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Sievers Y, Roser K, Scheinemann K, Michel G, Ilic A. The information needs of relatives of childhood cancer patients and survivors: A systematic review of quantitative evidence. PATIENT EDUCATION AND COUNSELING 2024; 126:108316. [PMID: 38788309 DOI: 10.1016/j.pec.2024.108316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/04/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE We aimed to: (1) summarize the quantitative evidence on the information needs of relatives of childhood cancer patients, survivors, and children deceased from cancer; and (2) identify factors associated with these needs. METHODS PubMed, PsycINFO, Scopus, and CINAHL were systematically searched. The methodological quality of all included publications was assessed, and the extracted data were analyzed using narrative synthesis. RESULTS Of 5810 identified articles, 45 were included. Information needs were classified as unmet, met (satisfied), and unspecified and categorized into five domains: medical information, cancer-related consequences, lifestyle, family, and support. Most unmet information needs concerned cancer-related consequences (e.g., late effects), while information needs on support were generally met. Migrant background and higher education were associated with higher information needs among parents. Siblings had lower information needs than parents. CONCLUSION This systematic review provides a comprehensive overview of the information needs of relatives in the context of childhood cancer, showing that information on cancer-related consequences is needed most often. The socioeconomic background of the relatives needs continued consideration throughout the cancer trajectory. PRACTICE IMPLICATIONS Our findings suggest the need for personalized information. Healthcare professionals should adapt their communication strategies to respond to the different and evolving needs of all affected relatives.
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Affiliation(s)
- Yara Sievers
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Katharina Roser
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Katrin Scheinemann
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Division of Hematology and Oncology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland; Department of Pediatrics, McMaster Children's Hospital and McMaster University, Hamilton, Canada
| | - Gisela Michel
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Anica Ilic
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
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Kelada L, Robertson EG, McKay S, McGill BC, Daly R, Mazariego C, Taylor N, Tyedmers E, Armitage N, Evans HE, Wakefield CE, Ziegler DS. Communicating with families of young people with hard-to-treat cancers: Healthcare professionals' perspectives on challenges, skills, and training. Palliat Support Care 2024; 22:539-545. [PMID: 38263685 DOI: 10.1017/s1478951523001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
OBJECTIVES Hard-to-treat childhood cancers are those where standard treatment options do not exist and the prognosis is poor. Healthcare professionals (HCPs) are responsible for communicating with families about prognosis and complex experimental treatments. We aimed to identify HCPs' key challenges and skills required when communicating with families about hard-to-treat cancers and their perceptions of communication-related training. METHODS We interviewed Australian HCPs who had direct responsibilities in managing children/adolescents with hard-to-treat cancer within the past 24 months. Interviews were analyzed using qualitative content analysis. RESULTS We interviewed 10 oncologists, 7 nurses, and 3 social workers. HCPs identified several challenges for communication with families including: balancing information provision while maintaining realistic hope; managing their own uncertainty; and nurses and social workers being underutilized during conversations with families, despite widespread preferences for multidisciplinary teamwork. HCPs perceived that making themselves available to families, empowering them to ask questions, and repeating information helped to establish and maintain trusting relationships with families. Half the HCPs reported receiving no formal training for communicating prognosis and treatment options with families of children with hard-to-treat cancers. Nurses, social workers, and less experienced oncologists supported the development of communication training resources, more so than more experienced oncologists. SIGNIFICANCE OF RESULTS Resources are needed which support HCPs to communicate with families of children with hard-to-treat cancers. Such resources may be particularly beneficial for junior oncologists and other HCPs during their training, and they should aim to prepare them for common challenges and foster greater multidisciplinary collaboration.
