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Nye RT, Hill DL, Carroll KW, Boyden JY, Katcoff H, Griffis H, Campos D, Hall M, Wolfe J, Feudtner C. The Design of a Data Management System for a Multicenter Palliative Care Cohort Study. J Pain Symptom Manage 2022; 64:e53-e60. [PMID: 35339611 PMCID: PMC10484234 DOI: 10.1016/j.jpainsymman.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/10/2022] [Accepted: 03/16/2022] [Indexed: 11/23/2022]
Abstract
CONTEXT Prospective cohort studies of individuals with serious illness and their family members, such as children receiving palliative care and their parents, pose challenges regarding data management. OBJECTIVE To describe the design and lessons learned regarding the data management system for the Pediatric Palliative Care Research Network's Shared Data and Research (SHARE) project, a multicenter prospective cohort study of children receiving pediatric palliative care (PPC) and their parents, and to describe important attributes of this system, with specific considerations for the design of future studies. METHODS The SHARE study consists of 643 PPC patients and up to two of their parents who enrolled from April 2017 to December 2020 at seven children's hospitals across the United States. Data regarding demographics, patient symptoms, goals of care, and other characteristics were collected directly from parents or patients at 6 timepoints over a 24-month follow-up period and stored electronically in a centralized location. Using medical record numbers, primary collected data was linked to administrative hospitalization data containing diagnostic and procedure codes and other data elements. Important attributes of the data infrastructure include linkage of primary and administrative data; centralized availability of multilingual questionnaires; electronic data collection and storage system; time-stamping of instrument completion; and a separate but connected study administrative database used to track enrollment. CONCLUSIONS Investigators planning future multicenter prospective cohort studies can consider attributes of the data infrastructure we describe when designing their data management system.
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Affiliation(s)
- Russell T Nye
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Data Science and Biostatistics Unit (R.T.N., H.K., H.G.), Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Douglas L Hill
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Division of General Pediatrics (D.L.H., J.Y.B., C.F.), The Children's Hospital of Philadelphia Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jackelyn Y Boyden
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Division of General Pediatrics (D.L.H., J.Y.B., C.F.), The Children's Hospital of Philadelphia Philadelphia, Pennsylvania, USA
| | - Hannah Katcoff
- Data Science and Biostatistics Unit (R.T.N., H.K., H.G.), Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit (R.T.N., H.K., H.G.), Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Diego Campos
- Department of Biomedical and Health Informatics (D.C.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matt Hall
- Children's Hospital Association (M.H.), Lenexa, Kansas, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care (J.W.), Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Boston Children's Hospital (J.W.), Boston, Massachusetts, USA
| | - Chris Feudtner
- Justin Ingerman Center for Palliative Care (R.T.N., D.L.H., K.W.C., J.Y.B., C.F.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Division of General Pediatrics (D.L.H., J.Y.B., C.F.), The Children's Hospital of Philadelphia Philadelphia, Pennsylvania, USA
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Walter JK, Hill DL, Schall TE, Szymczak JE, Parikh S, DiDomenico C, Carroll KW, Nye RT, Feudtner C. An Interprofessional Team-Based Intervention to Address Barriers to Initiating Palliative Care in Pediatric Oncology: A Multiple-Method Evaluation of Feasibility, Acceptability, and Impact. J Pain Symptom Manage 2021; 62:1135-1144. [PMID: 34153461 PMCID: PMC8648922 DOI: 10.1016/j.jpainsymman.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Many children with advanced cancer are not referred to palliative care despite both professional recommendations to do so and bereaved parental preference for earlier support from sub-specialty palliative care. OBJECTIVES To assess the feasibility, acceptability, and impact of an adaptive intervention to address individual and team-level barriers to specialty palliative care referrals. METHODS A multiple-method approach assessed feasibility and acceptability among clinicians from pediatric oncology teams at a single institution. Quantitative measures of comfort with palliative care consultations, team cohesion, and team collaboration were conducted before and after the intervention. Number of palliative care consults were examined before, during, and after sessions. Intervention satisfaction surveys and qualitative interviews were conducted after the intervention. RESULTS Twenty-six team members (90% of consented) attended at least one intervention session with 20 (69%) participants completing 75% or more sessions. The intervention was modified in response to participant feedback. After the intervention, participants reported greater team cohesion, comfort discussing palliative care consultation, team collaboration, process satisfaction, and decision satisfaction. Participants agreed that the training was useful, effective, helpful, and worthwhile, that they would use the skills, and that they would recommend the training to other providers. The numbers of palliative care consults increased before intervention sessions were conducted, but did not significantly change during or after the sessions. In the interviews, participants reported overall favorably regarding the intervention with some participants reporting changes in practice. CONCLUSION An adaptive intervention to reduce barriers to initiating palliative care for pediatric oncology teams is feasible and acceptable.
