care that promotes population-based healthcare decision-making, education, and awareness among young adults.
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Affiliation(s)
- Arianna Stone
- Home Care Association of New York State Inc, Albany, NY, USA
- University at Albany, Albany, NY, USA
| | - Taylor Perre
- University at Albany, Albany, NY, USA
- Health Policy, Management & Behavior, University at Albany, Albany, NY, USA
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Aasen ERHV, Søvik ML, Størdal K, Lee A. Are We on the Same Page? Exploring Pediatric Patients' Involvement With Advance Care Planning. J Pain Symptom Manage 2023; 66:e353-e363. [PMID: 37054956 DOI: 10.1016/j.jpainsymman.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/28/2023] [Accepted: 04/03/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND According to the UN Convention on the Rights of the Child, children have a right to be heard. This also applies to patients in pediatric palliative care (PPC). The aim of this literature review was to explore what is known about the involvement of children (<14 years of age), adolescents and young adults (AYAs) in advance care planning (ACP) in PPC. METHODS A search was conducted in PubMed including publications from January 1, 2002 until December 31, 2021. The identified citations had to report on ACP or related terms in any PPC context. RESULTS A total of n = 471 unique reports were identified. Final inclusion criteria were met by n = 21 reports, including children and AYAs with diagnoses related to oncology, neurology, HIV/AIDS and cystic fibrosis. Nine reports were from randomized controlled studies, investigating ACP methodology. The main findings were: 1) caregivers are included more often than children and adolescents in ACP, 2) some studies indicate an incongruence between AYAs and their caregivers regarding ACP and treatment preferences, 3) although the process evokes a wide range of emotions, ACP is perceived as helpful by many AYAs CONCLUSION: The majority of studies about ACP in PPC do not include children and AYAs. Whether incongruence reported in some studies between AYAs and their caregivers regarding treatment preferences could be reduced by ACP should be further explored, including the involvement of children and adolescents in ACP, and the impact of pediatric ACP on patient outcomes in PPC.
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Affiliation(s)
| | - Marte Løvaas Søvik
- Faculty of Medicine (E.R.H.V.A., M.L.S.), University of Oslo, Oslo, Norway
| | - Ketil Størdal
- Department of Pediatric Research (K.S.), Faculty of Medicine, University of Oslo, Oslo, Norway; Division of Pediatric and Adolescent Medicine (K.S., A.L.), Oslo University Hospital, Oslo, Norway
| | - Anja Lee
- Division of Pediatric and Adolescent Medicine (K.S., A.L.), Oslo University Hospital, Oslo, Norway.
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Mastropolo R, Altschuler A, Brock KE, Casperson M, Chao CR, Fisher L, Greenzang KA, Kushi LH, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L, Mack JW. Patient, Caregiver, and Clinician Perspectives on Core Components of Therapeutic Alliance for Adolescents and Young Adults With Advanced Cancer: A Qualitative Study. JAMA Netw Open 2023; 6:e2328153. [PMID: 37556137 PMCID: PMC10413170 DOI: 10.1001/jamanetworkopen.2023.28153] [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: 04/06/2023] [Accepted: 06/29/2023] [Indexed: 08/10/2023] Open
Abstract
Importance The patient-clinician therapeutic alliance is an important aspect of high-quality cancer care. However, components of the therapeutic alliance in adolescents and young adults (AYAs, aged 12-39 years) with cancer have not been defined. Objective To identify components of and barriers to the therapeutic alliance between AYAs, caregivers, and clinicians from the perspective of all key stakeholders. Design, Setting, and Participants In this qualitative study, semistructured in-depth interviews with patients, caregivers, and clinicians were conducted from 2018 to 2021 with no additional follow-up, with content analysis of resulting transcripts. Participants were recruited from Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an online cancer support community (Cactus Cancer Society). Eligible participants were English- or Spanish-speaking. Eligible patients were aged 12 to 39 years with stage IV or recurrent cancer. Eligible caregivers cared for an AYA living with advanced cancer or one who had died within 5 years. Eligible clinicians routinely provided care for AYAs with cancer. Main Outcomes and Measures Perspectives on therapeutic alliance. Results Interviews were conducted with 80 participants: 23 were patients (48% were female; 78% were White), 28 were caregivers (82% were female; 50% were White), and 29 were clinicians (69% were female; 45% were White). The mean (SD) age of patients was 29 (7.3) years. Interviews identified 6 components of therapeutic alliance: (1) compassion; (2) sense of connection; (3) clinician presence; (4) information sharing; (5) shared goals; and (6) individualization of care. While some domains were represented in prior models of therapeutic alliance, a unique domain was identified related to the need for individualization of the approach to care for AYA patients and their caregivers. Interviews also identified potential barriers to building the therapeutic alliance specific to the AYA population, including managing discordant needs between patients and caregivers and communication challenges at the end of life. Conclusions and Relevance This study identified core components and barriers to building therapeutic alliance in the AYA advanced cancer population from the perspective of all the key stakeholders in the relationship. A novel component highlighting the need for individualization was identified. This model enables a deeper understanding of how to build therapeutic alliance in the AYA advanced cancer population, which may guide clinician training and facilitate improved care for this vulnerable population.
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Affiliation(s)
- Rosemarie Mastropolo
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Katharine E. Brock
- Department of Pediatric Oncology, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Mallory Casperson
- Divisions of Pediatric Oncology and Palliative Care, Cactus Cancer Society, Oakland, California
| | - Chun R. Chao
- Department of Research and Evaluation (C.R.C.), Kaiser Permanente Southern California, Pasadena
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Katie A. Greenzang
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lawrence H. Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Joshua R. Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey M. Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Dov M. Shalman
- Department of Palliative Care, Kaiser Permanente Southern California, Pasadena
| | - Catherine B. Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lori Wiener
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland
| | - Jennifer W. Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
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Lusney N, van Breemen C, Lim E, Pawliuk C, Hussein Z. Pediatric Advance Care Planning: A Scoping Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1179. [PMID: 37508676 PMCID: PMC10378635 DOI: 10.3390/children10071179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023]
Abstract
To assess current practice and provide a basis for a provincial template, clinicians at a Canadian pediatric hospice reviewed the literature surrounding pediatric advance care planning (pACP) documentation, process, and implementation for children/youth. The scoping review protocol was developed in accordance with the Joanna Briggs Institute methodology for scoping reviews, and was prospectively registered on the Open Science Framework. MEDLINE, Embase, CINAHL, the Web of Science Core Collection, and Google Scholar, as well as sources of unpublished studies and grey literature, were reviewed. Sixty-four articles met the criteria. Fifteen pACP documentation forms/tools were also identified. Overall, the included articles highlighted that pACP should be a structured, collaborative and iterative process between the family and a trusted or relevant healthcare provider, encompassing medical and non-medical issues. Few articles provided insights into specific elements recommended for advance directive forms. Identified strategies for implementation included a structured, step-by-step pACP interventional tool along with ongoing training, mentorship, and defined organizational structures for the clinician. No single specific ACP tool was acknowledged as the gold standard. Use of a pACP tool, along with ongoing provider education and communication skill development, standardized/accessible documentation, and system-wide quality improvement support, were noted as integral components of pACP.
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Affiliation(s)
- Nadine Lusney
- Canuck Place Children's Hospice, Vancouver, BC V6J 2T2, Canada
| | - Camara van Breemen
- Canuck Place Children's Hospice, Vancouver, BC V6J 2T2, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Edlyn Lim
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Colleen Pawliuk
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Zahra Hussein
- Child Health British Columbia, Vancouver, BC V6J 4Y6, Canada
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Lin M, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. The Case for Advance Care Planning in the NICU. Pediatrics 2022; 150:189893. [PMID: 36321383 DOI: 10.1542/peds.2022-057824] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
Many NICUs have reached an inflection point where infant deaths following limitation of life-sustaining treatments outnumber those following unsuccessful resuscitations, and many infants who survive continue to require intensive supports. Families of such infants with serious illness may benefit from a standardized, process-oriented approach in decisional-support. Advance care planning (ACP), or communication that supports patients, or their surrogate decision-makers, in sharing values, goals, and preferences for future medical care, is recognized as a valuable strategy in supporting adults with serious and chronic illness. Although the role of ACP in older children and adolescents is evolving, its utility has not been systematically explored in the perinatal context. This article builds a case for formalizing a role for ACP in the NICU by defining ACP and appraising recent outcomes research, reviewing the current state of parental needs for decisional support and serious illness in the NICU, and describing how ACP may address current limitations in primary and specialty pediatric palliative care and challenges for decision-making in the newborn period.
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Affiliation(s)
- Matthew Lin
- Pediatric Palliative Care Program, Children's National Medical Center, Washington, District of Columbia
| | | | | | - Joanne Wolfe
- Departments of Psychosocial Oncology and Palliative Care and Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
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Voicing their choices: Advance care planning with adolescents and young adults with cancer and other serious conditions. Palliat Support Care 2022; 20:462-470. [PMID: 35876450 PMCID: PMC9315053 DOI: 10.1017/s1478951521001462] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine whether engaging in advance care planning (ACP) using a formal tool, Voicing My CHOiCES (VMC), would alleviate adolescent and young adults (AYAs) anxiety surrounding ACP and increase social support and communication about end-of-life care preferences with family members and health care providers (HCPs). METHODS A total of 149 AYAs aged 18-39 years receiving cancer-directed therapy or treatment for another chronic medical illness were enrolled at seven US sites. Baseline data included prior ACP communication with family members and HCPs and measures of generalized anxiety, ACP anxiety, and social support. Participants critically reviewed each page of VMC and then completed three pages of the document. ACP anxiety was measured again immediately after the completion of VMC pages. One month later, participants repeated anxiety and social support measures and were asked if they shared what they had completed in VMC with a family member or HCP. RESULTS At baseline, 50.3% of participants reported that they previously had a conversation about EoL preferences with a family member; 19.5% with an HCP. One month later, 65.1% had subsequently shared what they wrote in VMC with a family member; 8.9% shared with an HCP. Most (88.6%) reported they would not have had this conversation if not participating in the study. No significant changes occurred in social support. There was an immediate drop in anxiety about EoL planning after reviewing VMC which persisted at 1 month. Generalized anxiety was also significantly lower 1 month after reviewing VMC. SIGNIFICANCE OF RESULTS Having a document specifically created for AYAs to guide ACP planning can decrease anxiety and increase communication with family members but not necessarily with HCPs. Future research should examine ways ACP can be introduced more consistently to this young population to allow their preferences for care to be heard, respected, and honored, particularly by their healthcare providers.
