International Standards for Pediatric Palliative Care: From IMPaCCT to GO-PPaCS

CONTEXT

Since the publication of the IMPaCCT project in 2007, much effort has been made to develop new approaches to pediatric palliative care (PPC). Fifteen years later, it is time to redefine the standards in PPC.

OBJECTIVES

An international group of experts in PPC has revised the standards in PPC through the GO-PPaCS project (Global Overview - PPC Standards). The goal was to update the PPC standards considering the specificity of different settings, resources, and emerging challenges. The present document is intended to reach all people directly or indirectly involved in PPC.

METHODS

A literature review in MEDLINE was conducted to expand on the fundamental points and current standards on PPC and to cover an international setting. The literature search (updated on the 15th of April 2021) was carried out using different combinations of keywords and focusing on papers published in English over the past 5 years (2016-2020), but older articles were considered when relevant. The consensus on the fundamental points, standards of care and paper contents was reached by open discussion.

RESULTS

Fundamental points were defined regarding the definition of PPC, eligibility criteria and the magnitude of the need for PPC, while standards were redefined for the following six areas: 1) clinical, developmental, psychological, social, ethical and spiritual needs; 2) end-of-life care; 3) care models and settings of care; 4) PPC in humanitarian emergencies; 5) care tools; and 6) education and training for healthcare providers.

CONCLUSION

The present document, developed with the contribution of an international group of experts from different countries, experiences and models of care, provides fundamental points and standards for a wider implementation of PPC worldwide.

The Intervention Areas of the Psychologist in Pediatric Palliative Care: A Retrospective Analysis

Infants, children and adolescents with life-limiting and life-threatening disease need long-term care that may change according to disease's natural history. With the primary goal of quality of life, the psychologist of pediatric palliative care (PPC) network deals with a large variety of issues. Little consideration has been given to the variety of intervention areas of psychology in PPC that concern the whole life span of the patient and family. The PPC network is composed by a multidisciplinary team of palliative care specialists that intervenes at home, in the hospital and in every place where the patient is living. The network coordinates different public health services to respond to clinical, psychosocial and spiritual needs. In these scenarios, the psychological need is not a single event but a moment inserted in the complexity of the child's needs. This retrospective monocentric project consists of an analysis of characteristics of psychological interventions in our PPC service. The time frame taken into consideration is 2019-2020, analyzing the clinical records of 186 patients of Pediatric Palliative Care and Pain Service of Veneto Region (Italy). The areas that emerged in the analysis show how the intervention of the psychologist in PPC does not concern only end-of-life, but a series of topics that are significant for the family to guarantee psycho-social wellbeing oriented toward the best quality of life. In conclusion, these different topics highlight the complexity of the child and family experience. This variety must be taken into consideration, the psychologist must increase holistic support with a dedicated skills curriculum.

COVID-19 in pediatric palliative care: what can we learn from the pandemic and possible future directions

INTRODUCTION

Patients in pediatric palliative care (PPC) live with multiple comorbidities which represent a risk factor for severe form of COVID-19.

METHODS

This monocentric retrospective study was performed at the PPC Center of Padua (Italy). Testing methodology, prevention strategies and infection characteristics were documented and compared during the first and second peak of SARS-CoV-2 infection.

RESULTS

Between April-June 2020 a population swab screening was performed and a strong reduction of the habitual family support was observed. Between November 2020-January 2021 swab testing was limited to specific cases and the support network for families was partially restored. Incidence of COVID-19 was low, resulting in 0.04% of total pediatic cases in the Veneto Region. No severe forms were observed.

CONCLUSION

The use of adequate preventive measures by families and support networks associated with testing in specific contests is safe, cost effective and has a minor impact on caregiver's care load.

An estimation of the number of children requiring pediatric palliative care in Italy

Background

Pediatric palliative care (PPC) addresses the physical and psychological needs of children suffering from life-limiting diseases. To define prevention and educational plans and to properly allocate resources, a precise estimation of the PPC burden is required.

Objectives

To estimate the current number of children requiring PPC in Italy, useful to assist policy-makers and healthcare bodies in the organization and allocation of PPC resources.

Methods

Literature data, The Global Atlas of Palliative Care at the End of Life and Italian national databases have been consulted.