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Affiliation(s)
- Lauren Kelada
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Eden G Robertson
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Skye McKay
- School of Population Health, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Brittany C McGill
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Rebecca Daly
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Carolyn Mazariego
- School of Population Health, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Natalie Taylor
- School of Population Health, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Elijah Tyedmers
- School of Population Health, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
| | - Nicole Armitage
- Pain and Palliative Care Service, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Holly E Evans
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Claire E Wakefield
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - David S Ziegler
- Discipline of Pediatrics and Child Health, School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, NSW, Australia
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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3
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Kaye EC, Smith J, Zhou Y, Bagatell R, Baker JN, Cohn SL, Diller LR, Glade Bender JL, Granger MM, Marachelian A, Park JR, Rosenberg AR, Shusterman S, Twist CJ, Mack JW. Factors influencing parents' choice of palliative treatment goals for children with relapsed or refractory neuroblastoma: A multi-site longitudinal survey study. Cancer 2024; 130:1101-1111. [PMID: 38100619 PMCID: PMC10939929 DOI: 10.1002/cncr.35149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Many parents of children with advanced cancer report curative goals and continue intensive therapies that can compound symptoms and suffering. Factors that influence parents to choose palliation as the primary treatment goal are not well understood. The objective of this study was to examine experiences impacting parents' report of palliative goals adjusted for time. The authors hypothesized that awareness of poor prognosis, recall of oncologists' prognostic disclosure, intensive treatments, and burdensome symptoms and suffering would influence palliative goal-setting. METHODS The authors collected prospective, longitudinal surveys from parents of children with relapsed/refractory neuroblastoma at nine pediatric cancer centers across the United States, beginning at relapse and continuing every 3 months for 18 months or until death. Hypothesized covariates were examined for possible associations with parental report of palliative goals. Generalized linear mixed models were used to evaluate factors associated with parents' report of palliative goals at different time points. RESULTS A total of 96 parents completed surveys. Parents were more likely to report a primary goal of palliation when they recalled communication about prognosis by their child's oncologist (odds ratio [OR], 52.48; p = .010). Treatment intensity and previous ineffective therapeutic regimens were not associated with parents' report of palliative goals adjusted for time. A parent who reported new suffering for their child was less likely to report palliative goals (OR, 0.13; p = .008). CONCLUSIONS Parents of children with poor prognosis cancer may not report palliative goals spontaneously in the setting of treatment-related suffering. Prognostic communication, however, does influence palliative goal-setting. Evidence-based interventions are needed to encourage timely, person-centered prognostic disclosure in the setting of advanced pediatric cancer. PLAIN LANGUAGE SUMMARY Many parents of children with poor-prognosis cancer continue to pursue curative treatments that may worsen symptoms and suffering. Little is known about which factors influence parents to choose palliative care as their child's main treatment goal. To explore this question, we asked parents of children with advanced neuroblastoma across the United States to complete multiple surveys over time. We found that the intensity of treatment, number of treatments, and suffering from treatment did not influence parents to choose palliative goals. However, when parents remembered their child's oncologist talking about prognosis, they were more likely to choose palliative goals of care.
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Affiliation(s)
- Erica C. Kaye
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
| | - Jesse Smith
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, TN
| | - Yiwang Zhou
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, TN
| | - Rochelle Bagatell
- Division of Oncology, Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Justin N. Baker
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
| | - Susan L. Cohn
- Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL
| | - Lisa R. Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology-Oncology, Boston Children’s Hospital, Boston, MA
| | - Julia L. Glade Bender
- Department of Pediatric Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - M. Meaghan Granger
- Hematology and Oncology Center, Cook Children’s Hospital, Fort Worth, TX
| | - Araz Marachelian
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Julie R. Park
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
- Department of Pediatric Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA, USA
| | - Abby R. Rosenberg
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
- Department of Pediatric Hematology/Oncology, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Psychosocial Oncology and Palliative Care, Division of Pediatric Palliative Care; Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology-Oncology, Boston Children’s Hospital, Boston, MA
| | - Clare J. Twist
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jennifer W. Mack
- Department of Pediatrics, Comer Children’s Hospital, University of Chicago, Chicago, IL
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Population Sciences’ Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, MA, USA
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Cowfer B, Kang TI, McEvoy MT. Practical considerations for prognostic communication in pediatric cancer. Curr Probl Cancer 2023; 47:101009. [PMID: 37838548 DOI: 10.1016/j.currproblcancer.2023.101009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/13/2023] [Indexed: 10/16/2023]
Abstract
High-quality communication is essential for the optimal care of children with cancer and their families. There are opportunities for pediatric oncologists to engage in clear and compassionate prognostic communication across the disease trajectory including at the time of diagnosis, disease recurrence or progression, and end of life. Contrary to previously held beliefs, prognostic disclosure supports parental hope and meets the needs and expectations of families who prefer honest conversations about prognosis. These communication encounters can be challenging with many oncologists having little training in this important skill. In this summary, we aim to provide practical guidance for prognostic communication in pediatric cancer across the illness trajectory giving phrases we have found helpful including a brief overview of some published communication frameworks utilized in the care of pediatric oncology patients and families.
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Affiliation(s)
- Brittany Cowfer
- Division of Palliative Care, Texas Children's Hospital, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Tammy I Kang
- Division of Palliative Care, Texas Children's Hospital, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX.
| | - Matthew T McEvoy
- Division of Palliative Care, Texas Children's Hospital, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX; Division of Hematology/Oncology, Texas Children's Hospital, Houston, TX
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Svynarenko R, Cozad MJ, Mack JW, Keim-Malpass J, Hinds PS, Lindley LC. Application of Instrumental Variable Analysis in Pediatric End-of-Life Research: A Case Study. West J Nurs Res 2023; 45:571-580. [PMID: 36964702 PMCID: PMC10559266 DOI: 10.1177/01939459231163441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
Instrumental variable analysis (IVA) has been widely used in many fields, including health care, to determine the comparative effectiveness of a treatment, intervention, or policy. However, its application in pediatric end-of-life care research has been limited. This article provides a brief overview of IVA and its assumptions. It illustrates the use of IVA by investigating the comparative effectiveness of concurrent versus standard hospice care for reducing 1-day hospice enrollments. Concurrent hospice care is a relatively recent type of care enabled by the Affordable Care Act in 2010 for children enrolled in the Medicaid program and allows for receiving life-prolonging medical treatment concurrently with hospice care. The IVA was conducted using observational data from 18,152 pediatric patients enrolled in hospice between 2011 and 2013. The results indicated that enrollment in concurrent hospice care reduced 1-day enrollment by 19.3%.