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Ryan RE, Connolly M, Bradford NK, Henderson S, Herbert A, Schonfeld L, Young J, Bothroyd JI, Henderson A. Interventions for interpersonal communication about end of life care between health practitioners and affected people. Cochrane Database Syst Rev 2022; 7:CD013116. [PMID: 35802350 PMCID: PMC9266997 DOI: 10.1002/14651858.cd013116.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Communication about end of life (EoL) and EoL care is critically important for providing quality care as people approach death. Such communication is often complex and involves many people (patients, family members, carers, health professionals). How best to communicate with people in the period approaching death is not known, but is an important question for quality of care at EoL worldwide. This review fills a gap in the evidence on interpersonal communication (between people and health professionals) in the last year of life, focusing on interventions to improve interpersonal communication and patient, family member and carer outcomes. OBJECTIVES To assess the effects of interventions designed to improve verbal interpersonal communication about EoL care between health practitioners and people affected by EoL. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL from inception to July 2018, without language or date restrictions. We contacted authors of included studies and experts and searched reference lists to identify relevant papers. We searched grey literature sources, conference proceedings, and clinical trials registries in September 2019. Database searches were re-run in June 2021 and potentially relevant studies listed as awaiting classification or ongoing. SELECTION CRITERIA This review assessed the effects of interventions, evaluated in randomised and quasi-randomised trials, intended to enhance interpersonal communication about EoL care between patients expected to die within 12 months, their family members and carers, and health practitioners involved in their care. Patients of any age from birth, in any setting or care context (e.g. acute catastrophic injury, chronic illness), and all health professionals involved in their care were eligible. All communication interventions were eligible, as long as they included interpersonal interaction(s) between patients and family members or carers and health professionals. Interventions could be simple or complex, with one or more communication aims (e.g. to inform, skill, engage, support). Effects were sought on outcomes for patients, family and carers, health professionals and health systems, including adverse (unintended) effects. To ensure this review's focus was maintained on interpersonal communication in the last 12 months of life, we excluded studies that addressed specific decisions, shared or otherwise, and the tools involved in such decision-making. We also excluded studies focused on advance care planning (ACP) reporting ACP uptake or completion as the primary outcome. Finally, we excluded studies of communication skills training for health professionals unless patient outcomes were reported as primary outcomes. DATA COLLECTION AND ANALYSIS Standard Cochrane methods were used, including dual review author study selection, data extraction and quality assessment of the included studies. MAIN RESULTS Eight trials were included. All assessed intervention effects compared with usual care. Certainty of the evidence was low or very low. All outcomes were downgraded for indirectness based on the review's purpose, and many were downgraded for imprecision and/or inconsistency. Certainty was not commonly downgraded for methodological limitations. A summary of the review's findings is as follows. Knowledge and understanding (four studies, low-certainty evidence; one study without usable data): interventions to improve communication (e.g. question prompt list, with or without patient and physician training) may have little or no effect on knowledge of illness and prognosis, or information needs and preferences, although studies were small and measures used varied across trials. Evaluation of the communication (six studies measuring several constructs (communication quality, patient-centredness, involvement preferences, doctor-patient relationship, satisfaction with consultation), most low-certainty evidence): across constructs there may be minimal or no effects of interventions to improve EoL communication, and there is uncertainty about effects of interventions such as a patient-specific feedback sheet on quality of communication. Discussions of EoL or EoL care (six studies measuring selected outcomes, low- or very low-certainty evidence): a family conference intervention may increase duration of EoL discussions in an intensive care unit (ICU) setting, while use of a structured serious illness conversation guide may lead to earlier discussions of EoL and EoL care (each assessed by one study). We are uncertain about effects on occurrence of discussions and question asking in consultations, and there may be little or no effect on content of communication in consultations. Adverse outcomes or unintended effects (limited evidence): there is insufficient evidence to determine whether there are adverse outcomes associated with communication interventions (e.g. question prompt list, family conference, structured discussions) for EoL and EoL care. Patient and/or carer anxiety was reported by three studies, but judged as confounded. No other unintended consequences, or worsening of desired outcomes, were reported. Patient/carer quality of life (four studies, low-certainty evidence; two without useable data): interventions to improve communication may have little or no effect on quality of life. Health practitioner outcomes (three studies, low-certainty evidence; two without usable data): interventions to improve communication may have little or no effect on health practitioner outcomes (satisfaction with communication during consultation; one study); effects on other outcomes (knowledge, preparedness to communicate) are unknown. Health systems impacts: communication interventions (e.g. structured EoL conversations) may have little or no effect on carer or clinician ratings of quality of EoL care (satisfaction with care, symptom management, comfort assessment, quality of care) (three studies, low-certainty evidence), or on patients' self-rated care and illness, or numbers of care goals met (one study, low-certainty evidence). Communication interventions (e.g. question prompt list alone or with nurse-led communication skills training) may slightly increase mean consultation length (two studies), but other health service impacts (e.g. hospital admissions) are unclear. AUTHORS' CONCLUSIONS Findings of this review are inconclusive for practice. Future research might contribute meaningfully by seeking to fill gaps for populations not yet studied in trials; and to develop responsive outcome measures with which to better assess the effects of communication on the range of people involved in EoL communication episodes. Mixed methods and/or qualitative research may contribute usefully to better understand the complex interplay between different parties involved in communication, and to inform development of more effective interventions and appropriate outcome measures. Co-design of such interventions and outcomes, involving the full range of people affected by EoL communication and care, should be a key underpinning principle for future research in this area.
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Affiliation(s)
- Rebecca E Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Michael Connolly
- School of Nursing, Midwifery and Health Systems, University College Dublin and Our Lady's Hospice and Care Services, Dublin, Ireland
| | - Natalie K Bradford
- Centre for Children's Health Research, Cancer and Palliative Care Outcomes at Centre for Children's Health Research, Queensland University of Technology (QUT), South Brisbane, Australia
| | - Simon Henderson
- Department of Aviation, The University of New South Wales, Sydney, Australia
| | - Anthony Herbert
- Paediatric Palliative Care Service, Children's Health Queensland, Hospital and Health Service, South Brisbane, Australia
- Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Jeanine Young
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
| | | | - Amanda Henderson
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, Australia
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Malhotra C, Shafiq M, Batcagan-Abueg APM. What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials. BMJ Open 2022. [PMCID: PMC9301802 DOI: 10.1136/bmjopen-2021-060201] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives To conduct an up-to-date systematic review of all randomised controlled trials assessing efficacy of advance care planning (ACP) in improving patient outcomes, healthcare use/costs and documentation. Design Narrative synthesis conducted for randomised controlled trials. We searched electronic databases (MEDLINE/PubMed, Embase and Cochrane databases) for English-language randomised or cluster randomised controlled trials on 11 May 2020 and updated it on 12 May 2021 using the same search strategy. Two reviewers independently extracted data and assessed methodological quality. Disagreements were resolved by consensus or a third reviewer. Results We reviewed 132 eligible trials published between 1992 and May 2021; 64% were high-quality. We categorised study outcomes as patient (distal and proximal), healthcare use and process outcomes. There was mixed evidence that ACP interventions improved distal patient outcomes including end-of-life care consistent with preferences (25%; 3/12 with improvement), quality of life (0/14 studies), mental health (21%; 4/19) and home deaths (25%; 1/4), or that it reduced healthcare use/costs (18%; 4/22 studies). However, we found more consistent evidence that ACP interventions improve proximal patient outcomes including quality of patient–physician communication (68%; 13/19), preference for comfort care (70%; 16/23), decisional conflict (64%; 9/14) and patient-caregiver congruence in preference (82%; 18/22) and that it improved ACP documentation (a process outcome; 63%; 34/54). Conclusion This review provides the most comprehensive evidence to date regarding the efficacy of ACP on key patient outcomes and healthcare use/costs. Findings suggest a need to rethink the main purpose and outcomes of ACP. PROSPERO registration number CRD42020184080.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Mahham Shafiq
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
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Brunetta J, Fahner J, Legemaat M, van den Bergh E, Krommenhoek K, Prinsze K, Kars M, Michiels E. Age-Appropriate Advance Care Planning in Children Diagnosed with a Life-Limiting Condition: A Systematic Review. CHILDREN 2022; 9:children9060830. [PMID: 35740767 PMCID: PMC9221719 DOI: 10.3390/children9060830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 12/05/2022]
Abstract
Pediatric advance care planning (pACP) is an important strategy to support patient-centered care. It is known to be difficult, yet paramount, to involve the child in pACP while adjusting treatment to age and the corresponding stage of development. This systematic review was aimed to evaluate the age appropriateness of pACP interventions by assessing their characteristics, content, and evidence. CINAHL, Embase and MEDLINE were searched from 1 January 1998 to 31 August 2020 in order to identify peer-reviewed articles containing strategies and tools to facilitate pACP in both children (0–18 years) with life-limiting conditions and their families. An assessment of quality was performed using Cochrane tools and COREQ. The full protocol is available as PROSPERO CRD42020152243. Thirty-one articles describing 18 unique pACP tools were included. Most tools were developed for adolescents and young adults. In most cases, the interventions tried to assess the child’s and family’s preferences concerning their current and future hopes, wishes, and goals of the care. This was aimed to enhance communication about these preferences between children, their families, and health-care providers and to improve engagement in pACP. The relevance of an age-appropriate approach was mentioned in most articles, but this was mainly implicit. Seven articles implemented age-appropriate elements. Six factors influencing age appropriateness were identified. Tools to support pACP integrated age-appropriate elements to a very limited extent. They mainly focused on adolescents. The involvement of children of all ages may need a more comprehensive approach.
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Affiliation(s)
- Julie Brunetta
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3584 CG Utrecht, The Netherlands; (J.B.); (M.K.)
| | - Jurrianne Fahner
- Division of Pediatrics, Wilhelmina Children’s Hospital, 3584 EA Utrecht, The Netherlands
- Correspondence:
| | - Monique Legemaat
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.L.); (E.v.d.B.); (K.K.); (K.P.); (E.M.)
| | - Esther van den Bergh
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.L.); (E.v.d.B.); (K.K.); (K.P.); (E.M.)
| | - Koen Krommenhoek
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.L.); (E.v.d.B.); (K.K.); (K.P.); (E.M.)
| | - Kyra Prinsze
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.L.); (E.v.d.B.); (K.K.); (K.P.); (E.M.)
| | - Marijke Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3584 CG Utrecht, The Netherlands; (J.B.); (M.K.)
| | - Erna Michiels
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (M.L.); (E.v.d.B.); (K.K.); (K.P.); (E.M.)
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11
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Baker JN, Friebert S, Needle J, Jiang J, Wang J, Lyon ME. An Intervention in Congruence for End-of-Life Treatment Preference: A Randomized Trial. Pediatrics 2022; 149:e2021054796. [PMID: 35425986 PMCID: PMC9648108 DOI: 10.1542/peds.2021-054796] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There is a gap in family knowledge of their adolescents' end-of-life (EOL) treatment preferences. We tested the efficacy of Family Centered Advance Care Planning for Teens with Cancer (FACE-TC) pediatric advance care planning (to increase congruence in EOL treatment preferences. METHODS Adolescents with cancer/family dyads were randomized into a clinical trial from July 2016 to April 2019 at a 2:1 ratio: intervention (n = 83); control (n = 43) to either 3 weekly sessions of FACE-TC (Lyon Advance Care Planning Survey; Next Steps: Respecting Choices Interview; Five Wishes, advance directive) or treatment as usual (TAU). Statement of Treatment Preferences measured congruence. RESULTS Adolescents' (n = 126) mean age was 16.9 years; 57% were female and 79% were White. FACE-TC dyads had greater overall agreement than TAU: high 34% vs 2%, moderate 52% vs 45%, low 14% vs 52%, and P < .0001. Significantly greater odds of congruence were found for FACE-TC dyads than TAU for 3 of 4 disease-specific scenarios: for example, "a long hospitalization with low chance of survival," 78% (57 of 73) vs 45% (19 of 42); odds ratio, 4.31 (95% confidence interval, 1.89-9.82). FACE-TC families were more likely to agree to stop some treatments. Intervention adolescents, 67% (48 of 73), wanted their families to do what is best at the time, whereas fewer TAU adolescents, 43% (18 of 42), gave families this leeway (P = .01). CONCLUSIONS High-quality pediatric advance care planning enabled families to know their adolescents' EOL treatment preferences.