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Affiliation(s)
- Jennifer K Walter
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA.
| | - Theodore E Schall
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania (J.E.S.), Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
| | - Connie DiDomenico
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Division of Pediatric Oncology (C.D.), Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Russell T Nye
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
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Boyden JY, Hill DL, Carroll KW, Morrison WE, Miller VA, Feudtner C. The Association of Perceived Social Support with Anxiety over Time in Parents of Children with Serious Illnesses. J Palliat Med 2019; 23:527-534. [PMID: 31697175 DOI: 10.1089/jpm.2019.0387] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background: Parenting a child with a serious life-threatening illness (SLTI) may impact parents' mental health. The protective association of social support with anxiety over time following an acute medical event has not been empirically tested in a sample of parents of children with oncologic and nononcologic serious illnesses. Objective: To test the potential association of perceived social support with anxiety in parents of children with SLTIs over time. Design: Prospective cohort study. Setting/Subjects: Two hundred parents of 158 children in the Decision Making in Serious Pediatric Illness study, conducted at the Children's Hospital of Philadelphia. Measurements: Parental anxiety and perceived social support were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Social Provisions Scale (SPS). We performed bivariate linear regressions to test cross-sectional and longitudinal associations between the SPS and anxiety scores at baseline, 12 months, and 24 months. Results: The average SPS total and subscale scores decreased significantly from baseline to 12 months, and increased from 12 to 24 months. The average HADS-Anxiety scores decreased significantly from baseline to 12 months, and remained stable at 24 months. Cross-sectionally, total SPS scores were negatively associated with anxiety scores at each time point. Longitudinally, SPS scores were associated with anxiety scores, although this association weakened in adjusted modeling. Conclusions: Over a two-year period, higher levels of perceived social support were associated with lower levels of anxiety in parents of seriously ill children. Clinicians and researchers should work to optimize social support for families to improve parental mental health outcomes.
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Affiliation(s)
- Jackelyn Y Boyden
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Hill
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen W Carroll
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wynne E Morrison
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victoria A Miller
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Hill DL, Faerber JA, Li Y, Miller VA, Carroll KW, Morrison W, Hinds PS, Feudtner C. Changes Over Time in Good-Parent Beliefs Among Parents of Children With Serious Illness: A Two-Year Cohort Study. J Pain Symptom Manage 2019; 58:190-197. [PMID: 31026508 PMCID: PMC6679776 DOI: 10.1016/j.jpainsymman.2019.04.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022]
Abstract
CONTEXT Parents of seriously ill children hold personal beliefs about what they should do to be good parents. How these beliefs change over time is unknown. OBJECTIVES The objectives of this study were to describe the pattern of Good-Parent Beliefs over time, and determine whether parents' hopeful patterns of thinking, affect, and perceived child's health are associated with changes in beliefs at 12 and 24 months. METHODS Our longitudinal sample included 124 parents of 100 children hospitalized with serious illness. We used latent transition models to classify parents into groups with similar Good-Parent Beliefs during the baseline and follow-up periods and modeled the change in good-parent beliefs over time as a function of covariates using generalized linear mixed models. RESULTS Two parent belief profiles emerged from the latent transition model: Loved ("Making sure my child feels loved," n = 61 at baseline) and Informed ("Making informed decisions," n = 63 at baseline). At 12 months, 21 parents (20.4%) had moved into the Loved group and no parents transitioned to the Informed group. By 24 months, eight parents transitioned to the Loved group and four to the Informed group (13.04%). Transition into the Loved group was associated with parents' baseline degree of hopeful thinking and positive perceptions of child's health at baseline. CONCLUSION Some parents change their parenting priorities over time. Hopeful patterns of thinking and perception of child health appear to predict change. Clinicians should regularly reevaluate Good-Parent Beliefs over time to promote priority-congruent dialogue.
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Affiliation(s)
- Douglas L Hill
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer A Faerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yimei Li
- Departments of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Victoria A Miller
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pamela S Hinds
- Department of Nursing Science, Professional Practice, and Quality, Children's National Health System, Washington, DC, USA; Department of Pediatrics, School of Medicine and the Health Sciences, George Washington University, Washington, DC, USA
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Hill DL, Carroll KW, Snyder KJG, Mascarenhas M, Erlichman J, Patterson CA, Barakat LP, Feudtner C. Development and Pilot Testing of a Coping Kit for Parents of Hospitalized Children. Acad Pediatr 2019; 19:454-463. [PMID: 30415078 DOI: 10.1016/j.acap.2018.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/20/2018] [Accepted: 11/02/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Serious pediatric illness places great stress on families. Parents who learn coping skills may better manage these stressors. This study sought to develop and refine a stress coping intervention for parents of hospitalized children, assess the intervention acceptability among these parents, and gather preliminary data on stress, negative and positive affect, anxiety, depression, and self-efficacy. METHODS We conducted an observational study in 2 phases, enrolling parents of children who were inpatients with serious illness, 10 in Phase 1 and 40 in Phase 2. All parents completed at baseline measures of stress and psychological well-being and were introduced to the Coping Kit for Parents. Follow-up interviews were conducted at 1 week (all parents) and 1 month (Phase 2 parents only) regarding the acceptability of the intervention. RESULTS At baseline, parents reported that stressful situations were frequent (mean = 30.6, standard deviation [SD] = 6.8) and difficult (mean = 26.2, SD = 7.1) and revealed elevated levels of negative affect (mean = 27.3, SD = 7.7), depression (mean = 8.5, SD = 3.7), and anxiety (mean = 11.3, SD = 3.1) and moderate levels of self-efficacy related to their child's illness (mean = 3.3, SD = 0.5). The majority of parents used the kit regularly and on a scale of 1 to 7 agreed that the kit was helpful (mean = 6.0, SD = 0.9), interesting (mean = 5.7, SD = 1.3), practical (mean = 5.7, SD = 1.4), enjoyable (mean = 6.0, SD = 1.3), and they would recommend it to other parents (mean = 6.4, SD = 0.9). CONCLUSIONS The Coping Kit for Parents is an acceptable stress management intervention that could be made available to parents of children with serious illness at pediatric hospitals with minimal staff training or time commitment.