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Affiliation(s)
| | - Melanie J Cozad
- Department of Health Services Research and Administration, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, MA, USA
| | | | - Pamela S Hinds
- Department of Nursing Science, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University, Washington, DC, USA
| | - Lisa C Lindley
- College of Nursing, University of Tennessee, Knoxville, TN, USA
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Boeriu E, Borda A, Miclea E, Boeriu AI, Vulcanescu DD, Bagiu IC, Horhat FG, Kovacs AF, Avram CR, Diaconu MM, Vlaicu LF, Sirb OD, Arghirescu ST. Prognosis Communication in Pediatric Oncology: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:972. [PMID: 37371204 DOI: 10.3390/children10060972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/27/2023] [Accepted: 05/28/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND While communication plays an important role in medicine, it also often represents a challenge when the topic at hand is the prognosis of a high-risk condition. When it comes to pediatric oncology, the challenge becomes even greater for physicians who have to adapt their discourse to both the child and their family. METHODS Following the PRISMA guidelines, an advanced search on PubMed, Scopus and the Cochrane Library was performed, from 1 January 2017 to 31 October 2022. Demographic data for caregivers, pediatric patients and physicians were extracted, as well as diagnosis, prognosis, presence at discussion, emotional states and impact on life, trust, decision roles, communication quality and other outcomes. RESULTS A total of 21 articles were analyzed. Most studies (17) focused on caregivers, while only seven and five studies were focused on children and physicians, respectively. Most parents reported high trust in their physicians (73.01%), taking the leading role in decision making (48%), moderate distress levels (46.68%), a strong desire for more information (78.64%), receiving high-quality information (56.71%) and communication (52.73%). Most children were not present at discussions (63.98%); however, their desire to know more was expressed in three studies. Moreover, only two studies observed children being involved in decision making. Most physicians had less than 20 years of experience (55.02%) and reported the use of both words and statistics (47.3%) as a communication method. CONCLUSIONS Communication research is focused more on caregivers, yet children may understand more than they seem capable of and want to be included in the conversation. More studies should focus on and quantify the opinions of children and their physicians. In order to improve the quality of communication, healthcare workers should receive professional training.
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Affiliation(s)
- Estera Boeriu
- Department of Pediatrics, "Victor Babes" University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Department of Oncology and Haematology, "Louis Turcanu" Emergency Clinical Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania
| | - Alexandra Borda
- Department of Oncology and Haematology, "Louis Turcanu" Emergency Clinical Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania
| | - Eunice Miclea
- Department of Oncology and Haematology, "Louis Turcanu" Emergency Clinical Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania
| | - Amalia-Iulia Boeriu
- Anaesthesiology and Intensive Care Department, Klinikum Rechts der Isar Der Technischen, Universitat Munchen, Ismaninger Street 22, 81675 Munchen, Germany
| | - Dan Dumitru Vulcanescu
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, "Victor Babes" University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Iulia Cristina Bagiu
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, "Victor Babes" University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Florin George Horhat
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, "Victor Babes" University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Alexandra Flavia Kovacs
- Department of Oncology, Onco-Help Association, Ciprian Porumbescu Street 56-59, 300239 Timisoara, Romania
| | - Cecilia Roberta Avram
- Department of Residential Training and Post-University Courses, "Vasile Goldis" Western University, Liviu Rebreanu Street 86, 310414 Arad, Romania
| | - Mircea Mihai Diaconu
- Department of Obstetrics and Gynecology, "Victor Babes" University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Luiza Florina Vlaicu
- Department of Social Assistance, Faculty of Sociology and Psychology, Western University, Vasile Parvan Boulevard 4, 300223 Timisoara, Romania
| | - Otniel Dorian Sirb
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, "Victor Babes" University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Eduard Pamfil Psychiatry Clinic Timisoara, Iancu Vacarescu Street 21, 300425 Timisoara, Romania
| | - Smaranda Teodora Arghirescu
- Department of Pediatrics, "Victor Babes" University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Department of Oncology and Haematology, "Louis Turcanu" Emergency Clinical Hospital for Children, Iosif Nemoianu Street 2, 300011 Timisoara, Romania
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Mack JW. The Day One Talk, 20 Years Later: What Have We Learned? JCO Oncol Pract 2023; 19:164-166. [PMID: 36800565 PMCID: PMC10113114 DOI: 10.1200/op.23.00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/11/2023] [Indexed: 02/19/2023] Open
Affiliation(s)
- Jennifer W. Mack
- Division of Population Sciences and Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA
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Constantinou G, Cook EJ, Tolliday E, Randhawa G. 'A team around the child' professionals' experiences of unmet needs, access and expectations in children's palliative care services, a phenomenological study in the UK. J Child Health Care 2023:13674935221147716. [PMID: 36946427 DOI: 10.1177/13674935221147716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
This study aims to understand the experiences of professionals involved in caring for families of children with life-limiting illnesses to ascertain unmet needs, access issues and expectations of services.A phenomenological approach comprising semi-structured interviews with professionals from various services was used. Interviews that happened between July and November 2018 were audio-recorded, transcribed verbatim and thematically analysed based on descriptive phenomenology.In total, 29 interviews were conducted. Findings showed how essential collaborative working was for becoming a team around the child. Barriers to this include complex working relationships, overprotectiveness of families, roles and responsibilities and use of independent care records. The pressures of waiting times and the impact of staffing shortages affected the experiences of providing care. The reality of meeting families' expectations was shaped by family networking, online research and previous services resistance, which was influential in more challenging interactions. Expectations of care were also impacted by misunderstandings and anxieties surrounding access to services. Overall, professionals were concerned about families being used as a bottomless caring resource and stressed the need for short breaks to alleviate parents.Interventions that educate families and professionals on these services and how they can benefit the child and family would be well received.