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Affiliation(s)
- Justin N. Baker
- Division of Quality of Life and Palliative Care, St. Jude
Children’s Research Hospital, Memphis, Tennessee
| | - Sarah Friebert
- Haslinger Family Pediatric Palliative Care Center
- Rebecca D. Considine Research Institute, Akron
Children’s Hospital, Akron, Ohio
| | - Jennifer Needle
- Department of Pediatrics and Center for Bioethics,
University of Minnesota, Minneapolis, Minnesota
| | - JiJi Jiang
- Henry M. Jackson Foundation for the Advancement of
Military Medicine, Bethesda, Maryland
| | - Jichuan Wang
- Divisions of Biostatistics and Study Methodology
- Center for Translational Research/Children’s
National Research Institute, Children’s National Hospital, Washington,
DC
| | - Maureen E. Lyon
- Adolescent and Young Adult Medicine
- Center for Translational Research/Children’s
National Research Institute, Children’s National Hospital, Washington,
DC
- Department of Pediatrics, George Washington University
School of Medicine and Health Sciences, Washington, DC
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12
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Knochel K, Zaimovic V, Gatzweiler B, Hein KK, Heitkamp N, Monz A, Reimann D, Borasio GD, Führer M. Participatory Development of a Modular Advance Care Planning Program in Pediatric Palliative Care (MAPPS). J Pain Symptom Manage 2022; 63:189-198. [PMID: 34597758 DOI: 10.1016/j.jpainsymman.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
CONTEXT Decision-making in pediatric palliative care concerns mainly children without decision-making capacity. It has to balance the child's best interests, parental responsibility and the impact on the family system. OBJECTIVES Advance care planning (ACP) supports decision making about future medical care. A consistent pediatric approach is still missing. This study aimed at developing a pediatric ACP program (pedACP) meeting specific needs of children, parents and professionals. METHODS Bereaved parents of children with life-limiting conditions and professionals involved in pedACP participated. Employing the technique of constellation analysis, they collaboratively assigned content, actors, tools and warning notes about pedACP along a timeline. The researchers analyzed, systematized and translated these results into a pedACP program draft, which was revised by the participants. RESULTS The participants' overall focus was on the children's quality of life and an individualized interdisciplinary communication process along the disease trajectory. The program was conceptualized in modular design with fixed modules at the beginning (to build a trustful relationship and frame the process) and at the end (to summarize results and prepare implementation). The main discussions are structured in flexible modules (About the child, Emergencies, Disease-specific scenarios and End of life care). General themes cover timing, communication, engaging children and structural issues. The participants appreciated the program's comprehensiveness and flexibility. CONCLUSION Parents and professionals combined their perspectives on reflecting goals of care and the complexity of pedACP. They perceived the resulting modular program as suitable for meeting the individual needs of patients, families and professional stakeholders.
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Affiliation(s)
- Kathrin Knochel
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Vedrana Zaimovic
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Birga Gatzweiler
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Kerstin K Hein
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Nari Heitkamp
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Anna Monz
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Daniel Reimann
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service (G.D.B.), Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany.
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13
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Buang SNH, Loh SW, Mok YH, Lee JH, Chan YH. Palliative and Critical Care: Their Convergence in the Pediatric Intensive Care Unit. Front Pediatr 2022; 10:907268. [PMID: 35757116 PMCID: PMC9226486 DOI: 10.3389/fped.2022.907268] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
Palliative care (PC) is an integral component of optimal critical care (CC) practice for pediatric patients facing life-threatening illness. PC acts as an additional resource for patients and families as they navigate through critical illness. Although PC encompasses end of life care, it is most effective when integrated early alongside disease-directed and curative therapies. PC primarily focuses on improving quality of life for patients and families by anticipating, preventing and treating suffering throughout the continuum of illness. This includes addressing symptom distress and facilitating communication. Effective communication is vital to elicit value-based goals of care, and to guide parents through patient-focused and potentially difficult decision-making process which includes advanced care planning. A multidisciplinary approach is most favorable when providing support to both patient and family, whether it is from the psychosocial, practical, emotional, spiritual or cultural aspects. PC also ensures coordination and continuity of care across different care settings. Support for family carries on after death with grief and bereavement support. This narrative review aims to appraise the current evidence of integration of PC into pediatric CC and its impact on patient- and family-centered outcomes. We will also summarize the impact of integration of good PC into pediatric CC, including effective communication with families, advanced care planning, withholding or withdrawal of life sustaining measures and bereavement support. Finally, we will provide a framework on how best to integrate PC in PICU. These findings will provide insights on how PC can improve the quality of care of a critically ill child.
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Affiliation(s)
- Siti Nur Hanim Buang
- Pediatric Palliative Care Service, Department of Pediatric Subspecialities, KK Women's and Children's Hospital, Singapore, Singapore
| | - Sin Wee Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
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14
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Thomas T, Tan M, Ahmed Y, Grigorenko EL. A Systematic Review and Meta-Analysis of Interventions for Orphans and Vulnerable Children Affected by HIV/AIDS Worldwide. Ann Behav Med 2021; 54:853-866. [PMID: 32525205 DOI: 10.1093/abm/kaaa022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Worldwide, there are more than 13.3 million orphans and vulnerable children affected by Human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) (HIV OVC), defined as individuals below the age of 18 who have lost one or both parents to HIV/AIDS or have been made vulnerable by HIV/AIDS; they are at risk for negative psychosocial and cognitive outcomes. PURPOSE This meta-analysis aimed to examine the scientific literature on available interventions for HIV OVC, with a focus on community-based interventions (CBI). METHODS Systematic electronic searches were conducted from four databases between October 2016 and April 2017 to identify articles investigating the effectiveness of interventions for HIV OVC. Effect sizes were calculated for each article which provided enough information and data points for analyses. RESULTS Seventy-four articles were reviewed, including psychosocial interventions (d = 0.30), cognitive interventions (d = 0.14), social protection interventions (d = 0.36), and community-based interventions (CBI; d = 0.36). Study-specific effect sizes varied widely, ranging from -1.09 to 2.26, that is, from a negative effect to an impressively large positive one, but the majority of studies registered small to medium effects (the overall effect size for all studies was 0.32, SE = 0.03, 95% CI: 0.26-0.37). Social protection interventions had the highest positive outcomes whereas CBI tended to have the fewest significant positive outcomes, with some outcomes worsening instead of improving. CONCLUSIONS Overall, interventions provided to OVC have potential for improving cognitive, psychosocial, and risk-behavior outcomes. Social protection interventions and CBI had the highest effect sizes, but CBI had positive effects on fewer outcomes and demonstrated some negative effects. CBI warrant scrutiny for improvement, as they represent an important form of culturally embedded services with potentially long-term benefits to OVC, yet appear to be differentially effective. Successful components of other types of intervention were identified, including cash grants, mentorship, and family therapy. In addition, more research is needed that attends to which interventions may be more effective for specific populations, or that studies cost-effectiveness.
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Affiliation(s)
- Tina Thomas
- Department of Psychology, University of Houston, Houston, TX
| | - Mei Tan
- Department of Psychology, University of Houston, Houston, TX
| | - Yusra Ahmed
- Texas Institute for Measurement, Evaluation, and Statistics, University of Houston, Houston, TX
| | - Elena L Grigorenko
- Department of Psychology, University of Houston, Houston, TX.,Texas Institute for Measurement, Evaluation, and Statistics, University of Houston, Houston, TX.,Molecular and Human Genetics, Baylor College of Medicine, Houston, TX.,Moscow State University for Psychology and Education, Moscow, Russian Federation
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15
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Upshaw NC, Roche A, Gleditsch K, Connelly E, Wasilewski-Masker K, Brock KE. Palliative care considerations and practices for adolescents and young adults with cancer. Pediatr Blood Cancer 2021; 68:e28781. [PMID: 33089627 DOI: 10.1002/pbc.28781] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022]
Abstract
The definition of adolescents and young adults (AYAs) in oncology varies with upper limits up to age 39. Younger AYAs, ages 12-24 years, are often cared for within pediatrics. In caring for AYAs with cancer, there are unique considerations that become even more important to recognize, acknowledge, and address in AYAs with life-threatening cancer receiving palliative care. This review highlights important factors such as psychosocial development, cultural considerations, and support structure, which should be considered when providing palliative care to AYAs with cancer during the various stages of care: introduction of palliative care; symptom management; advanced care planning (ACP); end-of-life (EOL) care; and bereavement.
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Affiliation(s)
- Naadira C Upshaw
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Anna Roche
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Katrina Gleditsch
- Division of Hospice and Palliative Medicine, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina
| | - Erin Connelly
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Karen Wasilewski-Masker
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Katharine E Brock
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Hematology/Oncology, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Palliative Care, Emory University School of Medicine, Atlanta, Georgia
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16
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Jung MY, Matthews AK. A Systematic Review of Clinical Interventions Facilitating End-of-Life Communication Between Patients and Family Caregivers. Am J Hosp Palliat Care 2020; 38:180-190. [PMID: 32462895 DOI: 10.1177/1049909120929323] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Communication between patients and family caregivers plays a key role in successful end-of-life (EOL) care. In the majority of cases, health-care providers (HCP) are responsible for leading this communication in clinical settings. This systematic review aimed to examine the evidence for the efficacy of HCP-led interventions in enhancing communication between patients and family caregivers. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and involved a search of MEDLINE via PubMed, CINAHL, Scopus, Embase, and PsycINFO as well as a manual search for additional articles on Google Scholar without date restrictions. Of 2955 articles retrieved, 8 meeting the eligibility criteria were included in the review. A quality appraisal of the selected studies was performed using the van Tulder Scale, with 5 of 8 studies rated as high quality. All 8 studies employed psychoeducational interventions involving both patients and surrogate/family caregivers. Common elements of the interventions reviewed included encouraging participant dyads to share their concerns about the patient's medical condition, clarify their goals and values for EOL care, and discuss their EOL care preferences. Of 8 interventions reviewed, 6 measured EOL care preference congruence within dyads as a primary outcome, and all 6 interventions were effective in increasing congruence. Secondary outcomes measured included decisional conflict and relationship quality, with mixed outcomes reported. This review suggests that HCP-led EOL communication interventions show promise for improving EOL care preference congruence. However, further studies with improved methodological rigor are needed to establish the optimal timing, intensity, and duration of interventions.
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Affiliation(s)
- Min Young Jung
- Department of Health Systems Science, 14681College of Nursing, University of Illinois at Chicago, IL, USA
| | - Alicia K Matthews
- Department of Health Systems Science, 14681College of Nursing, University of Illinois at Chicago, IL, USA
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17
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Cousino MK, Miller VA, Smith C, Uzark K, Lowery R, Rottach N, Blume ED, Schumacher KR. Medical and end-of-life decision making in adolescents' pre-heart transplant: A descriptive pilot study. Palliat Med 2020; 34:272-280. [PMID: 31647374 PMCID: PMC8063635 DOI: 10.1177/0269216319874689] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Adolescents and young adults undergoing heart transplantation experience risks of morbidity and mortality both pre- and post-transplant. To improve end-of-life care for this population, it is necessary to understand their medical and end-of-life decision-making preferences. AIM (1) To examine adolescent/young adult decision-making involvement specific to heart transplant listing, and (2) to characterize their preferences specific to medical and end-of-life decision making. DESIGN This cross-sectional research study utilized survey methods. Data were collected from October 2016 to March 2018. SETTING/PARTICIPANTS Twelve adolescent and young adult patients listed for heart transplant (ages = 12-19 years) and one parent for each were enrolled at a single-center, US children's hospital. RESULTS Consistent with their preferences, the majority of adolescent/young adult participants (82%) perceived a high level of involvement in the decision to be listed for transplant. Patient involvement in this decision was primarily by way of seeking advice or information from their parents and being asked to express their opinion from parents. Despite a preference among patients to discuss their prognosis and be involved in end-of-life decision making if seriously ill, only 42% of patients had discussed their end-of-life wishes with anyone. Few parents recounted having such discussions. Preferences regarding the timing and nature of end-of-life decision-making discussions varied. CONCLUSIONS Although young people are involved in the decision to pursue heart transplantation, little attention is paid to involving them in discussions regarding end-of-life decision making in a manner that is consistent with individual preferences.
