Default Palliative Care Consultation for Seriously Ill Hospitalized Patients: A Pragmatic Cluster Randomized Trial

Importance

Increasing inpatient palliative care delivery is prioritized, but large-scale, experimental evidence of its effectiveness is lacking.

Objective

To determine whether ordering palliative care consultation by default for seriously ill hospitalized patients without requiring greater palliative care staffing increased consultations and improved outcomes.

Design, Setting, and Participants

A pragmatic, stepped-wedge, cluster randomized trial was conducted among patients 65 years or older with advanced chronic obstructive pulmonary disease, dementia, or kidney failure admitted from March 21, 2016, through November 14, 2018, to 11 US hospitals. Outcome data collection ended on January 31, 2019.

Intervention

Ordering palliative care consultation by default for eligible patients, while allowing clinicians to opt-out, was compared with usual care, in which clinicians could choose to order palliative care.

Main Outcomes and Measures

The primary outcome was hospital length of stay, with deaths coded as the longest length of stay, and secondary end points included palliative care consult rate, discharge to hospice, do-not-resuscitate orders, and in-hospital mortality.

Results

Of 34 239 patients enrolled, 24 065 had lengths of stay of at least 72 hours and were included in the primary analytic sample (10 313 in the default order group and 13 752 in the usual care group; 13 338 [55.4%] women; mean age, 77.9 years). A higher percentage of patients in the default order group received palliative care consultation than in the standard care group (43.9% vs 16.6%; adjusted odds ratio [aOR], 5.17 [95% CI, 4.59-5.81]) and received consultation earlier (mean [SD] of 3.4 [2.6] days after admission vs 4.6 [4.8] days; P < .001). Length of stay did not differ between the default order and usual care groups (percent difference in median length of stay, -0.53% [95% CI, -3.51% to 2.53%]). Patients in the default order group had higher rates of do-not-resuscitate orders at discharge (aOR, 1.40 [95% CI, 1.21-1.63]) and discharge to hospice (aOR, 1.30 [95% CI, 1.07-1.57]) than the usual care group, and similar in-hospital mortality (4.7% vs 4.2%; aOR, 0.86 [95% CI, 0.68-1.08]).

Conclusions and Relevance

Default palliative care consult orders did not reduce length of stay for older, hospitalized patients with advanced chronic illnesses, but did improve the rate and timing of consultation and some end-of-life care processes.

Trial Registration

ClinicalTrials.gov Identifier: NCT02505035.

Preferences for Predictive Model Characteristics among People Living with Chronic Lung Disease: A Discrete Choice Experiment

Background. Patients may find clinical prediction models more useful if those models accounted for preferences for false-positive and false-negative predictive errors and for other model characteristics. Methods. We conducted a discrete choice experiment to compare preferences for characteristics of a hypothetical mortality prediction model among community-dwelling patients with chronic lung disease recruited from 3 clinics in Philadelphia. This design was chosen to allow us to quantify "exchange rates" between different characteristics of a prediction model. We provided previously validated educational modules to explain model attributes of sensitivity, specificity, confidence intervals (CI), and time horizons. Patients reported their interest in using prediction models themselves or having their physicians use them. Patients then chose between 2 hypothetical prediction models each containing varying levels of the 4 attributes across 12 tasks. Results. We completed interviews with 200 patients, among whom 95% correctly chose a strictly dominant model in an internal validity check. Patients' interest in predictive information was high for use by themselves (n = 169, 85%) and by their physicians (n = 184, 92%). Interest in maximizing sensitivity and specificity were similar (0.88 percentage points of specificity equivalent to 1 point of sensitivity, 95% CI 0.72 to 1.05). Patients were willing to accept a reduction of 6.10 months (95% CI 3.66 to 8.54) in the predictive time horizon for a 1% increase in specificity. Discussion. Patients with chronic lung disease can articulate their preferences for the characteristics of hypothetical mortality prediction models and are highly interested in using such models as part of their care. Just as clinical care should become more patient centered, so should the characteristics of predictive models used to guide that care.