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Affiliation(s)
- Georgina Constantinou
- Institute for Health Research, 5195University of Bedfordshire, UK
- Centre for Maternal and Child Health Research, School of Health Sciences, 4895City University of London, London, UK
| | - Erica J Cook
- Department of Psychology, 5195University of Bedfordshire, UK
| | | | - Gurch Randhawa
- Institute for Health Research, 5195University of Bedfordshire, UK
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Porter AS, Woods C, Stall M, Baker JN, Mack JW, Kaye EC. Mismatch between Pediatric Oncologists' Private and Parent-Facing Prognostic Communication: Communication Patterns Used to Soften Prognostic Disclosure. J Palliat Med 2023; 26:210-219. [PMID: 35976087 DOI: 10.1089/jpm.2022.0265] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Purpose: Most parents of children with cancer desire honest prognostic communication, yet oncologists often avoid clear prognostic disclosure. This study explored differences between oncologists' private assessments of prognosis and their prognostic communication with patients and parents. Patients and Methods: In this prospective, longitudinal, mixed-methods study, we audio-recorded serial disease reevaluation conversations between children with advancing cancer, parents, and primary oncologists and separately surveyed and interviewed oncologists at disease progression time points. At time points when oncologists privately described curability as ≤10%, content analysis was used to compare prognostic language in recorded dialogue with private responses about prognosis. Results: Of 33 enrolled patient-parent dyads, 17 patients with high-risk cancer under the care of 6 primary oncologists experienced disease progression during the study period. In 95% of oncologist interviews at disease progression time points, oncologists either predicted curability to be ≤10% or incurable. In most interviews (82%), oncologists stated unequivocally that chances of cure were ≤10%, yet did not communicate these low odds during recorded discussions at the same time point. Analysis revealed three distinct communication patterns through which oncologists softened prognostic disclosure to patients and families: (1) space-holding for hope of cure: statements acknowledging difficult prognosis yet leaving room for possibility of cure; (2) vague warning: statements implying that cancer may progress without offering specifics; and (3) data without interpretation: statements describing disease progression findings in detail without explaining what this meant for the patient's future life or survival. Conclusion: Pediatric oncologists often temper their assessment of poor prognosis when speaking with patients and families. Future work should explore serious conversation guides and other clinical interventions aimed at encouraging person-centered prognostic disclosure for patients with advancing cancer and their families.
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Affiliation(s)
- Amy S Porter
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Cameka Woods
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Melanie Stall
- Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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10
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Hill DL, Boyden JY, Feudtner C. Hope in the context of life-threatening illness and the end of life. Curr Opin Psychol 2023; 49:101513. [PMID: 36481600 DOI: 10.1016/j.copsyc.2022.101513] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
Recent research shows the importance of hope in the context of life-threatening illness and the end of life for patients and their families. While some patients and family members continue to hope for a cure or extending life, others may develop more complex hopes related to quality of life and making the most of the time left. Clinicians often worry about taking hope away with bad news about the patient's prognosis, but patients and family members often appreciate honesty without losing hope. Clinicians should recognize that hopes in the context of serious, progressive illness may be complex, contradictory, culturally based, and evolve over time. Recent interventions have been developed to support hope for these patients, caregivers, and parents.