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Affiliation(s)
- Melissa K Cousino
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Transplant Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cynthia Smith
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Nichole Rottach
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Kurt R Schumacher
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,University of Michigan Transplant Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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18
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Needle JS, Peden-McAlpine C, Liaschenko J, Koschmann K, Sanders N, Smith A, Schellinger SE, Lyon ME. "Can you tell me why you made that choice?": A qualitative study of the influences on treatment decisions in advance care planning among adolescents and young adults undergoing bone marrow transplant. Palliat Med 2020; 34:281-290. [PMID: 31659933 DOI: 10.1177/0269216319883977] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Adolescent and young adult advance care planning is beneficial in improving communication between patients, surrogates, and clinicians. The influences on treatment decisions among adolescents and young adults are underexplored in the literature. AIM The aim of this study was to explore and better understand the influences on decision-making for adolescent and young adult bone marrow transplant patients about future medical care. DESIGN Clinical case studies and qualitative inductive content analysis of treatment decisions made during the Respecting Choices® Next Steps Pediatric Advance Care Planning conversation as a component of the Family-Centered Advance Care Planning Intervention. SETTINGS/PARTICIPANTS A total of 10 adolescent and young adult patients (aged 14-27 years) undergoing bone marrow transplant at an academic Midwest children's hospital were involved in the study. RESULTS Influences on participants' decisions were consideration for family, quality of life, and awareness of self. Desire to avoid suffering and maintain an acceptable quality of life was often in competition with participant's concern over the perceived negative impact of discontinuing treatment on their families. CONCLUSION This study highlights that adolescent and young adult bone marrow transplant patients are capable of meaningful deliberation about future treatment decisions. Influences on decision-making should be incorporated into advance care planning conversations to facilitate communication between patients and their surrogates. Longitudinal research is needed to explore these influences throughout the trajectory of illness.
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Affiliation(s)
| | | | | | - Kara Koschmann
- University of Minnesota School of Nursing, Minneapolis, MN, USA
| | - Noah Sanders
- University of Minnesota School of Medicine, Minneapolis, MN, USA
| | | | | | - Maureen E Lyon
- Children's Research Institute, George Washington University School of Medicine, Washington, DC, USA
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19
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Hein K, Knochel K, Zaimovic V, Reimann D, Monz A, Heitkamp N, Borasio GD, Führer M. Identifying key elements for paediatric advance care planning with parents, healthcare providers and stakeholders: A qualitative study. Palliat Med 2020; 34:300-308. [PMID: 31985331 PMCID: PMC7074656 DOI: 10.1177/0269216319900317] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although international guidelines recommend discussions about goals of care and treatment options for children with severe and life-limiting conditions, there are still few structured models of paediatric advance care planning. AIM The study aimed at identifying key components of paediatric advance care planning through direct discussions with all involved parties. DESIGN The study had a qualitative design with a participatory approach. Participants constituted an advisory board and took part in two transdisciplinary workshops. Data were collected in discussion and dialogue groups and analysed using content analysis. SETTING/PARTICIPANTS We included bereaved parents, health care providers and stakeholders of care networks. RESULTS Key elements were discussions, documentation, implementation, timing and participation of children and adolescents. Parents engage in discussions with facilitators and persons of trust to reach a decision. Documentation constitutes the focus of professionals, who endorse brief recommendations for procedures in case of emergencies, supplemented by larger advance directives. Implementation hindrances include emotional barriers of stakeholders, disagreements between parents and professionals and difficulties with emergency services. Discussion timing should take into account parental readiness. The intervention should be repeated at regular intervals, considering emerging needs and increasing awareness of families over time. Involving children and adolescents in advance care planning remains a challenge. CONCLUSION A paediatric advance care planning intervention should take into account potential pitfalls and barriers including issues related to timing, potential conflicts between parents and professionals, ambiguity towards written advance directives, the role of non-medical carers for paediatric advance care planning implementation, the need to involve the child and the necessity of an iterative process.
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Affiliation(s)
- Kerstin Hein
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Kathrin Knochel
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Vedrana Zaimovic
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Daniel Reimann
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Anna Monz
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Nari Heitkamp
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Gian Domenico Borasio
- Palliative Care Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
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20
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Snaman J, McCarthy S, Wiener L, Wolfe J. Pediatric Palliative Care in Oncology. J Clin Oncol 2020; 38:954-962. [PMID: 32023163 DOI: 10.1200/jco.18.02331] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pediatric palliative care aims to alleviate suffering and improve the quality of life of children with serious disease and increase support for their parents and other family members. Integration of palliative care into the routine care of children, adolescents, and young adults with cancer has resulted in improved outcomes in patients and their families. The field of pediatric palliative oncology-encompassing primary palliative care provided by the multidisciplinary oncology team as well as subspecialty palliative care provided by the palliative care team for more complex cases-is unique from palliative care in adults given its focus on care of the child and the larger family. In this review, we focus on advancements in the specific domains within pediatric palliative oncology care including family-centered communication, assessment and management of physical symptoms and distress, psychosocial concerns, and spiritual considerations of the patient, parents, and siblings.
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Affiliation(s)
- Jennifer Snaman
- Dana-Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, Boston, MA
| | | | - Lori Wiener
- Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Joanne Wolfe
- Dana-Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, Boston, MA
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21
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Cousino MK, Schumacher KR, Magee JC, Wolfe J, Yu S, Eder SJ, Fredericks EM. Communication about prognosis and end-of-life in pediatric organ failure and transplantation. Pediatr Transplant 2019; 23:e13373. [PMID: 30734455 DOI: 10.1111/petr.13373] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/02/2018] [Accepted: 11/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite advancements in treatment and survival, pediatric organ failure and transplant populations continue to face significant risks of morbidity and mortality. Little scientific attention has been given to addressing the end-of-life care needs of this growing population of young people. This study characterized current practices, beliefs, and challenges specific to the disclosure of prognosis and end-of-life care topics among providers caring for pediatric organ failure and transplant populations. METHODS This cross-sectional study included 144 healthcare providers actively caring for children, adolescents, and young adults with organ failure or solid organ transplant history. Participants completed an electronic survey measuring frequency and comfort in discussing the following topics with patients and parents: prognosis/survival statistics, re-transplantation, advance care planning (ACP), and death/dying. Descriptive statistics, two-sample t tests, and analysis of variance were used. RESULTS Fewer than half of respondents regularly discuss prognosis/survival statistics and potential need for re-transplantation with their pediatric and young adult patients. Less than 20% of providers engage their pediatric patients in ACP discussions, and approximately 30% facilitate such discussions with young adult patients. Pediatric organ failure and transplant providers endorse a number of barriers specific to discussing these topics. CONCLUSION Pediatric organ failure and transplant providers do not regularly discuss prognosis or end-of-life care topics with this patient population. Communication-focused intervention research is needed to improve honest and compassionate discussion of these topics that is aligned with both patients' and parents' needs and preferences.
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Affiliation(s)
- Melissa K Cousino
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan.,University of Michigan Transplant Center, Ann Arbor, Michigan
| | - Kurt R Schumacher
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan.,University of Michigan Transplant Center, Ann Arbor, Michigan
| | - John C Magee
- University of Michigan Transplant Center, Ann Arbor, Michigan.,Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Sunkyung Yu
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Sally J Eder
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan
| | - Emily M Fredericks
- Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan.,University of Michigan Transplant Center, Ann Arbor, Michigan
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Refinement of a Conceptual Model for Adolescent Readiness to Engage in End-of-Life Discussions. Cancer Nurs 2019; 41:E21-E39. [PMID: 28114261 DOI: 10.1097/ncc.0000000000000465] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adolescents living with incurable cancer require ongoing support to process grief, emotions, and information as disease progresses including treatment options (phase 1 clinical trials and/or hospice/palliative care). Little is known about how adolescents become ready for such discussions. OBJECTIVE The purpose of this study was to explore the process of adolescent readiness for end-of-life preparedness discussions, generating a theoretical understanding for guiding clinical conversations when curative options are limited. METHODS We explored 2 in-depth cases across time using case-study methodology. An à priori conceptual model based on current end-of-life research guided data collection and analysis. Multiple sources including in-depth adolescent interviews generated data collection on model constructs. Analysis followed a logical sequence establishing a chain of evidence linking raw data to study conclusions. Synthesis and data triangulation across cases and time led to theoretical generalizations. Initially, we proposed a linear process of readiness with 3 domains: a cognitive domain (awareness), an emotional domain (acceptance), and a behavioral domain (willingness), which preceded preparedness. RESULTS Findings led to conceptual model refinement showing readiness is a dynamic internal process that interacts with preparedness. Current awareness context facilitates the type of preparedness discussions (cognitive or emotional). Furthermore, social constraint inhibits discussions. CONCLUSIONS Data support theoretical understanding of the dynamism of readiness. Future research that validates adolescent conceptualization will ensure age-appropriate readiness representation. IMPLICATIONS FOR PRACTICE Understanding the dynamic process of readiness for engaging in end-of-life preparedness provides clinician insight for guiding discussions that facilitate shared decision making and promote quality of life for adolescents and their families.
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Lyon ME, Dallas RH, Garvie PA, Wilkins ML, Garcia A, Cheng YI, Wang J. Paediatric advance care planning survey: a cross-sectional examination of congruence and discordance between adolescents with HIV/AIDS and their families. BMJ Support Palliat Care 2019; 9:e22. [PMID: 28935629 PMCID: PMC5862773 DOI: 10.1136/bmjspcare-2016-001224] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 05/19/2017] [Accepted: 08/07/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To identify patient-reported paediatric advance care planning (pACP) needs of adolescents living with HIV and to examine the congruence with their family's perception of their needs. METHODS A cross-sectional survey among six paediatric hospital-based outpatient HIV specialty clinics. Participants included 48 adolescent/family dyads (n=96 participants) within a larger study facilitating pACP. The main outcome measure was the Lyon Advance Care Planning Survey - Adolescent and Surrogate Versions-Revised. RESULTS Adolescents' mean age was 18 years (range ≥14-<21); 54% male; 92% African-American; 27% with prior AIDS diagnosis. If dying, 92% believed in completing an advance directive; 85% preferred to die at home;88% knowing how to say good bye; 71% being off machines that extend life and 77% dying a natural death. Best timing for end-of-life (EOL) decisions was while healthy (38%), when first diagnosed (17%), when first sick from a life-threatening illness (4%), when first hospitalised (8%), if dying (4%) and all of the above (19%). Prevalence-adjusted bias-adjusted Kappa (PABAK) measured congruence in pACP needs within adolescent/family dyads. There was substantial congruence in that being free from pain (PABAK=0.83), and understanding your treatment choices (PABAK=0.92) were very important or important. There was discordance about being off machines that extend life (PABAK=0.08) and when is the best time to bring up EOL decisions (PABAK=0.32). CONCLUSIONS Areas of discordance were associated with life-sustaining choices and when to have the EOL conversation. Targeted, adolescent/family-centred, evidence-based pACP interventions are needed to improve family understanding of youth's EOL wishes. TRIAL REGISTRATION NUMBER NCT01289444; Results.