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Affiliation(s)
- Douglas L Hill
- Pediatric Advanced Care Team (DL Hill, KW Carroll, KJG Snyder, C Feudtner), Division of Gastroenterology (M Mascarenhas, J Erlichman), Division of Neonatology (CA Patterson), and Division of Oncology (LP Barakat), The Children's Hospital of Philadelphia, Philadelphia, Pa.
| | - Karen W Carroll
- Pediatric Advanced Care Team (DL Hill, KW Carroll, KJG Snyder, C Feudtner), Division of Gastroenterology (M Mascarenhas, J Erlichman), Division of Neonatology (CA Patterson), and Division of Oncology (LP Barakat), The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - K J G Snyder
- Pediatric Advanced Care Team (DL Hill, KW Carroll, KJG Snyder, C Feudtner), Division of Gastroenterology (M Mascarenhas, J Erlichman), Division of Neonatology (CA Patterson), and Division of Oncology (LP Barakat), The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Maria Mascarenhas
- Pediatric Advanced Care Team (DL Hill, KW Carroll, KJG Snyder, C Feudtner), Division of Gastroenterology (M Mascarenhas, J Erlichman), Division of Neonatology (CA Patterson), and Division of Oncology (LP Barakat), The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Jessi Erlichman
- Pediatric Advanced Care Team (DL Hill, KW Carroll, KJG Snyder, C Feudtner), Division of Gastroenterology (M Mascarenhas, J Erlichman), Division of Neonatology (CA Patterson), and Division of Oncology (LP Barakat), The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Chavis A Patterson
- Pediatric Advanced Care Team (DL Hill, KW Carroll, KJG Snyder, C Feudtner), Division of Gastroenterology (M Mascarenhas, J Erlichman), Division of Neonatology (CA Patterson), and Division of Oncology (LP Barakat), The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Lamia P Barakat
- Pediatric Advanced Care Team (DL Hill, KW Carroll, KJG Snyder, C Feudtner), Division of Gastroenterology (M Mascarenhas, J Erlichman), Division of Neonatology (CA Patterson), and Division of Oncology (LP Barakat), The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Chris Feudtner
- Pediatric Advanced Care Team (DL Hill, KW Carroll, KJG Snyder, C Feudtner), Division of Gastroenterology (M Mascarenhas, J Erlichman), Division of Neonatology (CA Patterson), and Division of Oncology (LP Barakat), The Children's Hospital of Philadelphia, Philadelphia, Pa
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Hill DL, Nathanson PG, Carroll KW, Schall TE, Miller VA, Feudtner C. Changes in Parental Hopes for Seriously Ill Children. Pediatrics 2018; 141:peds.2017-3549. [PMID: 29567813 PMCID: PMC5869332 DOI: 10.1542/peds.2017-3549] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Hopes of parents of children with serious illness play an important role in decision-making and coping. Little is known about how parent hopes change over time. We describe the changes in parent hopes across multiple domains and time intervals, examine hopes in a subgroup of parents whose child died, and explore the maintenance of domains over time. METHODS In a mixed-methods prospective cohort study on decision-making, parents of seriously ill children reported demographic characteristics and hopes at baseline and reported any changes in hopes at 4-, 8-, 12-, 16-, and 20-month follow-up visits. Hopes were coded into 9 domains. Hope changes and domain changes were identified for each parent at each visit. RESULTS One hundred and ninety-nine parents of 158 patients most often reported hopes in the domains of quality of life (75%), physical body (69%), future well-being (47%), and medical care (34%). Hope percentages increased over time for quality of life (84%), future well-being (64%), and broader meaning (21%). The hope domains reported by parents of children who died were similar to the rest of the sample. The majority of parents who completed 5 to 6 follow-up visits changed at least 1 domain. At the individual parent level, some domains revealed considerable change over time, whereas other domains were stable among a subset of parents. CONCLUSIONS The specific hopes and overall areas of hope of parents of seriously ill children vary over time, although most hopes fall within 4 major areas. Accordingly, clinicians should regularly check with parents about their current hopes.
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Affiliation(s)
| | | | | | | | | | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Hill DL, Nathanson PG, Fenderson RM, Carroll KW, Feudtner C. Parental Concordance Regarding Problems and Hopes for Seriously Ill Children: A Two-Year Cohort Study. J Pain Symptom Manage 2017; 53:911-918. [PMID: 28062346 PMCID: PMC6644049 DOI: 10.1016/j.jpainsymman.2016.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/02/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
Abstract
CONTEXT Parents of a seriously ill child may have different concerns and hopes for their child, and these concerns and hopes may change over time. OBJECTIVES In a mixed-method prospective cohort of parental dyads of children with serious illness, to describe the major problems and hopes perceived for their child, examine the degree of concordance between parents, and assess whether prevalence and concordance change over time. METHODS Eighty-four parents (42 dyads) of seriously ill children reported the major problems and hopes for their children at baseline. Thirty-two parents (16 dyads) answered the same questions at 24 months. Problems and hopes were classified into nine domains. Observed concordance was calculated between parents on each domain. Data for parents of 11 children who died are reported separately. RESULTS The most common major problem and hope domains at baseline were physical body, quality of life, future health and well-being, and medical care. Parental dyads demonstrated a moderately high percentage of concordance (69%) regarding reported problem domains and a slightly lower percentage of concordance on hopes (61%), with higher concordance for more common domains. Domain prevalence and concordance changed considerably at 24 months. Parents of children who later died showed markedly different patterns of domain prevalence and more extreme patterns of concordance. CONCLUSION Parents of children with serious illness may have different perspectives regarding major problems and hopes, and these perspectives change over time. Parents of sicker children are more likely to be in either complete agreement or disagreement regarding the problems and hopes they identify.