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Affiliation(s)
- Douglas L Hill
- Justin Ingerman Center for Palliative Care, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Jackelyn Y Boyden
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Chris Feudtner
- Justin Ingerman Center for Palliative Care, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Division of General Pediatrics, Department of Pediatrics, Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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11
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Blume ED, Kirsch R, Cousino MK, Walter JK, Steiner JM, Miller TA, Machado D, Peyton C, Bacha E, Morell E. Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000114. [PMID: 36633003 PMCID: PMC10472747 DOI: 10.1161/hcq.0000000000000114] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AIM This summary from the American Heart Association provides guidance for the provision of primary and subspecialty palliative care in pediatric congenital and acquired heart disease. METHODS A comprehensive literature search was conducted from January 2010 to December 2021. Seminal articles published before January 2010 were also included in the review. Human subject studies and systematic reviews published in English in PubMed, ClinicalTrials.gov, and the Cochrane Collaboration were included. Structure: Although survival for pediatric congenital and acquired heart disease has tremendously improved in recent decades, morbidity and mortality risks remain for a subset of young people with heart disease, necessitating a role for palliative care. This scientific statement provides an evidence-based approach to the provision of primary and specialty palliative care for children with heart disease. Primary and specialty palliative care specific to pediatric heart disease is defined, and triggers for palliative care are outlined. Palliative care training in pediatric cardiology; diversity, equity, and inclusion considerations; and future research directions are discussed.
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12
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Gupta D, October TW, Wolfe AHJ. Characteristics of Prognostic Statements During Family Conferences of Critically Ill Children. Pediatr Crit Care Med 2023; 24:34-40. [PMID: 36594798 DOI: 10.1097/pcc.0000000000003116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Discussion of prognosis is an essential component of decision-making family conferences in critical care. We do not know how clinicians convey prognosis to families of critically ill children. We, therefore, aimed to evaluate the frequency of prognostic statements and the message and meaning conveyed through each statement during PICU family conferences. DESIGN Retrospective, mixed-methods study. SETTING PICU of a single quaternary medical center. PATIENTS Critically ill children and their families participating in PICU family conferences of critical medical decision-making. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 72 transcripts from audio-recorded PICU family conferences to identify prognostic statements. Descriptive, thematic content analysis was used to elucidate the message and meaning of each prognostic statement. Prognosis was not discussed in 26% (19/72) of family conferences. Of the other (53/72) conferences where prognostic statements were made, 60% (67/112) of statements conveyed a message (i.e., prognostic medical information) and a meaning (i.e., anticipated impact on patient/family). "Messages" of prognostic statements fell within eight themes: uncertain recovery, delayed recovery, progressive decline, escalation of support, attributable complications, no progress, irreversible, and probability of death. "Meanings" of prognostic statements fell within six themes: restoration of health, activities of daily living, additional equipment, prolonged care needs, brain dysfunction, and death. Broadly, clinicians discussed prognostic information in three categories: loss of Time (i.e., prolonged care needs), Function (i.e., additional medical equipment), or Cure (i.e., death). CONCLUSIONS Nearly in half of discussions (32/72, 44%) where families were asked to make critical medical decisions, clinicians did not provide a prognostic statement including a message and meaning. When discussed, prognostic information was conveyed in three categories: loss of time, function, or cure. Providing families context in this framework, particularly in times of uncertainty, may improve the family's ability to make informed, value-driven medical decisions for their child.
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Affiliation(s)
- Divya Gupta
- Department of Critical Care Medicine, Children's National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Tessie W October
- Department of Critical Care Medicine, Children's National Hospital, Washington, DC
| | - Amy H J Wolfe
- Department of Critical Care Medicine, Children's National Hospital, Washington, DC
- Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
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13
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Alizadeh F, Morell E, Hummel K, Wu Y, Wypij D, Matthew D, Esteso P, Moynihan K, Blume ED. The Surprise Question as a Trigger for Primary Palliative Care Interventions for Children with Advanced Heart Disease. Pediatr Cardiol 2022; 43:1822-1831. [PMID: 35503117 DOI: 10.1007/s00246-022-02919-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/18/2022] [Indexed: 11/25/2022]
Abstract
There is significant uncertainty in describing prognosis and a lack of reliable entry criteria for palliative care studies in children with advanced heart disease (AHD). This study evaluates the utility of the surprise question-"Would you be surprised if this child died within the next year?"-to predict one-year mortality in children with AHD and assess its utility as entry criteria for future trials. This is a prospective cohort study of physicians and nurses caring for children (1 month-19 years) with AHD hospitalized ≥ 7 days. AHD was defined as single ventricle physiology, pulmonary vein stenosis or pulmonary hypertension, or any cardiac diagnosis with signs of advanced disease. Primary physicians were asked the surprise question and medical record review was performed. Forty-nine physicians responded to the surprise question for 152 patients. Physicians responded "No, I would not be surprised if this patient died" for 54 (36%) patients, 20 (37%) of whom died within 1 year, predicting one-year mortality with 77% sensitivity, 73% specificity, 37% positive predictive value, and 94% negative predictive value. Patients who received a "No" response had an increased 1-year risk of death (hazard ratio 7.25, p < 0.001). Physician years of experience, subspecialty, and self-rated competency were not associated with the accuracy of the surprise question. The surprise question offers promise as a bedside screening tool to identify children with AHD at high risk for mortality and help physicians identify patients who may benefit from palliative care and advance care planning discussions.