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Affiliation(s)
- Maureen E Lyon
- Center for Translational Science/Children’s Research Institute/Children’s National Medical Center, Washington, District of Columbia, USA
| | - Ronald H Dallas
- Department of Infectious Disease, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Patricia A Garvie
- Research Department, Children’s Diagnostic & Treatment Center, Lauderdale, Florida, USA
| | - Megan L Wilkins
- Department of Infectious Disease, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Ana Garcia
- Division of Infectious Disease, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yao Iris Cheng
- Center for Translational Science/Children’s Research Institute/Children’s National Medical Center, Washington, District of Columbia, USA
| | - Jichuan Wang
- Center for Translational Science/Children’s Research Institute/Children’s National Medical Center, Washington, District of Columbia, USA
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24
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Fahner JC, Beunders AJ, van der Heide A, Rietjens JA, Vanderschuren MM, van Delden JJ, Kars MC. Interventions Guiding Advance Care Planning Conversations: A Systematic Review. J Am Med Dir Assoc 2019; 20:227-248. [DOI: 10.1016/j.jamda.2018.09.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/11/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
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25
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Lyon ME, Squires L, D'Angelo LJ, Benator D, Scott RK, Greenberg IH, Tanjutco P, Turner MM, Weixel TE, Cheng YI, Wang J. FAmily-CEntered (FACE) Advance Care Planning Among African-American and Non-African-American Adults Living With HIV in Washington, DC: A Randomized Controlled Trial to Increase Documentation and Health Equity. J Pain Symptom Manage 2019; 57:607-616. [PMID: 30472318 PMCID: PMC6382515 DOI: 10.1016/j.jpainsymman.2018.11.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/09/2018] [Accepted: 11/14/2018] [Indexed: 12/25/2022]
Abstract
CONTEXT No prospective studies address disease-specific advance care planning (ACP) for adults living with HIV/AIDS. OBJECTIVE To examine the efficacy of FAmily-CEntered (FACE) ACP in increasing ACP and advance directive documentation in the medical record. METHODS Longitudinal, two-arm, randomized controlled trial with intent-to-treat design recruited from five hospital-based outpatient HIV clinics in Washington, DC. Adults living with HIV and their surrogate decision-makers (N = 233 dyads) were randomized to either an intensive facilitated two-session FACE ACP (Next Steps: Respecting Choices goals of care conversation and Five Wishes advance directive) or healthy living control (conversations about developmental/relationship history and nutrition). RESULTS Patients (n = 223) mean age: 51 years, 56% male, 86% African-American. One hundred ninety-nine dyads participated in the intervention. At baseline, only 13% of patients had an advance directive. Three months after intervention, this increased to 59% for the FACE ACP group versus 17% in the control group (P < 0.0001). Controlling for race, the odds of having an advance directive in the medical record in the FACE ACP group was approximately seven times greater than controls (adjusted odds ratio = 6.58, 95% CI: 3.21-13.51, P < 0.0001). Among African-Americans randomized to FACE, 58% had completed/documented advance directives versus 20% of controls (P < 0.0001). CONCLUSIONS The FACE ACP intervention significantly improved ACP completion and advance directive documentation in the medical record among both African-American and non-African-American adults living with HIV in Washington, DC, providing health equity in ACP, which can inform best practices.
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Affiliation(s)
- Maureen E Lyon
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Leah Squires
- Washington DC Veterans Affairs Medical Center, Washington, DC
| | - Lawrence J D'Angelo
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Debra Benator
- George Washington University School of Medicine and Health Sciences, Washington, DC; Washington DC Veterans Affairs Medical Center, Washington, DC
| | - Rachel K Scott
- MedStar: Health Research Institute and Washington Hospital Center; George Washington University Milken School of Public Health, Washington, DC, USA
| | - Isabella H Greenberg
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA
| | - Patricia Tanjutco
- MedStar: Health Research Institute and Washington Hospital Center; George Washington University Milken School of Public Health, Washington, DC, USA
| | | | - Tara E Weixel
- Office of the Clinical Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Yao I Cheng
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA
| | - Jichuan Wang
- Division of Adolescent and Young Adult Medicine, Children's National, Center for Translational Science/Children's Research Institute, Washington, DC, USA; George Washington University School of Medicine and Health Sciences, Washington, DC
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26
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Badarau DO, De Clercq E, Elger BS. Continuous Deep Sedation and Euthanasia in Pediatrics: Does One Really Exclude the Other for Terminally Ill Patients? THE JOURNAL OF MEDICINE AND PHILOSOPHY 2019; 44:50-70. [PMID: 30649451 DOI: 10.1093/jmp/jhy033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Debates on morally acceptable and lawful end-of-life (EOL) practices in pediatrics were reignited by the recent amendment in Belgian law to allow euthanasia for minors of any age who meet the criteria for capacity. Euthanasia and its legalization in pediatrics are often opposed based on the availability of aggressive palliative sedation. For terminally ill patients, this type of sedation is often identified as continuous and deep sedation until death (CDS). We demonstrate that this reasoning is based on flawed assumptions: (1) CDS is a morally preferable alternative to euthanasia; (2) CDS can meet the same patient needs as euthanasia; (3) children lack the capacity and experience to make EOL decisions; (4) unlike euthanasia, CDS does not raise capacity issues. Our aim is not to reject CDS as a valid option at the EOL, nor to offer a clear-cut defense of euthanasia for minors, but to emphasize the ethical issues with both practices.
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27
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Lyon ME, Garvie PA, D'Angelo LJ, Dallas RH, Briggs L, Flynn PM, Garcia A, Cheng YI, Wang J. Advance Care Planning and HIV Symptoms in Adolescence. Pediatrics 2018; 142:e20173869. [PMID: 30341154 PMCID: PMC6317555 DOI: 10.1542/peds.2017-3869] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To determine the effect of family-centered pediatric advance care planning (FACE pACP) on HIV-specific symptoms. METHODS In this single-blinded, randomized controlled trial conducted at 6 US hospital-based HIV clinics, 105 adolescent-family dyads, randomly assigned from July 2011 to June 2014, received 3 weekly sessions in either the FACE pACP arm ([1] pediatric advance care planning survey, [2] Respecting Choices interview, and [3] 5 Wishes directive) or the control arm ([1] developmental history, [2] safety tips, and [3] nutrition and exercise tips). The General Health Assessment for Children measured patient-reported HIV-specific symptoms. Latent class analyses clustered individual patients based on symptom patterns. Path analysis examined the mediating role of dyadic treatment congruence with respect to the intervention effect on symptom patterns. RESULTS Patients were a mean age of 17.8 years old, 54% male, and 93% African American. Latent class analysis identified 2 latent HIV-symptom classes at 12 months: higher symptoms and suffering (27%) and lower symptoms and suffering (73%). FACE pACP had a positive effect on dyadic treatment congruence (β = .65; 95% CI: 0.04 to 1.28), and higher treatment congruence had a negative effect on symptoms and suffering (β = -1.14; 95% CI: -2.55 to -0.24). Therefore, FACE pACP decreased the likelihood of symptoms and suffering through better dyadic treatment congruence (β = -.69; 95% CI: -2.14 to -0.006). Higher religiousness (β = 2.19; 95% CI: 0.22 to 4.70) predicted symptoms and suffering. CONCLUSIONS FACE pACP increased and maintained agreement about goals of care longitudinally, which lowered adolescents' physical symptoms and suffering, suggesting that early pACP is worthwhile.
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Affiliation(s)
- Maureen E Lyon
- Divisions of Adolescent and Young Adult Medicine and
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Patricia A Garvie
- Research Department, Children's Diagnostic and Treatment Center, Fort Lauderdale, Florida
| | - Lawrence J D'Angelo
- Divisions of Adolescent and Young Adult Medicine and
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Ronald H Dallas
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Linda Briggs
- Respecting Choices, Coalition to Transform Advanced Care Innovations, Washington, District of Columbia; and
| | - Patricia M Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Ana Garcia
- Department of Pediatrics, Division of Infectious Disease and Immunology, Batchelor Children's Research Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Yao I Cheng
- Biostatistics and Study Methodology, Center for Translational Science, Children's Research Institute, Children's National, Washington, District of Columbia
| | - Jichuan Wang
- Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
- Biostatistics and Study Methodology, Center for Translational Science, Children's Research Institute, Children's National, Washington, District of Columbia
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28
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Gutman T, Hanson CS, Bernays S, Craig JC, Sinha A, Dart A, Eddy AA, Gipson DS, Bockenhauer D, Yap HK, Groothoff J, Zappitelli M, Webb NJ, Alexander SI, Goldstein SL, Furth S, Samuel S, Blydt-Hansen T, Dionne J, Michael M, Wenderfer SE, Winkelmayer WC, Currier H, McTaggart S, Walker A, Ralph AF, Ju A, James LJ, Carter S, Tong A. Child and Parental Perspectives on Communication and Decision Making in Pediatric CKD: A Focus Group Study. Am J Kidney Dis 2018; 72:547-559. [DOI: 10.1053/j.ajkd.2018.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/02/2018] [Indexed: 11/11/2022]
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29
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Mack JW. The PRISM intervention for adolescents and young adults with cancer: Paying attention to the patient as a whole person. Cancer 2018; 124:3802-3805. [DOI: 10.1002/cncr.31664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/25/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Jennifer W. Mack
- Division of Population Sciences and Department of Pediatric Oncology, Dana-Farber Cancer Institute; Boston Massachusetts
- Division of Pediatric Hematology/Oncology; Boston Children’s Hospital; Boston Massachusetts
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30
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Blazin LJ, Cecchini C, Habashy C, Kaye EC, Baker JN. Communicating Effectively in Pediatric Cancer Care: Translating Evidence into Practice. CHILDREN-BASEL 2018. [PMID: 29534479 PMCID: PMC5867499 DOI: 10.3390/children5030040] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Effective communication is essential to the practice of pediatric oncology. Clear and empathic delivery of diagnostic and prognostic information positively impacts the ways in which patients and families cope. Honest, compassionate discussions regarding goals of care and hopes for patients approaching end of life can provide healing when other therapies have failed. Effective communication and the positive relationships it fosters also can provide comfort to families grieving the loss of a child. A robust body of evidence demonstrates the benefits of optimal communication for patients, families, and healthcare providers. This review aims to identify key communication skills that healthcare providers can employ throughout the illness journey to provide information, encourage shared decision-making, promote therapeutic alliance, and empathically address end-of-life concerns. By reviewing the relevant evidence and providing practical tips for skill development, we strive to help healthcare providers understand the value of effective communication and master these critical skills.
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Affiliation(s)
- Lindsay J. Blazin
- Department of Oncology, Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (L.J.B.); (E.C.K.)
| | - Cherilyn Cecchini
- Department of Pediatrics, Children’s National Medical Center, Washington, DC 20010, USA; (C.C); (C.H.)
| | - Catherine Habashy
- Department of Pediatrics, Children’s National Medical Center, Washington, DC 20010, USA; (C.C); (C.H.)
| | - Erica C. Kaye
- Department of Oncology, Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (L.J.B.); (E.C.K.)
| | - Justin N. Baker
- Department of Oncology, Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA; (L.J.B.); (E.C.K.)
- Correspondence: ; Tel.: +1-901-595-4446
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31
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Fletcher S, Hughes R, Pickstock S, Auret K. Advance Care Planning Discussions with Adolescent and Young Adult Cancer Patients Admitted to a Community Palliative Care Service: A Retrospective Case-Note Audit. J Adolesc Young Adult Oncol 2018; 7:112-119. [DOI: 10.1089/jayao.2017.0032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Sophie Fletcher
- Silver Chain Hospice Community Service, Perth, Western Australia
| | - Rachel Hughes
- Youth Cancer Services, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - Sarah Pickstock
- Silver Chain Hospice Community Service, Perth, Western Australia
| | - Kirsten Auret
- Rural Clinical School of Western Australia (Albany), University of Western Australia, Albany, Western Australia
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MacKenzie MA, Smith-Howell E, Bomba PA, Meghani SH. Respecting Choices and Related Models of Advance Care Planning: A Systematic Review of Published Evidence. Am J Hosp Palliat Care 2017; 35:897-907. [PMID: 29254357 DOI: 10.1177/1049909117745789] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
All individuals should receive care consistent with their expressed preferences during serious and chronic illnesses. Respecting Choices (RC) is a well-known model of advance care planning intended to assist individuals consider, choose, and communicate these preferences to health-care providers. In this systematic review, we evaluated the published literature on the outcomes of the RC and derivative models utilizing criteria developed by the Cochrane Collaborative. Eighteen articles from 16 studies were included, of which 9 were randomized controlled trials, 6 were observational, and 1 was a pre-posttest study. Only 2 specifically included a minority population (African American). Fourteen were conducted in the United States, primarily in the Wisconsin/Minnesota region (n = 8). Seven studies examined the RC model, whereas 9 examined derivative models. There was significant heterogeneity of outcomes examined. We found that there is a low level of evidence that RC and derivative models increase the incidence and prevalence of Advance Directive and Physician Orders for Life-Sustaining Treatment completion. There is a high level of evidence that RC and derivative models increase patient-surrogate congruence in Caucasian populations. The evidence is mixed, inconclusive, and too poor in quality to determine whether RC and derivative models change the consistency of treatment with wishes and overall health-care utilization in the end of life. We urge further studies be conducted, particularly with minority populations and focused on the outcomes of preference-congruent treatment and health-care utilization.