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Affiliation(s)
- Douglas L Hill
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Pamela G Nathanson
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rebecca M Fenderson
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Hill DL, Carroll KW, Dai D, Faerber JA, Dougherty SL, Feudtner C. Identifying Communication-Impaired Pediatric Patients Using Detailed Hospital Administrative Data. Hosp Pediatr 2016; 6:456-467. [PMID: 27381628 DOI: 10.1542/hpeds.2015-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Pediatric inpatients with communication impairment may experience inadequate pain and symptom management. Research regarding potential variation in care among patients with and without communication impairment is hampered because existing pediatric databases do not include information about patient communication ability per se, even though these data sets do contain information about diagnoses and medical interventions that are probably correlated with the probability of communication impairment. Our objective was to develop and evaluate a classification model to identify patients in a large administrative database likely to be communication impaired. METHODS Our sample included 236 hospitalized patients aged ≥12 months whose ability to communicate about pain had been assessed. We randomly split this sample into development (n = 118) and validation (n = 118) sets. A priori, we developed a set of specific diagnoses, technology dependencies, procedures, and medications recorded in the Pediatric Health Information System likely to be strongly associated with communication impairment. We used logistic regression modeling to calculate the probability of communication impairment for each patient in the development set, assessed the model performance, and evaluated the performance of the 11-variable model in the validation set. RESULTS In the validation sample, the classification model showed excellent classification accuracy (area under the receiver operating characteristic curve 0.92; sensitivity 82.6%; 95% confidence interval, 74%-100%; specificity 86.3%; 95% confidence interval, 80%-97%). For the complete sample, the predicted probability of communication impairment demonstrated excellent calibration with the observed communication impairment status. CONCLUSIONS Hospitalized pediatric patients with communication impairment can be accurately identified in a large hospital administrative database.
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Affiliation(s)
- Douglas L Hill
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Karen W Carroll
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Dingwei Dai
- Infomatics, Independence Blue Cross, Philadelphia, Pennsylvania
| | - Jennifer A Faerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Susan L Dougherty
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
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Madrigal VN, Carroll KW, Faerber JA, Walter JK, Morrison WE, Feudtner C. Parental Sources of Support and Guidance When Making Difficult Decisions in the Pediatric Intensive Care Unit. J Pediatr 2016; 169:221-6.e4. [PMID: 26651432 DOI: 10.1016/j.jpeds.2015.10.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 09/11/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess sources of support and guidance on which parents rely when making difficult decisions in the pediatric intensive care unit and to evaluate associations of sources of support and guidance to anxiety, depression, and positive and negative affect. STUDY DESIGN This was a prospective cohort study of 86 English-speaking parents of 75 children in the pediatric intensive care unit at The Children's Hospital of Philadelphia who were hospitalized greater than 72 hours. Parents completed standardized instruments and a novel sources of support and guidance assessment. RESULTS Most parents chose physicians, nurses, friends, and extended family as their main sources of support and guidance when making a difficult decision. Descriptive analysis revealed a broad distribution for the sources of support and guidance items related to spirituality. Parents tended to fall into 1 of 2 groups when we used latent class analysis: the more-spiritual group (n = 47; 55%) highly ranked "what my child wants" (P = .023), spouses (P = .002), support groups (P = .003), church community (P < .001), spiritual leader (P < .001), higher power (P < .001), and prayer (P < .001) compared with the less-spiritual group (n = 39; 45%). The more-spiritual parents had greater positive affect scores (P = .005). Less-spiritual parents had greater depression scores (P = .043). CONCLUSIONS Parents rely most on physicians, nurses, and friends and extended family when making difficult decisions for their critically ill child. Respondents tended to fall into 1 of 2 groups where the more-spiritual respondents were associated with greater positive affect and may be more resistant to depression.
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Affiliation(s)
- Vanessa N Madrigal
- Division of Critical Care Medicine, Children's National Medical Center; George Washington University School of Medicine, Washington, DC.
| | - Karen W Carroll
- Department of Pediatrics, The Children's Hospital of Philadelphia; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jennifer A Faerber
- Department of Pediatrics, The Children's Hospital of Philadelphia; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jennifer K Walter
- Department of Pediatrics, The Children's Hospital of Philadelphia; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Wynne E Morrison
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia; University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Chris Feudtner
- Department of Pediatrics, The Children's Hospital of Philadelphia; University of Pennsylvania School of Medicine, Philadelphia, PA
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Humphrey LM, Hill DL, Carroll KW, Rourke M, Kang TI, Feudtner C. Psychological Well-Being and Family Environment of Siblings of Children with Life Threatening Illness. J Palliat Med 2015; 18:981-4. [PMID: 26393493 DOI: 10.1089/jpm.2015.0150] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The psychological well-being of siblings of children with life threatening illness remains largely uncharted. Pediatric cancer research suggests that a supportive family environment may protect the psychological well-being of siblings. OBJECTIVE We hypothesized that (1) siblings of pediatric palliative care patients would show clinical/behavioral scores that were elevated but that rates of serious psychopathology would be comparable to the general population of children their age; and (2) higher family functioning scores would be associated with lower clinical scores and higher adaptive scores for these siblings. METHODS We conducted an observational study with families in which a patient receiving palliative care had one or more siblings between the ages of 6 and 11. Parents completed the Behavioral Assessment System for Children, Second Edition (BASC-2) to assess the siblings' psychological well-being and the Family Assessment Device (FAD) to assess the family environment. RESULTS Twenty-four parents reported data for 30 siblings. Only three siblings scored in the clinical range on a BASC-2 composite clinical scale, and 11 siblings scored in the at-risk range on one or more composite scales. Higher FAD scores predicted significantly higher externalization composite clinical scores (7.54, 95% CI: 1.12, 13.97, p < 0.05) and significantly higher behavioral composite scores (7.88, 95% CI: 1.55, 14.21, p < 0.05). DISCUSSION Siblings of pediatric palliative care patients are not experiencing lower psychological well-being than the general population. The prediction that a positive family environment would be associated with higher levels of psychological health was supported.