Numeracy and Understanding of Quantitative Aspects of Predictive Models: A Pilot Study

BACKGROUND

The assessment of user preferences for performance characteristics of patient-oriented clinical prediction models is lacking. It is unknown if complex statistical aspects of prediction models are readily understandable by a general audience.

OBJECTIVE

A pilot study was conducted among nonclinical audiences to determine the feasibility of interpreting statistical concepts that describe the performance of prediction models.

METHODS

We conducted a cross-sectional electronic survey using the Amazon Mechanical Turk platform. The survey instrument included educational modules about predictive models, sensitivity, specificity, and confidence intervals (CIs). Follow-up questions tested participants' abilities to interpret these characteristics with both verbatim and gist knowledge. Objective and subjective numeracy were assessed using previously validated instruments. We also tested understanding of these concepts when embedded in a sample discrete choice experiment task to establish feasibility for future elicitation of preferences using a discrete choice experiment design. Multivariable linear regression was used to identify factors associated with correct interpretation of statistical concepts.

RESULTS

Among 534 respondents who answered all nine questions, the mean correct responses was 95.9% (95% CI, 93.8-97.4) for sensitivity, 93.1% (95% CI, 90.5-95.0) for specificity, and 86.6% (95% CI, 83.3-89.3) for CIs. Verbatim interpretation was high for all concepts, but significantly higher than gist only for CIs (p < 0.001). Scores on each discrete choice experiment tasks were slightly lower in each category. Both objective and subjective numeracy were positively associated with an increased proportion of correct responses (p < 0.001).

CONCLUSION

These results suggest that a nonclinical audience can interpret quantitative performance measures of predictive models with very high accuracy. Future development of patient-facing clinical prediction models can feasibly incorporate patient preferences for model features into their development.

Willingness to participate in pragmatic dialysis trials: the importance of physician decisional autonomy and consent approach

BACKGROUND

Pragmatic clinical trials embedded in routine delivery of clinical care can lead to improvements in quality of care, but often have design features that raise ethical concerns.

METHODS

We performed a discrete choice experiment and used conjoint analysis to assess how specific attributes of pragmatic dialysis trials influenced patients' and physicians' willingness to have their dialysis facility participate in a hypothetical trial of hypertension management. Electronic survey data were collected from 200 patients enrolled from 11 outpatient hemodialysis units and from 203 nephrologists. The three attributes studied were physicians' treatment autonomy, participants' research burden, and the approach to consent. The influence of each attribute was quantified using mixed-effects logistic regression.

RESULTS

Similar proportions of patients were willing to have their facilities participate in a trial with high vs. low physician autonomy (77% vs. 79%; p = 0.13) and research burden (76% vs. 80%; p = 0.06). Opt-in, opt-out, and notification-only consent approaches were acceptable to most patients (84%, 82%, and 81%, respectively), but compared to each of these consent approaches, fewer patients (66%) were willing to have their facility participate in a trial that used no notification (p < 0.001 for each 2-way comparison). Among the physicians, similar proportions were willing to participate in trials with high and low physician autonomy (61% and 61%, respectively, p = 0.96) or with low and high burden (60 and 61%, respectively, p = 0.79). However, as for the patients, the consent approach influenced trial acceptability with 77%, 69%, and 62% willing to participate using opt-in, opt-out, and notification-only, respectively, compared to no notification (36%) (p < 0.001 for each 2-way comparison).

CONCLUSIONS

Curtailing physician's treatment autonomy and increasing the burden associated with participation did not influence patients' or physicians' willingness to participate in the hypothetical research, suggesting that pragmatic dialysis trials are generally acceptable to patients and physicians. Both patients and physicians preferred consent approaches that include at least some level of patient notification, but the majority of patients were still willing to participate in trials that did not notify patients of the research.

A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion

BACKGROUND

Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge.

OBJECTIVE

This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients.

METHODOLOGY

Outpatients ( N = 316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive either the option to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. Patients in both groups could decline to complete an advance directive or take their selected version home. The primary outcome was a returned, completed advance directive. Secondary outcomes included whether patients wanted to complete an advance directive, decision satisfaction, quality of life at 3 months, and patient factors associated with advance directive completion.