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Affiliation(s)
| | | | - Patricia A Bomba
- 3 Geriatrics, Excellus BlueCross BlueShield and MedAmerica Insurance Company, Rochester, NY, USA
| | - Salimah H Meghani
- 2 School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
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Lyon ME, D’Angelo LJ, Dallas RH, Hinds PS, Garvie PA, Wilkins ML, Garcia A, Briggs L, Flynn PM, Rana SR, Cheng YI, Wang J. A randomized clinical trial of adolescents with HIV/AIDS: pediatric advance care planning. AIDS Care 2017; 29:1287-1296. [PMID: 28359212 PMCID: PMC5846623 DOI: 10.1080/09540121.2017.1308463] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The objective of this study is to determine if pediatric advance care planning (pACP) increases adolescent/family congruence in end-of-life (EOL) treatment preferences longitudinally. Adolescents aged 14-21 years with HIV/AIDS and their families were randomized (N = 105 dyads) to three-60-minute sessions scheduled one week apart: either the pACP intervention (survey administered independently, facilitated conversation with adolescent and family present, completion of legal advance directive document with adolescent and family present) or an active control (developmental history, safety tips, nutrition and exercise education). This longitudinal, single-blinded, multi-site, randomized controlled trial was conducted in six pediatric hospital-based HIV-clinics, located in high HIV mortality cities. The Statement of Treatment Preferences measured adolescent/family congruence in EOL treatment preferences at immediately following the facilitated pACP conversation (Session 2), and at 3-month post-intervention. The mean age of adolescent participants was 18 years (range 14-21 years); 54% were male; and 93% were African-American. One-third had an AIDS diagnosis. Immediately post-intervention the Prevalence Adjusted Bias Adjusted Kappa showed substantial treatment preference agreement for pACP dyads compared to controls (High burden/low chance of survival, PABAK = 0.688 vs. 0.335; Functional impairment, PABAK = 0.687 vs. PABAK= 0.34; Mental impairment, PABKA = 0.717 vs. 0.341). Agreement to limit treatments was greater among intervention dyads than controls (High burden: 14.6% vs. 0%; Functional impairment = 22.9% vs. 4.4%; and Mental impairment: 12.5% vs. 4.4%). Overall treatment preference agreement among pACP dyads was high immediately post-intervention, but decreased over time. In contrast, treatment agreement among control dyads was low and remained low over time. As goals of care change over time with real experiences, additional pACP conversations are needed.
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Affiliation(s)
- Maureen E. Lyon
- Department of Pediatrics, Children’s National, Children’s Research Institute, Center for Translational Science and George Washington University School of Medicine and Health Sciences, Washington, USA
- Department of Pediatrics, Children’s National, Division of Adolescent & Young Adult Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Lawrence J. D’Angelo
- Department of Pediatrics, Children’s National, Division of Adolescent & Young Adult Medicine, George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Ronald H. Dallas
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, USA
| | - Pamela S. Hinds
- Department of Pediatrics, Children’s National, Children’s Research Institute, Center for Translational Science and George Washington University School of Medicine and Health Sciences, Washington, USA
| | - Patricia A. Garvie
- Research Department, Children’s Diagnostic & Treatment Center, Fort Lauderdale, USA
| | - Megan L. Wilkins
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, USA
| | - Ana Garcia
- Pediatric Infectious Disease & Immunology, University of Miami Miller School of Medicine, Miami, USA
| | - Linda Briggs
- Gundersen Lutheran Medical Foundation, Inc., La Crosse, USA
| | - Patricia M. Flynn
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, USA
| | - Sohail R. Rana
- Department of Pediatrics and Child Health, Howard University Hospital, Washington, USA
| | - Yao Iris Cheng
- Division of Biostatistics and Study Methodology, Children’s National, Children’s Research Institute, Center for Translational Science, Washington, USA
| | - Jichuan Wang
- Division of Biostatistics and Study Methodology, Children’s National, Children’s Research Institute, Center for Translational Science, Washington, USA
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Popejoy E, Pollock K, Almack K, Manning JC, Johnston B. Decision-making and future planning for children with life-limiting conditions: a qualitative systematic review and thematic synthesis. Child Care Health Dev 2017; 43:627-644. [PMID: 28402040 DOI: 10.1111/cch.12461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 02/24/2017] [Accepted: 03/13/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND In the last decade, the number of children with life-limiting and life-threatening conditions in England has almost doubled, and it is estimated that worldwide, there are 1.2 million children with palliative care needs. Families and professionals caring for children with life-limiting conditions are likely to face a number of difficult treatment decisions and develop plans for future care over the course of the child's life, but little is known about the process by which these decisions and plans are made. METHODS The purpose of this review is to synthesize findings from qualitative research that has investigated decision-making and future planning for children with life-limiting conditions. A systematic search of six online databases was conducted and identified 887 papers for review; five papers were selected for inclusion, using predefined criteria. Reference list searching and contacting authors identified a further four papers for inclusion. RESULTS Results sections of the papers were coded and synthesized into themes. Nineteen descriptive themes were identified, and these were further synthesized into four analytical themes. Analytical themes were 'decision factors', 'family factors', 'relational factors' and 'system factors'. CONCLUSIONS Review findings indicate that decision-making and future planning is difficult and needs to be individualized for each family. However, deficits in understanding the dynamic, relational and contextual aspects of decision-making remain and require further research.
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Affiliation(s)
- E Popejoy
- University of Nottingham School of Health Sciences, Nottingham, UK
| | - K Pollock
- Nottingham Children's Hospital, Nottingham, UK
| | - K Almack
- University of Nottingham School of Health Sciences, Nottingham, UK
| | - J C Manning
- University of Nottingham School of Health Sciences, Nottingham, UK
| | - B Johnston
- University of Glasgow School of Medicine, Glasgow, UK
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35
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Philpott SE, Witteman HO, Jones KM, Sonderman DS, Julien AS, Politi MC. Clinical trainees' responses to parents who question evidence-based recommendations. PATIENT EDUCATION AND COUNSELING 2017; 100:1701-1708. [PMID: 28495389 DOI: 10.1016/j.pec.2017.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 04/03/2017] [Accepted: 05/01/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We examined clinicians' attitudes, beliefs, and behavioral intentions about discussing evidence and eliciting values when patients question recommendations. METHODS We randomized trainees to read one of three scenarios about a parent of a one-year-old: 1) overuse (parent requests antibiotics for presumed viral infection); 2) equipoise (tubes for recurrent ear infections); 3) underuse (parent hesitates about vaccination). Participants then answered survey questions. Outcomes included time spent clarifying values (primary), attitudes and beliefs about the parent (secondary). RESULTS 132 medical students and pediatric residents enrolled; 119 (90%) completed the study. There were no differences in time participants would spend clarifying values (antibiotics 26±12%; equipoise 28±11%; vaccine-hesitancy 22±11%; p=0.058). Participants in the vaccine-hesitancy group (vs. other groups) would spend less time answering questions (p=0.006). Participants in the antibiotics (vs. equipoise) group perceived the parent as difficult (p=0.0002). Those in the vaccine-hesitancy group (vs. other groups) perceived the parent as difficult, saw less value in the conversation, and had lower respect for the parent's views (all ps<0.0001). Most (76%) wanted additional training navigating these discussions. CONCLUSION Clinicians' attitudes may impact conversations when patients question evidence-based recommendations. PRACTICE IMPLICATIONS Clinicians should consider ways to discuss evidence and clarify patients' values to optimize health without damaging patient-clinician relationships.
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Affiliation(s)
- Sydney E Philpott
- Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Office of Education and Professional Development, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Research Centre, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Katherine M Jones
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - David S Sonderman
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Anne-Sophie Julien
- Research Centre, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Mary C Politi
- Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
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Pediatric advance care planning (pACP) for teens with cancer and their families: Design of a dyadic, longitudinal RCCT. Contemp Clin Trials 2017; 62:121-129. [PMID: 28844985 DOI: 10.1016/j.cct.2017.08.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 12/30/2022]
Abstract
Cancer is the leading cause of disease-related death for adolescents and young adults (AYAs) in the United States. Parents of AYAs with life-threatening illnesses have expressed the desire to talk to their children about end of life (EOL) care, yet, like caregivers of adult patients, struggle to initiate this conversation. Building Evidence for Effective Palliative/End of Life Care for Teens with Cancer is a longitudinal, randomized, controlled, single-blinded clinical trial aimed at evaluating the efficacy of FAmily CEntered disease-specific advance care planning (ACP) for teens with cancer (FACE-TC). A total of 130 dyads (260 subjects) composed of AYAs 14-20years old with cancer and their family decision maker (≥18years old) will be recruited from pediatric oncology programs at Akron Children's Hospital and St. Jude Children's Research Hospital. Dyads will be randomized to either the FACE-TC intervention or Treatment as Usual (TAU) control. FACE-TC intervention dyads will complete three 60-minute ACP sessions held at weekly intervals. Follow-up data will be collected at 3, 6, 12, and 18months post-intervention by a blinded research assistant (RA). The effects of FACE-TC on patient-family congruence in treatment preferences, quality of life (QOL), and advance directive completion will be analyzed. FACE-TC is an evidenced-based and patient-centered intervention that considers QOL and EOL care according to the AYA's representation of illness. The family is involved in the ACP process to facilitate shared decision making, increase understanding of the AYA's preferences, and make a commitment to honor the AYA's wishes.
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Yotani N, Kizawa Y, Shintaku H. Differences between Pediatricians and Internists in Advance Care Planning for Adolescents with Cancer. J Pediatr 2017; 182:356-362. [PMID: 28040231 DOI: 10.1016/j.jpeds.2016.11.079] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/24/2016] [Accepted: 11/30/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate differences between pediatricians and internists in the practice of and barriers to advance care planning (ACP) for adolescent patients with cancer. STUDY DESIGN A self-reported questionnaire was administered to assess the practice of ACP, advance directives, and barriers to ACP for adolescent patients with cancer. All 3392 Japanese board-certified hematologists were surveyed, and 600 hematologists (227 pediatricians, 373 internists) who take care of adolescent patients with cancer with decision-making capacity were analyzed. RESULTS If a patient's prognosis for survival was <3 months, pediatricians were significantly less likely to discuss ACP with their patients than internists, including discussions regarding the patient's medical condition (59% vs 70%), the patient's understanding of his/her medical condition (55% vs 66%), do not attempt resuscitation orders (17% vs 24%), and ventilator treatment if the patient's condition worsened (19% vs 25%). More than 75% of hematologists (both pediatricians and internists) discussed all ACP topics with patients' families. Similarly, with regard to advance directives, pediatricians were less likely than internists to discuss cardiopulmonary resuscitation (24% vs 47%) and the use of ventilators (31% vs 51%), vasopressors (24% vs 42%), and antibiotics (21% vs 31%) with their patients. Both pediatricians and internists discussed these issues more often with patients' families than with patients, especially cardiopulmonary resuscitation (98%) as well as the use of ventilators (98%) and vasopressors (91%). CONCLUSIONS Pediatricians were less likely than internists to discuss ACP and advance directives with patients, and both pediatricians and internists tended to discuss ACP and advance directives more often with patients' families.