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Affiliation(s)
| | - Douglas L Hill
- 2 The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Karen W Carroll
- 2 The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Mary Rourke
- 3 Widener University , Chester, Pennsylvania
| | - Tammy I Kang
- 2 The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Chris Feudtner
- 2 The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
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Feudtner C, Walter JK, Faerber JA, Hill DL, Carroll KW, Mollen CJ, Miller VA, Morrison WE, Munson D, Kang TI, Hinds PS. Good-parent beliefs of parents of seriously ill children. JAMA Pediatr 2015; 169:39-47. [PMID: 25419676 PMCID: PMC4946564 DOI: 10.1001/jamapediatrics.2014.2341] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Parents' beliefs about what they need to do to be a good parent when their children are seriously ill influence their medical decisions, and better understanding of these beliefs may improve decision support. OBJECTIVE To assess parents' perceptions regarding the relative importance of 12 good-parent attributes. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional, discrete-choice experiment was conducted at a children's hospital. Participants included 200 parents of children with serious illness. MAIN OUTCOMES AND MEASURES Ratings of 12 good-parent attributes, with subsequent use of latent class analysis to identify groups of parents with similar ratings of attributes, and ascertainment of whether membership in a particular group was associated with demographic or clinical characteristics. RESULTS The highest-ranked good-parent attribute was making sure that my child feels loved, followed by focusing on my child's health, making informed medical care decisions, and advocating for my child with medical staff. We identified 4 groups of parents with similar patterns of good-parent-attribute ratings, which we labeled as: child feels loved (n=68), child's health (n=56), advocacy and informed (n=55), and spiritual well-being (n=21). Compared with the other groups, the child's health group reported more financial difficulties, was less educated, and had a higher proportion of children with new complex, chronic conditions. CONCLUSIONS AND RELEVANCE Parents endorse a broad range of beliefs that represent what they perceive they should do to be a good parent for their seriously ill child. Common patterns of how parents prioritize these attributes exist, suggesting future research to better understand the origins and development of good-parent beliefs among these parents. More important, engaging parents individually regarding what they perceive to be the core duties they must fulfill to be a good parent may enable more customized and effective decision support.
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Affiliation(s)
- Chris Feudtner
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer K. Walter
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer A. Faerber
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Douglas L. Hill
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen W. Carroll
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cynthia J. Mollen
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Victoria A. Miller
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wynne E. Morrison
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Munson
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tammy I. Kang
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pamela S. Hinds
- Department of Nursing Research and Quality Outcomes, Children’s National Health System, Washington, DC4Department of Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, DC
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Hill DL, Carroll KW, Dougherty S, Vega C, Feudtner C. Point prevalence study of pediatric inpatients who are unable to communicate effectively about pain. Hosp Pediatr 2014; 4:382-386. [PMID: 25362081 DOI: 10.1542/hpeds.2014-0006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Pediatric inpatients may be at risk for inadequate pain management if they are unable to communicate effectively because of age, physical or cognitive impairment, or medical procedures. We conducted a point prevalence study to estimate the proportion of inpatients at a children's hospital who have difficulty communicating to hospital staff. METHODS We obtained nurse reports of ability to communicate for all inpatients aged ≥12 months in a pediatric hospital. Demographic information was obtained from the medical record. RESULTS Questionnaires were completed for 254 inpatients. Forty percent of inpatients had some difficulty communicating, and 69% had experienced pain during the hospitalization. Patient ability to communicate was not related to experiencing pain (χ(2) test, P = .30) or effectiveness of pain management (χ(2) test, P = .80) but was associated with difficulty communicating about pain and nurses needing help from the caretaker to communicate with the patient (χ(2) tests, Ps < .001). CONCLUSIONS A substantial proportion of inpatients aged ≥12 months at a large children's hospital had difficulties communicating effectively and experienced pain during hospitalization. These communication difficulties were not associated with nurse reports of the effectiveness of pain management. However, patients who had difficulties communicating in general were also more likely to have difficulty communicating about pain specifically, and nurses were more likely to need help from the caregiver to understand these patients. Future directions include identifying which conditions, procedures, and medications are associated with inability to communicate.