RESULTS

Although offering more advance directive options was not significantly associated with increased rates of completion (13.1% in the standard group v. 12.2% in the expanded group, P = 0.80), it did significantly increase the proportion of patients who wanted to complete an advance directive and took one home (71.9% in standard v. 85.3% in expanded, P = 0.004). There was no difference in satisfaction ( P = 0.65) or change in quality of life between groups ( P = 0.63). A higher baseline quality of life was independently associated with advance directive completion ( P = 0.006).

CONCLUSIONS AND RELEVANCE

These results suggest that although an expanded choice set may initially nudge patients toward completing advance directives without restricting choice, increasing actual completion requires additional interventions that overcome downstream barriers.

Thinking Forward: Future-oriented Thinking among Patients with Tobacco-associated Thoracic Diseases and Their Surrogates

RATIONALE

The goal of shared decision making is to match patient preferences, including evaluation of potential future outcomes, with available management options. Yet, it is unknown how patients with smoking-related thoracic diseases or their surrogates display future-oriented thinking.

OBJECTIVES

To document prevalent themes in patients' and potential surrogate decision makers' future-oriented thinking when facing preference-sensitive choices.

METHODS

We conducted 44 scenario-based semistructured interviews among a diverse group of outpatients with smoking-associated thoracic diseases and potential surrogates for whom one of three preference-sensitive decisions would be medically relevant. Using content analysis, we documented prevalent themes to understand how these individuals display future-oriented thinking.

MEASUREMENTS AND MAIN RESULTS

Patients and potential surrogates generally expressed expectations for future outcomes but also acknowledged their limitations in doing so. When thinking about potential outcomes, decision makers relied on past experiences, including those only loosely related; perceived familiarity with treatment options; and spirituality. The content of these expectations included effects on family, emotional predictions, and prognostication. For surrogates, a tension existed between hope-based and fact-based expectations.

CONCLUSIONS

Patients and surrogates may struggle to generate expectations, and these future-oriented thoughts may be based on loosely related past experiences or unrealistic optimism. These tendencies may lead to errors, preventing selection of treatments that promote true preferences. Clinicians should explore how decision makers engage in future-oriented thinking and what their expectations are as a component of the shared decision-making process. Future research should evaluate whether targeted guidance in future-oriented thinking may improve outcomes important to patients.

Patient and Physician Views about Protocolized Dialysis Treatment in Randomized Trials and Clinical Care

BACKGROUND

Pragmatic trials comparing standard-of-care interventions may improve the quality of care for future patients, but raise ethical questions about limitations on decisional autonomy. We sought to understand how patients and physicians view and respond to these questions in the contexts of pragmatic trials and of usual clinical care.

METHODS

We conducted scenario-based, semi-structured interviews with 32 patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis in outpatient dialysis units and with 24 nephrologists. Each participant was presented with two hypothetical scenarios in which a protocolized approach to hemodialysis treatment time was adopted for the entire dialysis unit as part of a clinical trial or a new clinical practice.

RESULTS

A modified grounded theory analysis revealed three major themes: 1) the value of research, 2) the effect of protocolized care on patient and physician autonomy, and 3) information exchange between patients and physicians, including the mechanism of consent. Most patients and physicians were willing to relinquish decisional autonomy and were more willing to relinquish autonomy for research purposes than in clinical care. Patients' concerns towards clinical trials were tempered by their desires for certainty for a positive outcome and for physician validation. Patients tended to believe that being informed about research was more important than the actual mechanism of consent, and most were content with being able to opt out from participating.

CONCLUSIONS

This qualitative study suggests the general acceptability of a pragmatic clinical trial comparing standard-of-care interventions that limits decisional autonomy for nephrologists and patients receiving hemodialysis. Future studies are needed to determine whether similar findings would emerge among other patients and providers considering other standard-of-care trials.

Association between medical home characteristics and staff professional experiences in pediatric practices

BACKGROUND

The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature.