Results

According to our estimation, at present, a total of 20,540–32,864 children in Italy require PPC (34–54 children/100,000 inhabitants) of whom 18 children/100,000 inhabitants require specialized PPC.

Conclusions

The present work is a fundamental tool to be used by the institutions, the local networks of PPC and the health programmers when formulating organizational models and care plans consistent with the actual need for PPC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13052-020-00952-y.

A Tool for the Evaluation of Clinical Needs and Eligibility to Pediatric Palliative Care: The Validation of the ACCAPED Scale

Background: Despite their importance, pediatric palliative care (PPC) services are still scantly diffused. In addition, eligibility criteria for PPC are quite complex. Consequently, clinicians require a tool that suggests how to refer patients with life-limiting diseases to the most appropriate service and how to properly allocate health care resources. Objective: Recently, the Accertamento dei bisogni Clinico-Assistenziali Complessi in PEDiatria (ACCAPED) scale has been developed by a group of experts in PPC to evaluate the specific clinical needs of pediatric patients with a life-limiting disease. This study presents the validation of the ACCAPED scale. Design: Validation of ACCAPED scale was pursued by means of description and analysis of clinical vignettes representing patients with challenging-to-evaluate needs who have to be referred to the most appropriate service (community care, general PPC, and specialized PPC). The evaluation of vignettes according to the clinical experience of the experts represented the gold standard against which the validity of the ACCAPED scale was tested by groups with different levels of experience (experts, pediatricians, and health care providers (HCPs) not involved in PPC). Results: Results show a very high concordance between the evaluation of the vignettes through the ACCAPED scale and the evaluation by the clinical experience for experts in PPC and pediatricians. A less favorable grade of concordance has been recorded for HCPs not involved in PPC, suggesting that educational efforts to improve basic knowledge of PPC within the medical community are needed. Conclusions: Overall, this study suggests that the ACCAPED scale is a useful tool to improve rationalization of resources and eligibility criteria for PPC.

A consensus conference report on defining the eligibility criteria for pediatric palliative care in Italy

Background

The definition of the eligibility criteria of newborn, infant, child, or adolescent patients for palliative care (PC) is complicated by the fact that these patients generally present with very specific case histories that make it inadvisable to directly adopt existing PC protocols devised for adult patients. Thus, the goal of this paper is to define a standard set of criteria for establishing pediatric palliative care (PPC) eligibility.

Methods

The method adopted was that of the consensus conference. According to the guidelines issued by the Higher Institute of Health, the Board of the Italian Society for Palliative Care (i.e. steering committee) appointed a multidisciplinary group of eight health care professionals (i.e. doctors, nurses and psychologists) who worked from May 2014 to February 2016 to reach a consensus over PPC eligibility. This panel of relevant experts redacted a report summarizing all available scientific information concerning PPC, which was then submitted to the attention of a multidisciplinary jury composed of specialists and non-specialists of the field. The document thus produced was subsequently reviewed by an extended team of experts.

Results

The consensus conference drafted a final document determining the guidelines for PPC eligibility of newborns, infants, children, and adolescents suffering from either oncological or non-oncological diseases.

Conclusions

This report provides health care providers with practical guidelines on how to define the eligibility of pediatric patients for PPC. Given the current situation in Italy, these guidelines will be instrumental in assisting the implementation of adequate generalist and specialist PPC services as well as in helping policymakers draft and implement national legislation pertaining to PPC.

Rights of the Dying Child: The Nurses' Perception

AIM

The Charter of the Rights of the Dying Child was formulated as a professional guide for caring the child in the final stages. The study examines the nurses' degree of agreement with the Charter's principles and their perception of the implementation of those principles in hospital.

MATERIALS AND METHODS

A multicenter, cross-sectional study to observe the nurses' positions about the 10 rights outlined in the Charter, using an online questionnaire in 5 pediatric hospitals in northern Italy.

RESULTS

A total of 119 nurses (44.9%) completed the questionnaire. The majority (range: 86.6-100%) expressed their agreement with the Charter's principles (Likert ≥4). Lower ratings were reported in Charter's principles implementation items (range: 42.9-89.1%). Being older and working in a smaller hospital lead the nurses to overlook the child's right to be informed and to be given the opportunity to make decisions about his/her own life and death (p = 0.02, p < 0.01). Postgraduate training induced greater awareness of the dying child (p = 0.01).