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Affiliation(s)
- Douglas L Hill
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karen W Carroll
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Dougherty
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cassandra Vega
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris Feudtner
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Hill DL, Miller V, Walter JK, Carroll KW, Morrison WE, Munson DA, Kang TI, Hinds PS, Feudtner C. Regoaling: a conceptual model of how parents of children with serious illness change medical care goals. BMC Palliat Care 2014; 13:9. [PMID: 24625345 PMCID: PMC3975157 DOI: 10.1186/1472-684x-13-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 03/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Parents of seriously ill children participate in making difficult medical decisions for their child. In some cases, parents face situations where their initial goals, such as curing the condition, may have become exceedingly unlikely. While some parents continue to pursue these goals, others relinquish their initial goals and generate new goals such as maintaining the child's quality of life. We call this process of transitioning from one set of goals to another regoaling. DISCUSSION Regoaling involves factors that either promote or inhibit the regoaling process, including disengagement from goals, reengagement in new goals, positive and negative affect, and hopeful thinking. We examine these factors in the context of parental decision making for a seriously ill child, presenting a dynamic conceptual model of regoaling. This model highlights four research questions that will be empirically tested in an ongoing longitudinal study of medical decision making among parents of children with serious illness. Additionally, we consider potential clinical implications of regoaling for the practice of pediatric palliative care. SUMMARY The psychosocial model of regoaling by parents of children with a serious illness predicts that parents who experience both positive and negative affect and hopeful patterns of thought will be more likely to relinquish one set of goals and pursue a new set of goals. A greater understanding of how parents undergo this transition may enable clinicians to better support them through this difficult process.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Chris Feudtner
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Hill DL, Miller VA, Hexem KR, Carroll KW, Faerber JA, Kang T, Feudtner C. Problems and hopes perceived by mothers, fathers and physicians of children receiving palliative care. Health Expect 2013; 18:1052-65. [PMID: 23683168 DOI: 10.1111/hex.12078] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2013] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The quality of shared decision making for children with serious illness may depend on whether parents and physicians share similar perceptions of problems and hopes for the child. OBJECTIVE (i) Describe the problems and hopes reported by mothers, fathers and physicians of children receiving palliative care; (ii) examine the observed concordance between participants; (iii) examine parental perceived agreement; and (iv) examine whether parents who identified specific problems also specified corresponding hopes, or whether the problems were left 'hopeless'. METHOD Seventy-one parents and 43 physicians were asked to report problems and hopes and perceived agreement for 50 children receiving palliative care. Problems and hopes were classified into eight domains. Observed concordance was calculated between parents and between each parent and the physicians. RESULTS The most common problem domains were physical body (88%), quality of life (74%) and medical knowledge (48%). The most common hope domains were quality of life (88%), suffering (76%) and physical body (39%). Overall parental dyads demonstrated a high percentage of concordance (82%) regarding reported problem domains and a lower percentage of concordance on hopes (65%). Concordance between parents and physicians regarding specific children was lower on problem (65-66%) and hope domains (59-63%). Respondents who identified problems regarding a child's quality of life or suffering were likely to also report corresponding hopes in these domains (93 and 82%, respectively). CONCLUSION Asking parents and physicians to talk about problems and hopes may provide a straightforward means to improve the quality of shared decision making for critically ill children.
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Affiliation(s)
- Douglas L Hill
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Victoria A Miller
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kari R Hexem
- Pediatric Advanced Care Team, The University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA
| | - Karen W Carroll
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer A Faerber
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tammy Kang
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Hexem KR, Miller VA, Carroll KW, Faerber JA, Feudtner C. Putting on a happy face: emotional expression in parents of children with serious illness. J Pain Symptom Manage 2013; 45:542-51. [PMID: 22926092 PMCID: PMC3510342 DOI: 10.1016/j.jpainsymman.2012.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 03/07/2012] [Accepted: 03/10/2012] [Indexed: 11/20/2022]
Abstract
CONTEXT Communication is widely acknowledged as a crucial component of high-quality pediatric medical care, which is provided in situations in which parents typically experience strong emotions. OBJECTIVES To explore emotion using the Linguistic Inquiry and Word Count (LIWC) and a self-report questionnaire to better understand the relationship between these two measures of emotion in a pediatric care context. METHODS Sixty-nine parents of 47 children who were participants in the Decision Making in Pediatric Palliative Care Study at The Children's Hospital of Philadelphia took part in this study. Parents completed the Positive and Negative Affect Schedule (PANAS) and a semistructured interview about their children and experience with medical decision making. The transcribed interviews were analyzed with the LIWC program, which yields scores for positive and negative emotional expression. The association between LIWC and PANAS scores was evaluated using multivariate linear regression to adjust for potential confounders. RESULTS Parents who used more positive words when speaking about the illnesses of their children and the experience of medical decision making were more likely to report lower levels of positive affect on the PANAS: increase in the standard deviation of positive emotional expression was associated with an unadjusted 7.4% decrease in the self-reported positive affect (P = 0.015) and an adjusted 7.0% decrease in the self-reported positive affect (P = 0.057) after modeling for potential confounders. Increase in the standard deviation of negative emotional expression was associated with an adjusted 9.4% increase in the self-reported negative affect (P = 0.036). CONCLUSION The inverse relationship between parents' positive emotional expression and their self-reported positive affect should remind both researchers and clinicians to be cognizant of the possibilities for emotional miscues, and consequent miscommunication, in the pediatric care setting.
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Affiliation(s)
- Kari R Hexem
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Abstract
OBJECTIVE To identify and illustrate common explicit heuristics (decision-making aids or shortcuts expressed verbally as terse rules of thumb, aphorisms, maxims, or mantras and intended to convey a compelling truth or guiding principle) used by parents of children with life-threatening illnesses when confronting and making medical decisions. METHODS Prospective cross-sectional observational study of 69 parents of 46 children who participated in the Decision-making in Pediatric Palliative Care Study between 2006 and 2008 at the Children's Hospital of Philadelphia. Parents were guided individually through a semistructured in-depth interview about their experiences and thoughts regarding making medical decisions on behalf of their ill children, and the transcribed interviews were qualitatively analyzed. RESULTS All parents in our study employed explicit heuristics in interviews about decision-making for their children, with the number of identified explicit heuristics used by an individual parent ranging from tens to hundreds. The heuristics served 5 general functions: (1) to depict or facilitate understanding of a complex situation; (2) to clarify, organize, and focus pertinent information and values; (3) to serve as a decision-making compass; (4) to communicate with others about a complex topic; and (5) to justify a choice. CONCLUSIONS Explicit heuristics played an important role in decision-making and communication about decision-making in our population of parents. Recognizing explicit heuristics in parent interactions and understanding their content and functions can aid clinicians in their efforts to partner with parents in the decision-making process.