METHODS

Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware's seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice's medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%.

RESULTS

Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout.

CONCLUSIONS

Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.

Health status and health-related quality of life in a pediatric palliative care program

BACKGROUND

Children with life-threatening illnesses have unique physical and psychosocial needs that pediatric palliative care programs can address. Integrated programs strive to address these needs from the point of diagnosis through death, if needed, at the same time that curative care is provided. To better understand the variation in these needs, we assessed the health status and health-related quality of life (HRQOL) of children enrolled in an integrated pediatric palliative care program.

METHODS

A telephone survey was conducted with 98 parents whose children were enrolled in an integrated pediatric palliative care program in Florida. The Health Utilities Index (HUI) system was used to assess health status and HRQOL.

RESULTS

HUI2 attribute levels show that children have the greatest impairment with moderate-to-severe burdens related to self-care, mobility, and sensation, and the least impairment with emotion. HUI3 attribute levels show that children have the greatest impairment with moderate-to-severe burdens related to ambulation and cognition and the least impairment with hearing and emotional functioning. Mean overall HUI2 and HUI3 utility scores are 0.37 and 0.15, respectively.

CONCLUSION

Children with life-threatening illnesses in our sample had a high level of morbidity compared with those found in other HUI studies of children with acute or chronic health conditions. Not only do our results highlight severely impaired HRQOL, they also demonstrate the wide variety of health states and needs for children in integrated palliative care programs. This information can help develop strategies to encourage more providers to participate in integrated pediatric palliative care programs.

Internet use and eHealth literacy of low-income parents whose children have special health care needs

BACKGROUND

The Internet has revolutionized the way in which many Americans search for health care information. Unfortunately, being able to use the Internet for this purpose is predicated on having access to the Internet and being able to understand and comprehend online health information. This is especially important for parents of children with special health care needs who are forced to make many medical decisions throughout the lives of their children. Yet, no information is available about this vulnerable group.

OBJECTIVE

For parents of children with special health care needs we sought to (1) describe their Internet access and use, (2) determine which child and household factors were associated with Internet use, (3) describe eHealth literacy of Internet users, and (4) determine which child and household factors were associated with greater eHealth literacy.

METHODS

This was a cross-sectional telephone survey of 2371 parents whose children with special health care needs were enrolled in Florida's Medicaid and State Children's Health Insurance Plan (SCHIP) programs (4072 parents were approached). To be enrolled in the program, families must have incomes that are less than or equal to 200% of the federal poverty level. The eHealth Literacy Scale (eHEALS) was used to measure eHealth literacy. Descriptive and multivariate analyses were conducted to address the study objectives.

RESULTS

The survey response rate was 58.2%. Participating parents were mainly female (2154/2371, 91%), white non-Hispanic (915/2371, 39%), English speaking (1827/2371, 77%), high school graduates (721/2371, 30%), married (1252/2371, 53%), and living in a two-parent household (1212/2371, 51%). Additionally, 82% of parents (1945/2371) in the sample reported that they used the Internet, and 49% of those parents used it daily (1158/2371). Almost three-quarters of Internet users had access to the Internet at home while about one-half had access at work. Parents who were African American, non-English speaking, older, and not college graduates were less likely to use the Internet than their referent groups (P < .001). About 74% of Internet users (1448/1945) reported that they knew how to find health information for their children. However, only about one-half (1030/1945) reported that they can tell high quality from low quality resources online or that they feel confident in using information accessed online to make health decisions. Multivariate regression results consistently showed that being a non-English speaker, having less than a high school education, and being older were all significantly associated with lower eHealth literacy (all P < .001).

CONCLUSION

Low-income parents of children with special health care needs have access to and use the Internet as a source of information about their children's health. However, some parents are unable to distinguish between high and low quality information and are not confident in using the Internet. This information is timely because as the pressure to use the Internet to empower consumers and exchange information increases, issues related to access and disparities must be better understood.

Information seeking behaviors of parents whose children have life-threatening illnesses

OBJECTIVES

For children with life-threatening illnesses we sought to (1) understand the associations between parental characteristics and preferred health information sources, and (2) assess the e-health literacy of Internet-users.