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Affiliation(s)
- Faraz Alizadeh
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Emily Morell
- Division of Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, San Francisco, CA, USA
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Kevin Hummel
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Yunhong Wu
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Danes Matthew
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Paul Esteso
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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14
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Cortes M, Carceller F, Rubio-San-Simón A, Vaidya SJ, Bautista F, Moreno L. Access to early-phase clinical trials for children with relapsed and refractory neuroblastoma: A multicentre international study. Pediatr Blood Cancer 2022; 69:e29551. [PMID: 35029330 DOI: 10.1002/pbc.29551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/10/2021] [Accepted: 12/11/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Neuroblastoma is the most common extracranial tumour in children, and prognosis for refractory and relapsed disease is still poor. Early-phase clinical trials play a pivotal role in the development of novel drugs. Ensuring adequate recruitment is crucial. The primary aim was to determine the rate of participation trials for children with refractory/relapsed neuroblastoma in two of the largest drug development European institutions. METHODS Data from patients diagnosed with refractory/relapsed neuroblastoma between January 2012 and December 2018 at the two institutions were collected and analysed. RESULTS Overall, 48 patients were included. A total of 31 (65%) refractory/relapsed cases were enrolled in early-phase trials. The main reasons for not participating in clinical trials included not fulfilling eligibility criteria prior to consent (12/17, 70%) and screening failure (2/17, 12%). Median time on trial was 4.3 months (range 0.6-13.4). Most common cause for trial discontinuation was disease progression (67.7%). Median overall survival was longer in refractory (28 months, 95% CI: 20.9-40.2) than in relapsed patients (14 months, 95% CI: 8.1-20.1) (p = .034). CONCLUSIONS Although two thirds of children with refractory/relapsed neuroblastoma were enrolled in early-phase trials, recruitment rates can still be improved. The main cause for not participating on trials was not fulfilling eligibility criteria prior to consent, mainly due to performance status and short life expectancy. This study highlights the hurdles to access to innovative therapies for children with relapsed/refractory neuroblastomas, and identifies key areas of development to improve recruitment to early-phase trials.
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Affiliation(s)
- Marta Cortes
- Paediatric Oncology Unit, Hospital Universitario de Málaga, Málaga, Spain.,Clinical Trials Unit, Paediatic Oncology, Haematology & Stem Cell Transplant, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Fernando Carceller
- Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Alba Rubio-San-Simón
- Clinical Trials Unit, Paediatic Oncology, Haematology & Stem Cell Transplant, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sucheta J Vaidya
- Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Francisco Bautista
- Clinical Trials Unit, Paediatic Oncology, Haematology & Stem Cell Transplant, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Lucas Moreno
- Division of Clinical Studies, The Institute of Cancer Research, London, UK.,Division of Paediatric Haematology & Oncology, Hospital Universitari Vall d'Hebron, and Translational Research in Childhood and Adolescent Cancer, Vall d'Hebron Institute de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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15
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Sisk BA, Keenan M, Goodman MS, Servin AE, Yaeger LH, Mack JW, DuBois JM. Racial and ethnic disparities in communication study enrollment for young people with cancer: A descriptive analysis of the literature. PATIENT EDUCATION AND COUNSELING 2022; 105:2067-2073. [PMID: 34991915 PMCID: PMC9203904 DOI: 10.1016/j.pec.2021.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/20/2021] [Accepted: 12/27/2021] [Indexed: 05/04/2023]
Abstract
OBJECTIVE We aimed to evaluate the racial and ethnic diversity of study participants in recent pediatric cancer communication literature. METHODS We systematically searched for communication studies in pediatric oncology published between January 2018 and September 2020, limiting analysis to US studies. We considered race and ethnicity as separate categories in our analysis. Two authors screened studies and abstracted characteristics of race and ethnicity reporting and enrollment. RESULTS Of 98 articles included in this analysis, many studies failed to report participants' race (21/98) and ethnicity (40/98). Most studies ascertained race and ethnicity by self-report (51/98); 25 studies did not describe how they ascertained race and ethnicity. White participants were overrepresented in studies relative to the US population (median 80% in studies vs 72% in 2020 US census). Racial and ethnic minorities were underrepresented (Black: 7% vs 14%; Asian: 4% vs 7%; Pacific Islander: 0% vs 0.5%; Native American: 0.5% vs 3%; Hispanic 8% vs 19%). CONCLUSION Communication literature in pediatric oncology underrepresents all racial and ethnic minority populations and is inconsistent in the reporting of race and ethnicity. PRACTICE IMPLICATIONS Future work should follow best practices to ensure this literature adequately represents the experiences of all families in pediatric oncology.