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Affiliation(s)
| | - James W. Womer
- Pediatric Advanced Care Team,,Department of Medical Ethics
| | | | - Tammy I. Kang
- Pediatric Advanced Care Team,,Division of Oncology, and
| | - Chris Feudtner
- Pediatric Advanced Care Team,,Department of Medical Ethics,,PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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17
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Carroll KW, Mollen CJ, Aldridge S, Hexem KR, Feudtner C. Influences on Decision Making Identified by Parents of Children Receiving Pediatric Palliative Care. ACTA ACUST UNITED AC 2012; 3:1-7. [PMID: 26137345 DOI: 10.1080/21507716.2011.638019] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Parental decision making is a critical component in the provision of palliative and end-of-life care, yet factors that parents perceive as influencing this process, when they are making decisions for their children, have not been well characterized. METHODS As part of a mixed-methods cohort study, we interviewed 73 parents of 50 pediatric patients who were referred to the hospital's pediatric palliative care service. The semistructured interviews focused on "decision making for your child"; the interviews were recorded and transcribed. A random sample (n = 13) was first coded and analyzed for core themes, and these themes were then cross-validated with a second random sample (n = 3) of interviews. RESULTS Four dominant interrelated themes permeated parents' discussions about the decisions they were making for their children and the process of decision making. First, Orientation and Direction (including the subthemes of Goals and Hopes, Spirituality and Meaning, and Purposeful Effort) connotes the parents' effort to establish and clarify the broad context of decision making. Second, Defining What Is Good for the Child (including the subthemes of Quality of Life and Suffering, and Normalcy and Normalization) conveys how the parents posed questions and pondered what decisions would be in the child's best interests. Third, the entwined theme of Relationships, Communication, and Support reflects how parents reported the social and interactive nature of decision making. Fourth, the theme of Feelings and Personal Accountability focuses inward as parents report efforts to deal with their emotional responses and self-judgments. CONCLUSIONS Parents report grappling with several influences upon their decision-making processes that extend well beyond the standard discussions of medical information exchanges and the evaluation of risks and benefits. Decision support for these parents should account for these diverse influences.
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Affiliation(s)
- Karen W Carroll
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Cynthia J Mollen
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Sarah Aldridge
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Kari R Hexem
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Chris Feudtner
- The Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia PA
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18
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Feudtner C, Carroll KW, Hexem KR, Silberman J, Kang TI, Kazak AE. Parental hopeful patterns of thinking, emotions, and pediatric palliative care decision making: a prospective cohort study. ACTA ACUST UNITED AC 2010; 164:831-9. [PMID: 20819965 DOI: 10.1001/archpediatrics.2010.146] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To test the hypothesis that hopeful patterns of thoughts and emotions of parents of pediatric patients receiving palliative care consultative services are related to subsequent decisions, specifically regarding limit of intervention (LOI) orders. DESIGN Prospective cohort study. SETTING Children's hospital and surrounding region. PARTICIPANTS Thirty-three pediatric patients receiving palliative care consultative services who did not have LOI orders at time of cohort entry and their 43 parental adults. MAIN EXPOSURES Parental levels at time of cohort entry of hopeful patterns of thinking and emotions, in conjunction with perceptions about patients' health trajectories. MAIN OUTCOME MEASURE Enactment of an LOI order after entry into the cohort. RESULTS During the 6 months of observation, 14 patients (42.4%) had an LOI order enacted. In adjusted analyses, higher levels of parental hopeful patterns of thinking were significantly associated with increased odds of enactment of an LOI order (adjusted odds ratio [AOR], 2.73; 95% confidence interval [CI], 1.04-7.22). Increased odds of LOI enactment were associated to nonsignificant degrees with lower levels of parental positive affect (AOR, 0.44; 95% CI, 0.17-1.12), higher levels of parental negative affect (AOR, 2.02; 95% CI, 0.98-4.16), and parental perceptions of worsening health over time (AOR, 1.72; 95% CI, 0.73-4.07). CONCLUSION For pediatric patients receiving palliative care consultative services, higher levels of parents' hopeful patterns of thinking are associated with subsequent enactment of LOI orders, suggesting that emotional and cognitive processes have a combined effect on medical decision making.
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Affiliation(s)
- Chris Feudtner
- General Pediatrics, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104. USA.
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Carroll KW, Helms CA. Magnetic resonance imaging of the shoulder: a review of potential sources of diagnostic errors. Skeletal Radiol 2002; 31:373-83. [PMID: 12107570 DOI: 10.1007/s00256-002-0528-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2001] [Revised: 12/07/2001] [Accepted: 04/12/2002] [Indexed: 02/02/2023]
Abstract
Shoulder magnetic resonance (MR) imaging and MR arthrography are frequently utilized in the evaluation of shoulder pain and instability. The clinical scenario and imaging findings may be confusing to clinicians and radiologists and may present diagnostic challenges for those involved in evaluating and treating shoulder pathology. Often rotator cuff and labral abnormalities may be coexistent, clinical manifestations of denervation syndromes may be confusing to clinicians, and normal anatomic variations, imaging pitfalls, and various artifacts may cause dilemmas for the radiologist. This article will review the most frequently encountered mimickers and pitfalls of MR imaging of the shoulder.