CONCLUSIONS

This study highlights the value of the Charter of the Rights of the Dying Child as a reference guideline for nurses working in pediatric hospitals. Better training is important to improve the nurse's communication skills and the pediatric palliative care should be offered to all families that have a child with incurable disease mostly in the end of life.

Parents spend an average of nine hours a day providing palliative care for children at home and need to maintain an average of five life-saving devices

AIM

This Italian study investigated home-based palliative care for young children and how long it took parents to meet their needs.

METHODS

The study population consisted of 33 families with a child under the responsibility of the Veneto Regional Center for Pediatric Palliative Care, northern Italy, who needed medical support in at least two of the following areas: respiratory, feeding, pain and seizures.

RESULTS

The children had a mean age of 6.8 ± 4.7 years. We found that 72% of the patients needed medical devices for feeding, 36% had a tracheostomy and 55% were on mechanical ventilatory support. The children needed an average of five different life-supporting medical appliances, and the time taken to provide for their care increased significantly with each additional appliance (p = 0.016). Their most time-consuming daily needs were feeding (174 minutes) and support when they woke up at night (67 minutes). The average daily time that parents spent taking care of their child amounted to eight hours and 54 minutes per day.

CONCLUSION

Parents providing palliative care for children with life-limiting diseases spent an average of nine hours a day caring for them each day and had to maintain an average of five medical appliances.

Barriers to the development of pediatric palliative care in Italy

INTRODUCTION

In recent years the emergence of new types of patient, clinical situations, technological frontiers and "health" objectives have changed considerably the needs of ill children, this also concerns pediatric palliative care (PPC). In Italy, despite the introduction of legislation (Law 38/2010) stipulating the right of children and families to access appropriate services for pain control and pediatric palliative care, the availability of these services is still limited.

AIM

The aim of this study is to highlight, through a review of the existing data and published literature, the critical issues that obstacle the planning and development of PPC services in Italy.

RESULTS

Four main areas identified were: socio-cultural setting; types of patients and nature of diseases requiring PPC; training for PPC providers; regulatory and political issues.

CONCLUSIONS

This type of analysis can provide the rational for advancing proposals and developing supportive, corrective and implementation strategies.

[Takayasu's arteritis. A concise review and some observations on a putative case reported by Giovanni Battista Morgagni (1761)]

The discovery of Takayasu's arteritis is likely to date back as far as 1830, owing to the first description of the Japanese Rokushu Yamamoto. Thereafter, several authors from certain geographical areas and in various historical periods described such a vascular disorder, by introducing a quantity of definitions. At present, it is defined as an eponymic disease, namely Takayasu's arteritis, since Makito Takayasu, a Japanese ophtalmologist, reported in 1908 the clinical history of a woman showing some particular retinal anastomotic shunts of arterioles and venules. In the present study the description of an about 40 year-old woman suffering from a pulseless disease, as reported by Giovanni Battista Morgagni in 1761, is summarized. Such a description could be the first case report of Takayasu's arteritis, according to some previous literature data and our critical analysis.

[Femoral and humeral head osteonecrosis in a patient with hypofibrinolysis and hyperhomocysteinemia. A case report and a review of the literature]

Osteonecrosis is a disease characterized by the death of marrow and bone tissues. All bones may be affected, most commonly those of the hip, knee, shoulder, ankle as well as the small bones of the hands and feet. When the disease involves a weight-bearing joint there is a significant risk that subarticular fracture may develop leading to disabling arthrosis and requiring, therefore, arthroplasty surgery. Osteonecrosis typically affects patients in their third, fourth and fifth decades of life and is associated with many factors including other diseases and co-morbidities. Multifocal osteonecrosis is defined according to the involvement of at least three separated anatomic sites. We describe the case of a young man with osteonecrosis of the shoulder and hip joints which required total arthroplasty. Among biochemical investigations, an increase in the plasminogen activator inhibitor type 1 (PAI-1) levels associated with mild hyperhomocysteinemia was present. Another finding was the HLA B27, without signs of spondyloarthropathies. In patients with osteonecrosis, especially if multifocal, a careful medical history, a complete physical examination and some biochemical investigations, particularly those related to thrombophilia and hypofibrinolysis, should be performed.