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Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA; Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Megan Keenan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Melody S Goodman
- School of Global Public Health, New York University, New York, NY, USA
| | - Argentina E Servin
- Department of Medicine, University of California - San Diego, San Diego, CA, USA
| | - Lauren H Yaeger
- Bernard Becker Medical Library, Washington University School of Medicine, St. Louis, MO, USA
| | - Jennifer W Mack
- Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - James M DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
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16
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Uber A, Ebelhar JS, Lanzel AF, Roche A, Vidal-Anaya V, Brock KE. Palliative Care in Pediatric Oncology and Hematopoietic Stem Cell Transplantation. Curr Oncol Rep 2022; 24:161-174. [DOI: 10.1007/s11912-021-01174-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 12/18/2022]
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17
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Sisk BA, Schulz G, Kaye EC, Baker JN, Mack JW, DuBois JM. Conflicting goals and obligations: Tensions affecting communication in pediatric oncology. PATIENT EDUCATION AND COUNSELING 2022; 105:56-61. [PMID: 33992486 PMCID: PMC8978564 DOI: 10.1016/j.pec.2021.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To describe the tensions experienced by clinicians and psychosocial professionals that affect communication in pediatric oncology. METHODS Ten focus groups with nurses, nurse practitioners, physicians, and psychosocial professionals at 2 US institutions. We analyzed transcripts using thematic analysis, assessing tensions experienced when communicating with parents. RESULTS We identified 5 themes of tensions, defined as challenges experienced when clinicians and psychosocial professionals are trying to achieve multiple conflicting goals or obligations while communicating: (1) Supporting parental hopes while providing honest opinions and information; (2) disclosing all possible outcomes while avoiding the creation of new worries or uncertainties; (3) building relationships while maintaining personal boundaries; (4) disclosing sensitive information while adhering to professional role and perceived authority; (5) validating parental beliefs or decisions while fulfilling obligation for honesty. Some tensions represented conflicts between different communication goals. Others represented conflicts between a communication goal and another obligation. CONCLUSION Clinicians and psychosocial professionals experience tensions that affect communication with parents in pediatric oncology. Some tensions might be addressed with interventions or education. Others will require further analysis to provide sufficient guidance to clinicians. PRACTICE IMPLICATIONS Unaddressed tensions might lead to poor communication and clinician burnout. Future work should explore solutions to these tensions.
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Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Ginny Schulz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA; Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - James M DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
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18
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Sisk BA, Harvey K, Friedrich AB, Antes AL, Yaeger LH, Mack JW, DuBois J. Multilevel barriers and facilitators of communication in pediatric oncology: A systematic review. Pediatr Blood Cancer 2022; 69:e29405. [PMID: 34662485 PMCID: PMC8875310 DOI: 10.1002/pbc.29405] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 01/03/2023]
Abstract
Multiple factors can facilitate or impede the fulfillment of communication functions in pediatric cancer. In this systematic review, we evaluated 109 studies from the preceding 20 years that presented qualitative or quantitative evidence of barriers or facilitators to communication in pediatric cancer. Using a multilevel framework developed in our prior study, we then analyzed and categorized the levels of barriers and facilitators identified in included studies. The vast majority of studies focused on individual-level barriers, rather than team, organization/system, collaborating hospital, community, or policy-level barriers. Future studies should explore the full range of factors that affect communication.
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Affiliation(s)
- Bryan A. Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri.,Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kieandra Harvey
- Brown School of Social Work, Washington University School of Medicine, St. Louis, Missouri
| | - Annie B. Friedrich
- Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, Missouri
| | - Alison L. Antes
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Lauren H Yaeger
- Bernard Becker Medical Library, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer W. Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts; and Division of Pediatric Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts
| | - James DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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19
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Sisk BA, Keenan MA, Blazin LJ, Kaye E, Baker JN, Mack JW, DuBois JM. "Don't be afraid to speak up": Communication advice from parents and clinicians of children with cancer. Pediatr Blood Cancer 2021; 68:e29052. [PMID: 33861026 PMCID: PMC8286806 DOI: 10.1002/pbc.29052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/02/2021] [Accepted: 03/25/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Parents and clinicians of children with cancer can provide advice to improve communication that reflects lessons learned through experience. We aimed to identify categories of communication advice offered to parents of children with cancer from clinicians and other parents. PROCEDURE (1) Semi-structured interviews with 80 parents of children with cancer at three sites; (2) single-item, open-ended survey administered following 10 focus groups with 58 pediatric oncology clinicians at two sites. We asked participants for communication advice to parents, and analyzed responses using semantic content analysis. RESULTS Parents provided five categories of communication advice to other parents. Advocacy involved asking questions, communicating concerns, and speaking up for the child. Support involved pursuing self-care, seeking and accepting help, and identifying supportive communities. Managing information involved taking and organizing notes, remaining open to difficult truths, and avoiding inaccurate information. Partnership involved establishing open lines of communication with clinicians, making the family's values and priorities known, and trusting the clinical team. Engaging and supporting the child involved, understanding and incorporating the child's preferences and values, and creating a loving environment. Clinicians' advice addressed similar categories, although only one clinician described engaging and supporting the child. Furthermore, parental advice expanded beyond interactions with the clinical team, whereas clinician advice focused more on the role of clinicians. CONCLUSIONS Parents and clinicians of children with cancer provided five categories of communication advice. With these data, clinicians, health care organizations, support groups, and patient advocates could offer experience-informed advice to parents who are seeking information and support.