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Affiliation(s)
- K W Carroll
- Radiology Regional Center, 700 Goodlette Rd. N, Naples, FL 34102, USA.
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Abstract
OBJECTIVE We describe the MR imaging findings of focal articular cartilage lesions of the superior humeral head and the clinical features in seven patients. CONCLUSION Focal articular cartilage lesions of the superior humeral head are rare lesions that may cause clinical symptoms and may be easily overlooked on MR imaging. These lesions occur in a particular location (along the superior surface of the posterior humeral head, medial to the expected location of a Hill-Sachs lesion), are caused by trauma, and do not seem to have a specific mechanism of injury. Because of improvements in MR imaging of cartilage, this area of the shoulder should be inspected for this lesion.
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Affiliation(s)
- K W Carroll
- Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA
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21
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Cvitanic O, Tirman PF, Feller JF, Bost FW, Minter J, Carroll KW. Using abduction and external rotation of the shoulder to increase the sensitivity of MR arthrography in revealing tears of the anterior glenoid labrum. AJR Am J Roentgenol 1997; 169:837-44. [PMID: 9275908 DOI: 10.2214/ajr.169.3.9275908] [Citation(s) in RCA: 135] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The purpose of this study was to compare oblique axial MR arthrograms obtained with the patient's shoulder in abduction and external rotation (ABER) position with conventional axial MR arthrograms obtained with the patient's arm in neutral position and the shoulder not rotated in revealing tears of the anterior glenoid labrum (AGL). SUBJECTS AND METHODS MR arthrography of the shoulder that included an additional oblique axial imaging sequence with the patient in the ABER position was performed in 256 patients. Assessment of AGL integrity with patients in both conventional axial and ABER positions was made before surgery. These assessments were compared with the surgical findings. RESULTS Of the 92 patients who underwent surgery, AGL tears were found in 27. Conventional axial MR arthrograms revealed 13 tears (sensitivity, 48%; specificity, 91%). A separate review of MR arthrograms obtained with patients in the ABER position revealed 24 tears (sensitivity, 89%; specificity, 95%). Reviewed together, axial MR arthrograms and MR arthrograms obtained with patients in the ABER position revealed 26 tears (sensitivity, 96%; specificity, 97%). CONCLUSION Oblique axial MR arthrograms obtained with the patient's shoulder in the ABER position were significantly more sensitive in revealing AGL tears (p = .005) than were conventional axial MR arthrograms obtained with the patient's aim in a neutral position and the shoulder not rotated.
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Affiliation(s)
- O Cvitanic
- Medical Imaging Center of Oklahoma, Oklahoma City 73139, USA
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Carroll KW, Feller JF, Tirman PF. Useful internal standards for distinguishing infiltrative marrow pathology from hematopoietic marrow at MRI. J Magn Reson Imaging 1997; 7:394-8. [PMID: 9090597 DOI: 10.1002/jmri.1880070224] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The objective of this study was to establish internal standards on MRI differentiating infiltrative marrow pathology from hematopoietic marrow. The T1-weighted images of 74 patients (51 biopsy-proven; 23 clinical follow-up) were reviewed retrospectively. The relative signal intensity of bone marrow was compared to adjacent skeletal muscle (n = 65) and/or nondegenerated intervertebral disk (n = 53). Twenty foci were hyperintense compared to muscle, of which 17 (85%) cases represented normal red marrow (P < .0001); 45 were isointense or hypointense compared to muscle, of which 44 (98%) represented infiltrative marrow processes (P < .0001). Twelve were hyperintense compared to disk, of which 12 (100%) represented normal red marrow (P < .0001); 41 were isointense or hypointense compared to disk, of which 40 (98%) represented infiltrative marrow processes (P < .0001). On T1-weighted spin-echo MRI, skeletal muscle and intervertebral disk may serve as internal standards for differentiating infiltrative pathology from normal hematopoietic marrow. Marrow lesions that are relatively isointense or hypointense to muscle and/or disk should not be considered normal hematopoietic marrow.
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Affiliation(s)
- K W Carroll
- Department of Radiology, David Grant Medical Center, Travis AFB CA 94535-1800, USA
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Tirman PF, Feller JF, Palmer WE, Carroll KW, Steinbach LS, Cox I. The Buford complex--a variation of normal shoulder anatomy: MR arthrographic imaging features. AJR Am J Roentgenol 1996; 166:869-73. [PMID: 8610565 DOI: 10.2214/ajr.166.4.8610565] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of this study was to show the MR arthrographic imaging features of a normal anatomic variation of the shoulder: the absence of the anterior superior labrum and the presence of a "cordlike" middle glenohumeral ligament,which together are known as the Buford complex. MATERIALS AND METHODS We retrospectively analyzed the MR arthrographic examinations of 10 patients with arthroscopically proven Buford complexes. RESULTS MR arthrographic examinations showed an absent anterior superior labrum and an associated cordlike middle glenohumeral ligament in all patients. No contiguous tear of the superior labrum or anterior inferior labrum was evident. Originally, this variation was mistakenly diagnosed as a labral avulsion in two of the 10 patients. Also, a differential diagnosis of a superior labral tear was mistakenly offered for four patients. CONCLUSION An absent anterior superior labrum and an associated cordlike middle glenohumeral ligament represent the normal variation that is known as the Buford complex rather than an avulsed labrum. This normal variation may be mistaken for a detached labrum.
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Affiliation(s)
- P F Tirman
- San Francisco Magnetic Resonance Center, CA, USA
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