STUDY DESIGN

Cross-sectional, telephone survey of 129 parents whose children are in a pediatric palliative care program in Florida.

RESULTS

Four out of five parents report that they use the Internet, and 64% of Internet-users use it daily. Parents who never use the Internet, versus parents who do use the Internet, are predominately Hispanic (50%) and have less than a high school education (64%) (P ≤ 0.023). Internet-users have high levels of e-health literacy; however, they are not confident or are unsure about the quality of information on the Internet. Not having graduated from high school was associated with a decrease in e-health literacy and using the Internet as the primary information source (vs. doctor as primary source) was associated with an increase in e-health literacy.

CONCLUSION

Parents of children with life-threatening illnesses have access to and use the Internet as a source of information about their children's health. More information is needed to explore how electronic-based interventions could be used to impact information seeking of parents whose children are in pediatric palliative care programs.

Pediatric nurses' attitudes toward hospice and pediatric palliative care

Several studies have investigated nurses' attitudes toward hospice and palliative care for adults, yet little information exists about pediatrics. Assessing pediatric nurses' attitudes is especially important in Florida, where a publicly funded pediatric palliative care program operates in eight cities across the State. The aims of this study were 1) to assess the attitudes toward hospice and palliative care, and 2) to examine the associations between sociodemographic and nursing care factors and nurses' attitudes toward hospice and palliative care. A cross-sectional research design using online and mail-in survey data was used to address the study aims. Surveys were conducted with 279 pediatric nurses across Florida. Bivariate results showed there were significant differences between the attitudes of pediatric nurses employed in a city with a pediatric palliative care program versus those not employed in a program site (p = 0.05). Multivariate analyses also showed that being employed in a program site increased attitudinal scores toward hospice and pediatric palliative care by 0.6 points. Beyond being employed in an area city where a pediatric palliative care program operates, results also suggest that having prior training in palliative care could alter nurses' attitudes, which might subsequently lead to increased referrals and improved outcomes for children and families.

Partnerships between pediatric palliative care and psychiatry

Children with life-threatening illnesses and their families may face physical, emotional, psychosocial, and spiritual challenges throughout the children's course of illness. Pediatric palliative care is designed to meet such challenges. Given the psychosocial and emotional needs of children and their families it is clear that psychiatrists can, and do, play a role in delivering pediatric palliative care. In this article the partnership between pediatric palliative care and psychiatry is explored. The authors present an overview of pediatric palliative care followed by a summary of some of the roles for psychiatry. Two innovative pediatric palliative care programs that psychiatrists may or may not be aware of are described. Finally, some challenges that are faced in further developing this partnership and suggestions for future research are discussed.

Conducting Outcomes Research in Pediatric Palliative Care

Around the globe, health care costs continue to rise resulting in the emphasis on allocating scarce resources toward interventions that have been found to be cost- and clinically effective. Palliative care is no exception, yet the science of outcomes measurement in palliative care, and especially in pediatric palliative care, lags behind other disciplines. National and international experts and organizations have recognized the importance of outcomes measurement and have included this as a research priority. This article outlines some of the complexities of measuring outcomes in pediatric palliative care. It is recommended that national and international collaborations include representatives of the pediatric palliative care community.

Parents' experiences in choosing a health plan for their children with special health care needs

To investigate the information sources, and the perceived helpfulness of each source, that parents used when choosing a health plan for their children with special health care needs (CSHCN) and to determine how parents' perceptions varied by their sociodemographic characteristics and their children's enrollment status (newly versus previously enrolled). In Florida, a cross sectional study was carried out using 2007 telephone survey data from 500 parents. Sixty-three percent of parents used at least one information source to choose a health plan for their CSHCN. More parents used the Help Line, yet more parents found it to be the least helpful resource. Multivariate analyses suggest that Hispanic parents were 79% more likely and parents of prior enrollees were 1.2 times less likely to use one of the four information sources versus their referent groups. African American parents were 85% more likely and parents residing in Broward County were 55% less likely to indicate that the process was easy versus their referent groups. Hispanic parents were 77% more likely, African American parents were 67% more likely and college graduates were 59% less likely to report that the information they received was adequate versus their referent groups. The results did not highlight one source of information as more useful and helpful. Race and ethnicity seemed to have the most systematic effect on the parents' experiences in choosing a health plan for their CSHCN, highlighting the need for further research to ensure that information is appropriate across subgroups.