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Affiliation(s)
- Nobuyuki Yotani
- Kobe University Graduate School of Medicine, Kobe, Japan; Osaka City University Graduate School of Medicine, Osaka, Japan.
| | | | - Haruo Shintaku
- Osaka City University Graduate School of Medicine, Osaka, Japan
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Yotani N, Kizawa Y, Shintaku H. Advance care planning for adolescent patients with life-threatening neurological conditions: a survey of Japanese paediatric neurologists. BMJ Paediatr Open 2017; 1:e000102. [PMID: 29637131 PMCID: PMC5862176 DOI: 10.1136/bmjpo-2017-000102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/11/2017] [Accepted: 09/05/2017] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To evaluate current attitudes and barriers to advance care planning for adolescent patients with life-threatening conditions among paediatric neurologists. DESIGN Cross-sectional study. A self-reported questionnaire was administered to assess the practice of advance care planning, advance directives and barriers to advance care planning for adolescent patients with life-threatening conditions. All board-certified paediatric neurologists in Japan were surveyed and those who had experience in taking care of adolescent patients with decision-making capacity were analysed. We compared the results with those of paediatric haematologists reported previously. RESULTS In total, 186 paediatric neurologists were analysed. If the patient's prognosis was <3 months, only about 30% of paediatric neurologists reported having discussions with patients, such as 'do not attempt resuscitation' orders (28%) and ventilator use (32%), whereas more than 70% did discuss these topics with patients' families. About half of the paediatric neurologists did not discuss advance directives at the end of life with their patients, whereas over 75% did discuss advance directives with patients' families. Compared with paediatric haematologists, paediatric neurologists had more end-of-life discussions with patients, such as where treatment and care will take place, do not attempt resuscitation orders, and the use of a ventilator, if the patient's prognosis was >1 year. CONCLUSION About half or less of the paediatric neurologists discussed advance care planning and advance directives with their adolescent patients who had life-threatening conditions, even if the patient's prognosis was <3 months. They tended to discuss advance care planning and advance directives more with families than with patients themselves.
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Affiliation(s)
- Nobuyuki Yotani
- Department of Palliative Medicine, National Centre for Child Health and Development, Tokyo, Japan.,Department of Palliative Medicine, Kobe University School of Medicine, Kobe, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University School of Medicine, Kobe, Japan
| | - Haruo Shintaku
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
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Dallas RH, Kimmel A, Wilkins ML, Rana S, Garcia A, Cheng YI, Wang J, Lyon ME. Acceptability of Family-Centered Advanced Care Planning for Adolescents With HIV. Pediatrics 2016; 138:peds.2016-1854. [PMID: 27940700 PMCID: PMC5127070 DOI: 10.1542/peds.2016-1854] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Small pilot studies support the appropriateness of engaging adolescents with chronic or life-limiting illnesses in pediatric advance care planning (pACP). We do not yet know if pACP is acceptable, feasible, and worthwhile, even if emotionally intense, in a fully powered randomized controlled trial. METHODS We conducted a prospective 2-arm randomized controlled trial at 6 US urban hospitals. Adolescent/family member dyads were randomized to receive the 1-session-a-week 3-session FAmily-CEntered Advance Care Planning (FACE) pACP intervention (1, ACP Survey; 2, Goals of Care Conversation/Treatment Preferences; 3, Completion of Advance Directive) or active comparator (1, Developmental History; 2, Safety Tips; 3, Nutrition/Exercise). The Satisfaction Questionnaire was administered to participants independently after each session by a blinded research assistant. RESULTS We enrolled 53% of eligible participants and intervened with 97 adolescent/family dyads. Adolescents ranged in age from 14 to 21 years; 54% were male individuals; 93% African American; and 73% perinatally infected. Attendance was 99% for all 3 sessions in each arm. At session 3, FACE adolescents and family dyad members, respectively, found the session useful (98%, 98%) and helpful (98%, 100%), despite feelings of sadness (25%, 17%). FACE adolescents' improvement in the total subscale A score (useful, helpful, like a load off my mind, satisfied, something I needed to do, courageous, worthwhile) was better than control adolescents at session 3 (β = 1.16, P = .02). There were no adverse events. CONCLUSIONS FACE enabled worthwhile conversations, while simultaneously eliciting intense emotions. No participants withdrew, 99% of those enrolled completed each session, and there were no adverse events, evidence of pACP's feasibility, acceptability, and safety.
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Affiliation(s)
- Ronald H. Dallas
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Allison Kimmel
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia
| | - Megan L. Wilkins
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Sohail Rana
- Howard University College of Medicine, Washington, District of Columbia
| | - Ana Garcia
- The University of Miami Miller School of Medicine, Miami, Florida; and
| | - Yao I. Cheng
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia
| | - Jichuan Wang
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia;,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Maureen E. Lyon
- Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children’s Research Institute, Children’s National, Washington, District of Columbia;,The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Sanders S, Robinson EL. Engaging College Undergraduates in Advance Care Planning. OMEGA-JOURNAL OF DEATH AND DYING 2016; 74:329-344. [PMID: 28038509 DOI: 10.1177/0030222815598912] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Advance care planning (ACP) is a critical part of long-term health-care planning, as no one knows when the ability to make personal medical decisions may be impaired. Many assume ACP is only necessary for older adults or those with life-threatening health conditions; however, there are growing discussions about healthy, young adults also engaging in ACP, as they too suffer from unexpected medical events that limit their ability to make medical decisions. The current study examined the reactions of college students following the completion of their advance care plans and then sharing these plans with friends and family. The students reported that while completing their advance care plans created many emotions, they found the experience to be valuable and facilitated conversations with family and friends about end-of-life care that may not have occurred otherwise.
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Affiliation(s)
- Sara Sanders
- 1 The University of Iowa School of Social Work, IA, USA
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Rhodes RL, Nazir F, Lopez S, Xuan L, Nijhawan AE, Alexander-Scott NE, Halm EA. Use and Predictors of End-of-Life Care Among HIV Patients in a Safety Net Health System. J Pain Symptom Manage 2016; 51:120-5. [PMID: 26384554 PMCID: PMC4763921 DOI: 10.1016/j.jpainsymman.2015.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 08/19/2015] [Accepted: 09/03/2015] [Indexed: 11/18/2022]
Abstract
CONTEXT Although highly active antiretroviral therapy has improved survival among many HIV patients, there are still those with advanced illness and limited access to care who may benefit from palliative care and hospice. OBJECTIVES To examine completion of advance directives, use of palliative care, and enrollment in hospice among HIV patients who receive care at an urban safety net hospital. METHODS This was a retrospective cohort study of HIV patients in a large, urban safety net hospital in 2010. Physicians abstracted data from the electronic medical record on patient and clinical factors and end-of-life care use. Logistic regression examined predictors of hospice use. RESULTS Overall, 367 HIV patients identified electronically by International Classification of Disease (ICD)-9 code were hospitalized in 2010. The mean age was 42 years, and 57% were African American. Although 28% died, only 6% of the sample received palliative care consultation, and 6% of the sample enrolled in hospice. Those who received hospice had lower albumin levels (adjusted odds ratio [AOR] 4.53, 95% CI 1.19-17.34) had received palliative care (AOR 9.73, 95% CI 2.10-45.09) and completed an advance directive (AOR 16.33, 95% CI 4.23-61.68). Of those patients who received hospice, the mean time to death after enrollment was 11 days. CONCLUSION Among an urban cohort of HIV patients, the rates of advance directive completion, palliative care use, and hospice use were low. Despite advancements in the treatment of HIV, many patients with advanced illness may benefit from palliative care and hospice services. Advances should be made in identifying those patients earlier in their disease trajectories.
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Affiliation(s)
- Ramona L Rhodes
- Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.
| | - Fiza Nazir
- Division of Geriatric Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sonya Lopez
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Lei Xuan
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ank E Nijhawan
- Division of Infectious Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole E Alexander-Scott
- Division of Infectious Diseases, Department of Internal Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ethan A Halm
- Division of General Internal Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas, USA
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Wyatt KD, List B, Brinkman WB, Prutsky Lopez G, Asi N, Erwin P, Wang Z, Domecq Garces JP, Montori VM, LeBlanc A. Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis. Acad Pediatr 2015; 15:573-83. [PMID: 25983006 DOI: 10.1016/j.acap.2015.03.011] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Little is known about the impact of interventions to support shared decision making (SDM) with pediatric patients. OBJECTIVES To summarize the efficacy of SDM interventions in pediatrics on patient-centered outcomes. DATA SOURCES We searched Ovid Medline, Ovid Embase, Ovid Cochrane Library, Web of Science, Scopus, and Ovid PsycInfo from database inception to December 30, 2013, and performed an environmental scan. STUDY ELIGIBILITY CRITERIA We included interventions designed to engage pediatric patients, parents, or both in a medical decision, regardless of study design or reported outcomes. STUDY APPRAISAL AND SYNTHESIS METHODS We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias assessment. Meta-analysis was performed on 3 outcomes: knowledge, decisional conflict, and satisfaction. RESULTS Sixty-one citations describing 54 interventions met eligibility criteria. Fifteen studies reported outcomes such that they were eligible for inclusion in meta-analysis. Heterogeneity across studies was high. Meta-analysis revealed SDM interventions significantly improved knowledge (standardized mean difference [SMD] 1.21, 95% confidence interval [CI] 0.26 to 2.17, P = .01) and reduced decisional conflict (SMD -1.20, 95% CI -2.01 to -0.40, P = .003). Interventions showed a nonsignificant trend toward increased satisfaction (SMD 0.37, 95% CI -0.04 to 0.78, P = .08). LIMITATIONS Included studies were heterogeneous in nature, including their conceptions of SDM. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS A limited evidence base suggests that pediatric SDM interventions improve knowledge and decisional conflict, but their impact on other outcomes is unclear. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42013004761 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004761).
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Affiliation(s)
- Kirk D Wyatt
- Pediatric and Adolescent Medicine Residency Program, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, Minn; Mayo Medical School, Mayo Clinic, Rochester, Minn; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | - Betsy List
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William B Brinkman
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Gabriela Prutsky Lopez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine/Detroit Medical Center, Detroit, Mich
| | - Noor Asi
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | | | - Zhen Wang
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn
| | - Juan Pablo Domecq Garces
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Internal Medicine, Henry Ford Hospital, Detroit, Mich
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minn; Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn
| | - Annie LeBlanc
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minn; Department of Health Sciences Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minn.
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Keim-Malpass J, Stegenga K, Loudin B, Kennedy C, Kools S. “It’s Back! My Remission Is Over”. J Pediatr Oncol Nurs 2015; 33:209-17. [DOI: 10.1177/1043454215600424] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cancer in adolescence presents unique challenges to patients and families due to the dramatic physical and psychological vulnerabilities that occur during a time of identity development. Additionally, adolescents who experience progression of their cancer, or failure of first-line therapies, represent an understudied group within pediatric oncology. Illness blogs offer a unique opportunity to understand the experience of a chronic or serious illness through a naturalistic and longitudinal perspective that is inherently patient centered. The purpose of this exploratory qualitative study was to describe the experiences of adolescents with cancer who experienced disease progression through analysis of their online illness blogs. Seven illness blogs written by adolescents with cancer diagnosed between the ages of 13 and 18 years were analyzed using thematic analysis. Several key themes were described among the adolescents, including normalizing the news, facing treatment failure, and reconciling chronos—the finite concept of time. These findings provide vital descriptive evidence for the experience of disease progression as described by adolescents, as well as identifying key points of further study and intervention development for nurse researchers and nurses who care for this vulnerable patient population.
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Affiliation(s)
| | | | - Beth Loudin
- University of Virginia School of Nursing, Charlottesville, VA, USA
| | | | - Susan Kools
- University of Virginia School of Nursing, Charlottesville, VA, USA
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Conner NE, Uddin N. Predictors of Intention to Refer to Pediatric Palliative or Hospice Care. Am J Hosp Palliat Care 2015; 33:617-24. [PMID: 26150677 DOI: 10.1177/1049909115593062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this descriptive correlational study was to determine whether nurse characteristics, level of comfort with care of the dying, and spirituality predict intention to refer and timing of referral to pediatric palliative/hospice care. The Behavioral Model of Health Services Use served as the framework for this study. Data were collected from 105 pediatric nurses recruited from 7 patient units of one pediatric hospital. Regression analysis revealed several nurse factors (practice unit, years of experience, age, race/ethnicity) that predicted intent to refer and timing of referral to pediatric palliative/hospice care. The relationship between nurse characteristics and intent to refer was specific to certain medical conditions (HIV, extreme prematurity, brain injuries). Healthcare providers can use these findings to improve care for children with life-limiting illnesses.