[Assessment and measurement of pain in infants and children]

The assessment of global pain in infants and children involves the analysis of subjective, behavioural and physiological components, beyond the psychological, familiar and environmental factors that influence and modulate the manifestation of painful symptom. Therefore, researchers and clinicians need valid and reliable instruments to obtain a correct measure of pain. Although subjective indices carry out a fundamental role in the assessment of pain (instruments adjusted to the age of the child), behavioural and physiological indices should be used when intelligence deficit or serious physical handicaps exclude such possibility. Behavioural aspects, associated and correlated to physiological changes, allow to obtain a reliable enough measure of pain. In this paper, the main instruments for measuring pain in infants and children will be described, and their advantages and disadvantages underlined.

Thrombosis of the subclavian vein in SAPHO syndrome. A case-report

The hallmark of SAPHO Syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis) is osteitis of the anterior chest wall, which can be so pronounced as to cause thoracic outlet syndrome, thrombosis of the subclavian vein, and compression of the superior vena cava. Suggestive skin manifestations, namely palmoplantar pustulosis and severe acne, generally antedate the bone and joint lesions. We report a case of SAPHO syndrome that went unrecognized for many years and eventually caused compression and thrombosis of the right subclavian vein requiring cleidectomy. SAPHO syndrome should be considered in every patients with anterior chest wall inflammation, particularly when skin lesions are also present.

[Stress hormones liberated by fangotherapy. ACTH and beta-endorphin levels under heat stress]

In 6 healthy subjects submitted to fango therapy in the Euganean thermal baths (Italy), the plasma concentrations of beta-endorphin and ACTH increased transitorily but significantly. These results correlate with the release of these peptides by the pituitary in response to thermal stressing. The analgesic and hypothermic action responsible for good toleration of thermal stress induced by fango therapy, can be explained by this increase in plasma beta-endorphin. The repeated brief increases in plasma beta-endorphin during thermal treatment result in progressive improvement in articular and muscular symptomatology. The results of our study on plasma levels of ACTH confirm that the thermal stress associated with fango therapy activates the pituitary gland. Immunomodulatory effects are discussed.

Renal artery thrombosis and hypertension in a 13 year old girl with antiphospholipid syndrome

The case of a 13 year old girl with renal artery thrombosis and hypertension is described. A cerebrovascular accident and a probable occlusion of the superior mesenteric artery also occurred. Very high levels of 'lupus anticoagulant', anticardiolipin antibodies as well as false positive Venereal Disease Research Laboratory tests were repeatedly shown. Moreover, the patient fulfilled at least four classification criteria for systemic lupus erythematosus, but only a slight positivity for antinucleolar antibodies was present. The striking relation between antiphospholipid antibody levels and clinical events and the treatment of this complex syndrome are discussed.

Hyper-IGD syndrome: a new case treated with colchicine

We report a new case of hyper-IgD syndrome, a recently described disease characterized by recurrent episodes of fever with headache, bilateral cervical lymphadenopathy and, more rarely, abdominal pain and diarrhoea. Polyclonal increase of serum IgD is the most important laboratory finding. Etiopathogenesis and differences with familial Mediterranean fever are discussed. Moreover, good results obtained with colchicine treatment are also reported.

[Proglumetacin for the treatment of inflammatory and degenerative arthropathies]

Twenty patients with inflammatory (15) or degenerative (5) joint disorders had been treated with 450 mg/day of proglumetacin during 35 +/- 18 days. Articular symptoms showed a definite and continued improvement, particularly evident during the initial 15 days of treatment on both painful and inflammatory components. The final physician's evaluation rated 75% of results as excellent or good, versus 15% of poor (3 patients, one of whom already refractory to diclofenac). The tolerance was defined as excellent to good in 90% of patients: one (5%) was dropped out upon the onset of sweating and palpitation, already observed with other drugs. Overall, only one case each of heartburn, anorexia and diarrhoea were considered as possibly related to the treatment. Laboratory tests did not show any variation that could be attributed to the drug. Proglumetacin therefore, by force of its efficacy and safety, appears to be particularly suited as a first-choice drug for the management of both inflammatory and degenerative joint disorders.