Adolescents With Life-Threatening Illnesses

Adolescents have unique physical and psychosocial needs. Adolescents want to gain autonomy, yet they must still rely on their parents for support. These unique needs are further complicated by a life-threatening illness. Adolescents with life-threatening illnesses must rely on their parents, due to legal aspects of decision making, and they also face potential loss of peer interaction as they spend more time in hospitals and away from their friends. Adolescents may also be concerned with fertility, reproduction, and sexuality, issues that are often not addressed in palliative care programs. To meet the unique needs of adolescents, specific palliative care programs may need to be developed.

An evaluation of two decision-making scales for children with life-limiting illnesses

PURPOSE

Annually, about 500,000 children are coping with life-limiting illnesses. Many of these children could benefit from pediatric palliative care which provides supportive services. These services can also aid parents in decision making. In order to measure the effect of pediatric palliative care programs on decision making, a valid and reliable tool must be identified. This study aims to validate the psychometric properties of the Decisional Conflict Scale (DCS) and the COMRADE instruments for children with life-limiting illnesses.

METHODS

Analyses were conducted using survey data collected from 266 parents whose Medicaid enrolled children have life-limiting illnesses.

RESULTS

Results of the analyses suggest that the DCS has better psychometric properties for measuring decision making within the population of children with life-limiting illnesses than the COMRADE.

CONCLUSION

Pediatric palliative care programs should use the DCS to measure the effectiveness of services aimed at supporting families with high levels of decisional conflict.

Music therapy in an integrated pediatric palliative care program

National experts have recommended that children with life-limiting illnesses receive integrated palliative and medical care. These programs offer a variety of services, including music therapy. Using survey data from parents whose were enrolled in Florida's Partners in Care: Together for Kids (PIC:TFK) program, this study investigates parents' experiences with music therapy. About 44% of children with life-limiting illnesses and 17% of their siblings used music therapy. For children who used music therapy, multivariate results suggest that their parents were 23 times as likely to report satisfaction with the overall PIC:TFK program (P < .05) versus parents whose children did not use music therapy. Pediatric palliative care programs should include music therapy, although recruiting licensed music therapists may be challenging.

Paediatricians' perceptions on referrals to paediatric palliative care

Children have traditionally been referred to palliative care when curative treatments were exhausted. Recently, experts have suggested that children could benefit from palliative care early in their courses of illness. Using survey data from 303 paediatricians in Florida and California, this study assesses if paediatricians would refer children to palliative care early in their course of illness. Results showed that more years in practice were associated with decreased odds of referring children to palliative care. Academic practice setting and more Medicaid patients were associated with greater odds of referral prior to the end of life. Hispanic paediatricians, those with more experience and those who practice in a hospital setting were associated with decreased odds of referral prior to the end of life. Results suggest that health planners who wish to implement or refine integrated paediatric palliative care programs should consider outreach strategies targeted at paediatricians with specific characteristics.

Pediatricians' perceptions of and preferred timing for pediatric palliative care

OBJECTIVES

This study investigates how pediatricians define palliative care and their preferences regarding the timing of referrals for children with life-limiting diseases.

METHODS

A random sample of 800 pediatricians in Florida and California received mail and online surveys. Analyses included descriptive and multivariate regression analyses.

RESULTS

Of all respondents (N = 303), 49.1% were female, 34.0% had been practicing for > or =20 years, 44.2% were members of a racial/ethnic minority, and 76.2% were in private practice. Pediatricians were divided in their definitions of palliative care; 41.9% defined it as hospice care, 31.9% offered alternative definitions, and 26.2% did not know. Although pediatricians overwhelmingly cited the need for many types of palliative care services, only 49.3% had ever referred patients to palliative care and 29.4% did not know whether local services existed. For 13 diseases that vary in life limitation, there was no consensus regarding the timing of referrals. Diversity across diseases predicted the most variation in referrals, whereas pediatrician characteristics did not.