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Affiliation(s)
- Norma E Conner
- College of Nursing, University of Central Florida, Orlando, FL, USA
| | - Nizam Uddin
- Department of Statistics, University of Central Florida, Orlando, FL, USA
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Kimmel AL, Wang J, Scott RK, Briggs L, Lyon ME. FAmily CEntered (FACE) advance care planning: Study design and methods for a patient-centered communication and decision-making intervention for patients with HIV/AIDS and their surrogate decision-makers. Contemp Clin Trials 2015; 43:172-8. [PMID: 26044463 DOI: 10.1016/j.cct.2015.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/28/2015] [Accepted: 06/01/2015] [Indexed: 01/14/2023]
Abstract
Although the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has become a chronic illness, disease-specific advance care planning has not yet been evaluated for the palliative care needs of adults with HIV/AIDS. This prospective, longitudinal, randomized, two-arm controlled clinical trial aims to test the efficacy of FAmily CEntered advance care planning among adults living with AIDS and/or HIV with co-morbidities on congruence in treatment preferences, healthcare utilization, and quality of life. The FAmily CEntered intervention arm is two face-to-face sessions with a trained, certified facilitator: Session 1) Disease-Specific Advance Care Planning Respecting Choices Interview; Session 2) Completion of advance directive. The Healthy Living Control arm is: Session 1) Developmental/Relationship History; Session 2) Nutrition. Follow-up data will be collected at 3, 6, 12, and 18 months post-intervention. A total of 288 patient/surrogate dyads will be enrolled from five hospital-based, out-patient clinics in Washington, District of Columbia. Participants will be HIV positive and ≥ 21 years of age; surrogates will be ≥ 18 years of age. Exclusion criteria are homicidality, suicidality, psychosis, and impaired cognitive functioning. We hypothesize that this intervention will enhance patient-centered communication with a surrogate decision-maker about end of life treatment preferences over time, enhance patient quality of life and decrease health care utilization. We further hypothesize that this intervention will decrease health disparities for Blacks in completion of advance directives. If proposed aims are achieved, the benefits of palliative care, particularly increased treatment preferences about end-of-life care and enhanced quality of life, will be extended to people living with AIDS.
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Affiliation(s)
- Allison L Kimmel
- Center for Translational Science, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, USA.
| | - Jichuan Wang
- Center for Translational Science, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, USA; The George Washington University School of Medicine and Health Sciences, 2300 I Street NW, Washington, DC, USA.
| | - Rachel K Scott
- MedStar Washington Hospital Center, 110 Irving St NW, Washington, DC, USA.
| | - Linda Briggs
- Gunderson Lutheran Medical Foundation, Inc., 1900 South Avenue, La Crosse, WI, USA.
| | - Maureen E Lyon
- Center for Translational Science, Children's National Health System, 111 Michigan Avenue NW, Washington, DC, USA; The George Washington University School of Medicine and Health Sciences, 2300 I Street NW, Washington, DC, USA.
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Abstract
Increasing numbers, complexities and technology dependencies of children and young people with life-limiting conditions require paediatricians to be well prepared to meet their changing needs. Paediatric Advance Care Planning provides a framework for paediatricians, families and their multidisciplinary teams to consider, reflect and record the outcome of their conversations about what might happen in the future in order to optimise quality of clinical care and inform decision-making. For some children and young people this will include discussions about the possibility of death in childhood. This may be unexpected and sudden, in the context of an otherwise active management plan or may be expected and necessitate discussions about the process of dying and attention to symptoms. Decision-making about appropriate levels of intervention must take place within a legal and ethical framework, recognising that the UK Equality Act (2010) protects the rights of disabled children and young people and infants and children of all ages to the same high quality healthcare as anyone else.
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Lotz JD, Jox RJ, Borasio GD, Führer M. Pediatric advance care planning from the perspective of health care professionals: a qualitative interview study. Palliat Med 2015; 29:212-22. [PMID: 25389347 PMCID: PMC4359209 DOI: 10.1177/0269216314552091] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pediatric advance care planning differs from the adult setting in several aspects, including patients' diagnoses, minor age, and questionable capacity to consent. So far, research has largely neglected the professionals' perspective. AIM We aimed to investigate the attitudes and needs of health care professionals with regard to pediatric advance care planning. DESIGN This is a qualitative interview study with experts in pediatric end-of-life care. A qualitative content analysis was performed. SETTING/PARTICIPANTS We conducted 17 semi-structured interviews with health care professionals caring for severely ill children/adolescents, from different professions, care settings, and institutions. RESULTS Perceived problems with pediatric advance care planning relate to professionals' discomfort and uncertainty regarding end-of-life decisions and advance directives. Conflicts may arise between physicians and non-medical care providers because both avoid taking responsibility for treatment limitations according to a minor's advance directive. Nevertheless, pediatric advance care planning is perceived as helpful by providing an action plan for everyone and ensuring that patient/parent wishes are respected. Important requirements for pediatric advance care planning were identified as follows: repeated discussions and shared decision-making with the family, a qualified facilitator who ensures continuity throughout the whole process, multi-professional conferences, as well as professional education on advance care planning. CONCLUSION Despite a perceived need for pediatric advance care planning, several barriers to its implementation were identified. The results remain to be verified in a larger cohort of health care professionals. Future research should focus on developing and testing strategies for overcoming the existing barriers.
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Affiliation(s)
- Julia D Lotz
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University, Munich, Germany
| | - Gian Domenico Borasio
- Service de Soins Palliatifs, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
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Kavalieratos D, Ernecoff NC, Keim-Malpass J, Degenholtz HB. Knowledge, attitudes, and preferences of healthy young adults regarding advance care planning: a focus group study of university students in Pittsburgh, USA. BMC Public Health 2015; 15:197. [PMID: 25885778 PMCID: PMC4349677 DOI: 10.1186/s12889-015-1575-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To date, research and promotion regarding advance care planning (ACP) has targeted those with serious illness or the elderly, thereby ignoring healthy young adults. The purpose of this study was to explore young adults' knowledge, attitudes, and preferences regarding advance care planning (ACP) and medical decision-making. Further, we aimed to understand the potential role of public health to encourage population-based promotion of ACP. METHODS Between February 2007 and April 2007, we conducted six focus groups comprising 56 young adults ages 18-30. Topics explored included (1) baseline knowledge regarding ACP, (2) preferences for ACP, (3) characteristics of preferred surrogates, and (4) barriers and facilitators to completing ACP specific to age and individuation. We used a qualitative thematic approach to analyze transcripts. RESULTS All participants desired more information regarding ACP. In addition, participants expressed (1) heterogeneous attitudes regarding triggers to perform ACP, (2) the opinion that ACP is a marker of individuation, (3) the belief that prior exposure to illness plays a role in prompting ACP, and (4) an appreciation that ACP is flexible to changes in preferences and circumstances throughout the life-course. CONCLUSION Young adults perceive ACP as a worthwhile health behavior and view a lack of information as a major barrier to discussion and adoption. Our data emphasize the need for strategies to increase ACP knowledge, while encouraging population-level, patient-centered, healthcare decision-making.
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Affiliation(s)
- Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA, 15213, USA.
| | - Natalie C Ernecoff
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Howard B Degenholtz
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
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Rosenberg AR, Yi-Frazier JP, Eaton L, Wharton C, Cochrane K, Pihoker C, Baker KS, McCauley E. Promoting Resilience in Stress Management: A Pilot Study of a Novel Resilience-Promoting Intervention for Adolescents and Young Adults With Serious Illness. J Pediatr Psychol 2015; 40:992-9. [PMID: 25678533 DOI: 10.1093/jpepsy/jsv004] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/07/2015] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To examine the feasibility and format of the Promoting Resilience in Stress Management (PRISM) intervention among two groups of adolescents and young adults (AYAs) at-risk for poor outcomes: those with Type 1 diabetes (T1D) or cancer. METHODS PRISM consists of two long or four short skills-based modules. English-speaking patients 12-25 years old were eligible if they had T1D for >6 months or cancer for >2 weeks. Feasibility was defined as an 80% completion rate and high satisfaction. Ongoing monitoring shaped iterative refinement of disease-specific approach. RESULTS 12 of 15 patients with T1D (80%) completed the two-session intervention. 3 of 15 patients with cancer declined to complete the two-session version, citing prohibitive length of individual sessions. 12 (80%) completed the four-session version. Patient-reported satisfaction was high across groups. CONCLUSIONS The PRISM intervention is feasible and well-accepted by AYAs with cancer or T1D. Differences in patient populations warrant differences in approach.
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Affiliation(s)
- Abby R Rosenberg
- Seattle Children's Research Institute, University of Washington School of Medicine and Fred Hutchinson Cancer Research Center
| | - Joyce P Yi-Frazier
- Seattle Children's Research Institute, University of Washington School of Medicine and
| | - Lauren Eaton
- Seattle Children's Research Institute, University of Washington School of Medicine and
| | - Claire Wharton
- Seattle Children's Research Institute, University of Washington School of Medicine and
| | - Katherine Cochrane
- Seattle Children's Research Institute, University of Washington School of Medicine and
| | - Catherine Pihoker
- Seattle Children's Research Institute, University of Washington School of Medicine and
| | - K Scott Baker
- Seattle Children's Research Institute, University of Washington School of Medicine and Fred Hutchinson Cancer Research Center
| | - Elizabeth McCauley
- Seattle Children's Research Institute, University of Washington School of Medicine and
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50
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Feenstra B, Lawson ML, Harrison D, Boland L, Stacey D. Decision coaching using the Ottawa family decision guide with parents and their children: a field testing study. BMC Med Inform Decis Mak 2015; 15:5. [PMID: 25889602 PMCID: PMC4326318 DOI: 10.1186/s12911-014-0126-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 12/19/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Although children can benefit from being included in health decisions, little is known about effective interventions to support their involvement. The objective of this study was to evaluate the feasibility and acceptability of decision coaching guided by the Ottawa Family Decision Guide with children and parents considering insulin delivery options for type 1 diabetes (insulin pump, multiple daily injections, or standard insulin injections). METHODS Pre-/post-test field testing design. Eligible participants were children (≤18 years) with type 1 diabetes and their parents attending an ambulatory diabetes clinic in a tertiary children's hospital. Parent-child dyads received decision coaching using the Ottawa Family Decision Guide that was pre-populated with evidence on insulin delivery options, benefits, and harms. Primary outcomes were feasibility of recruitment and data collection, and parent and child acceptability of the intervention. RESULTS Of 16 families invited to participate, 12 agreed and 7 attended the decision coaching session. For the five missed families, two families were unable to attend the session or the decision coach was not available (N=3). Baseline and immediately post-coaching questionnaires were all completed and follow-up questionnaires two weeks post-coaching were missing from one parent-child dyad. Missing questionnaire items were 5 of 340 items for children (1.5%) and 1 of 429 for parents (0.2%). Decision coaching was rated as acceptable with higher scores from parents and their children who were in earlier stages of decision making. CONCLUSION Decision coaching with children and their parents considering insulin options was feasible implement and evaluate in our diabetes clinic and was acceptable to participants. Recruitment was difficult due to scheduling restrictions related to the timing of the study. Coaching should target participants earlier in the decision making process and be scheduled at times that are convenient for families and coaches. Findings were used to inform a full-scale evaluation that is currently underway.
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Affiliation(s)
- Bryan Feenstra
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road (Rm 1118), Ottawa, ON, K1H 8 M5, Canada.
| | - Margaret L Lawson
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.
| | - Denise Harrison
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road (Rm 1118), Ottawa, ON, K1H 8 M5, Canada.
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
| | - Laura Boland
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road (Rm 1118), Ottawa, ON, K1H 8 M5, Canada.
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.
| | - Dawn Stacey
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road (Rm 1118), Ottawa, ON, K1H 8 M5, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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