CONCLUSIONS

Despite recommendations to refer children to palliative care early in the course of illness, most pediatricians define palliative care as similar to hospice care and refer patients once curative therapy is no longer an option. Creating a more-practical definition of care, one that emphasizes an array of services throughout the course of an illness, as opposed to hospice care, may increase earlier palliative care referrals for children with life-limiting illnesses.

Patient satisfaction with a pilot chronic pain management programme in Cape Town, South Africa

Background: The goals of a chronic pain management clinic includeincreasing patient knowledge about pain, developing pain management skillsand increasing patients’ confidence in their pain management abilities.A  Chronic Pain Management Programme (CPMP) based on evidence basedguidelines was developed at a chronic pain management clinic to facilitatepatient discharge to a primary healthcare level. Aim: The aim of this study was to explore patient satisfaction with, acceptability of and the perceived success which could be due to the CPMP developed at the Chronic Pain Management Clinic of Groote Schuur Hospital,Cape Town.Methods: Patients (n=14) were referred to the pilot study from the Chronic Pain Management Clinic. A s a pilot, four courses were run over a period ofone year. In order to reach the research aim, an eleven-question, structuredopen-ended interview was conducted with all participants. Results: Fourteen patients enrolled in the CPMP. Responses were favourable with participants emphasising the roleof increased knowledge about pain, the role of exercise and of stress management techniques. Participants also recog-nised a positive change in behaviours and attitudes following participation in the CPMP.Conclusions: Findings suggest that participants found the format of the course acceptable as regards course content,structure and delivery. Participant responses suggest that the course was acceptable and perceived as useful. However,future courses would benefit from refresher courses or structured support groups.

Innovative pediatric palliative care programs in four countries

Over the past three decades, pediatric palliative care programs have been developed and refined throughout the world. The purpose of this study was to provide information on experiences from four of those programs, yet we acknowledge that there are many other innovative programs that deserve recognition for the services they provide to children and families. This study is limited in that it is unable to compare outcomes from the four programs, such as patient-reported quality of life, that might help to better understand the impact of pediatric palliative care. Nonetheless, information sharing can inspire and educate others with the overarching goal of globally advancing pediatric palliative care.

Gene therapy for prostate cancer delivered by ovine adenovirus and mediated by purine nucleoside phosphorylase and fludarabine in mouse models

A gene-directed enzyme pro-drug therapy (GDEPT) based on purine nucleoside phosphorylase (PNP), that converts the prodrug, fludarabine to 2-fluoroadenine, has been described, but studies are limited compared with other GDEPTs. We investigated the in vitro and in vivo efficacies of PNP-GDEPT for treating androgen-independent (AI) prostate cancer. The PNP gene controlled by Rous sarcoma virus (RSV) constitutive promoter was delivered using a recombinant ovine adenovirus vector (OAdV220) that uses a different receptor from human adenovirus type 5. In vitro, OAdV220 provided increased transgene expression over a comparable human Ad5 vector in infected AI, murine RM1 prostate cancer cells. Subsequent in vivo testing was therefore confined to OAdV220. Transduction of RM1 cells with OAdV220 before implantation in immunocompetent mice dramatically inhibited subcutaneous (s.c.) tumor growth when fludarabine phosphate was administered systemically and increased mouse survival in a dose-dependent manner. In tumor-bearing C57BL/6 mice, a single intratumoral injection of OAdV220 produced detectable PNP activity for at least 6 days and with prodrug, retarded the growth of aggressive RM1 s.c. tumors by 35% at day 14. There was a consistent trend to reduction of pre-established intraprostatic RM1 tumors. A similar regimen induced significant therapeutic efficacy in human PC3 xenografts. Thus, ovine adenovirus-mediated GDEPT using the PNP system was effective in vivo against AI prostate cancers, the aggressive murine RM1, and the human PC3 lines. Methods that improve viral dissemination and stimulate the immune system in vivo may further improve efficacy.

Nutritional benefits of drinks

Much is known about the importance of promoting adequate nutrition, but the fluid content of a patient's diet is not always as strongly emphasised. Vicki Madden discusses the benefits of various drinks in helping to keep patients hydrated.

Procathepsin L self-association as a mechanism for selective secretion

The lysosomal cysteine pro-protease procathepsin L was enriched in dense vesicles detectable when microsomes prepared from wild-type or transformed mouse fibroblasts were resolved on sucrose gradients. These dense vesicles did not comigrate with proteins characteristic of the endoplasmic reticulum, Golgi, endosomes or lysosomes. When gradient fraction vesicles were lysed at acidic pH in the presence of excess mannose 6-phosphate to prevent binding to mannose phosphate receptors, the majority of the procathepsin L was associated with the membrane, not the soluble, fraction. Immunogold labeling of procathepsin L in thin sections of cells or gradient fractions, using antibodies directed against the propeptide to avoid detection of the mature enzyme in dense lysosomes, revealed that the proenzyme was concentrated in dense cores localized in small vesicles near the plasma membrane and in multivesicular bodies. Consistent with the density of the gradient fraction and the electron density of the cores, yeast two-hybrid assays indicated the proenzyme could bind itself but could not interact with the aspartic proprotease procathepsin D. The data suggest that in mouse fibroblasts procathepsin L may self-associate into aggregates, initiating the formation of dense vesicles that could mediate the selective secretion of procathepsin L independent of mannose phosphate receptors.

Croup

As many as 3% of children under six years of age are affected by croup, usually at two to three years. Symptoms include a barking cough and inspiratory stridor. The preceding infection of the larynx is usually viral; bacterial infection can complicate the condition. Mist inhalation has been the traditional treatment. Dexamethasone and now budesonide may be used as first-line treatment.

Asthma: how early to start using inhaled steroids?

Using inhaled steroids to prevent inflammation is a standard part of treatment for moderate to severe asthma. The "early intervention concept" is to give inhaled steroids early in the disease--in children as well as adults--to prevent irreversible lung damage. The START study, involving nearly 7,000 patients in 32 countries, will investigate the effectiveness of early intervention with inhaled steroids in newly-diagnosed asthmatics aged 6-60 years. Results from a 10 year Danish study by Professor Pedersen suggests that in children, early preventive intervention with inhaled steroids leads to improved lung function with no significant adverse effect on the child's growth rate. At present, medical opinion is divided about whether very early use of inhaled steroids is justified, particularly in children. The START study should provide more evidence about the optimum time to begin this treatment.

von Willebrand factor in plasma, platelets, and selected tissues of ferrets

By standard laboratory methods the presence and activity of von Willebrand factor (vWF) was detected and characterized in the ferret (Mustela putorius furo); vWF in plasma, platelets, and selected tissues (thoracic aorta, cranial vena cava, thoracic portion of caudal vena cava, and lung) was documented. Activity, antigenic concentration, plasma multimeric distribution, and localization within tissues were similar to those features in other species. Two differences were apparent: multimeric distribution of platelet vWF was skewed toward the smaller molecular weight multimers, and mucous goblet, but not ciliated, cells of the bronchial epithelium stained positive for vWF. Larger molecular weight multimers were not released subsequent to administration of 1-deamino-8-D-arginine-vasopressin. The ferret may be a useful animal model in studying the role of vWF in hemostasis, thrombosis, and atherosclerosis. In particular, the role of small molecular weight multimers found in ferret platelets may provide further insight into the roles of platelet vWF multimeric distribution, platelet adhesion, and thrombosis.

Anorectal bleeding vs penile activity. A potential diagnostic problem

Intrapenile blood pool activity may be a source of artefact in interpreting a gastrointestinal bleeding study employing Tc-99m sulfur colloid or erythrocytes. Proper positioning should avoid a false reading of rectal bleeding.