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Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Megan A Keenan
- Bioethics Research Center, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lindsay J Blazin
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Erica Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - James M DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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20
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Providing Palliative and Hospice Care to Children, Adolescents and Young Adults with Cancer. Semin Oncol Nurs 2021; 37:151166. [PMID: 34175165 DOI: 10.1016/j.soncn.2021.151166] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To describe palliative, concurrent, and hospice care in pediatric oncology in the United States (US), we present a clinical scenario illustrating palliative and hospice care, including eligibility for concurrent care, insurance coverage and billing, barriers to accessing quality pediatric palliative and hospice care, and implications for oncology nursing practice. DATA SOURCES Peer-reviewed articles, clinical practice guidelines, professional organizations, and expert clinical opinion examining pediatric oncology, palliative care, and hospice care. CONCLUSION Understanding the goals of palliative and hospice care and the differences between them is important in providing holistic, goal-directed care. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses play a pivotal role in supporting the goals of pediatric palliative care and hospice care and in educating patients and their families. Nurses form trusting relationships with pediatric oncology patients and their families and are in a position to advocate for best palliative care practices as disease progresses to end of life, including when appropriate concurrent care or hospice.
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21
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Kaye EC, Stall M, Woods C, Velrajan S, Gattas M, Lemmon M, Baker JN, Mack JW. Prognostic Communication Between Oncologists and Parents of Children With Advanced Cancer. Pediatrics 2021; 147:peds.2020-044503. [PMID: 33952691 PMCID: PMC8503785 DOI: 10.1542/peds.2020-044503] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Parents of children with cancer perceive deficits in quality of prognostic communication. How oncologists disclose information about disease progression and incurability and how prognostic communication impacts parental understanding of prognosis are poorly understood. In this study, we aimed to (1) characterize communication strategies used by pediatric oncologists to share prognostic information across a child's advancing illness course and (2) explore relationships between different communication approaches and concordance of oncologist-parent prognostic understanding. METHODS In this prospective, longitudinal, mixed-methods study, serial disease reevaluation conversations were audio recorded across an advancing illness course for children with cancer and their families. Surveys and interviews also were conducted with oncologists and caregivers at specific time points targeting disease progression. RESULTS Seventeen children experienced advancing illness on study, resulting in 141 recordings (40 hours). Fewer than 4% of recorded dialogue constituted prognostic communication, with most codes (77%) occurring during discussions about frank disease progression. Most recordings at study entry contained little or no prognosis communication dialogue, and oncologists rated curability lower than parents across all dyads. Parent-oncologist discordance typically was preceded by conversations without incurability statements; ultimately, concordance was achieved in most cases after the oncologist made direct statements about incurability. Content analysis revealed 3 distinct patterns (absent, deferred, and seed planting) describing the provision of prognostic communication across an advancing pediatric cancer course. CONCLUSIONS When oncologists provided direct statements about incurability, prognostic understanding appeared to improve. Further research is needed to determine optimal timing for prognostic disclosure in alignment with patient and family preferences.
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Affiliation(s)
- Erica C. Kaye
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Melanie Stall
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Cameka Woods
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | | | - Melanie Gattas
- St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Monica Lemmon
- Department of Pediatrics, Duke University, Durham, North Carolina
| | | | - Jennifer W. Mack
- Dana-Farber Cancer Institute, Boston, Massachusetts,Boston Children’s Hospital, Boston, Massachusetts
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22
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Sisk BA, Schulz G. Moving Toward a Basic Science of Prognostic Communication. Pediatrics 2021; 147:peds.2021-050208. [PMID: 33952690 DOI: 10.1542/peds.2021-050208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Bryan A Sisk
- Division of Hematology and Oncology, Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Ginny Schulz
- Division of Hematology and Oncology, Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
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23
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Sisk BA, Zavadil JA, Blazin LJ, Baker JN, Mack JW, DuBois JM. Assume It Will Break: Parental Perspectives on Negative Communication Experiences in Pediatric Oncology. JCO Oncol Pract 2021; 17:e859-e871. [PMID: 33848191 DOI: 10.1200/op.20.01038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Communication breakdowns in pediatric oncology can have negative consequences for patients and families. A detailed analysis of these negative encounters will support clinicians in anticipating and responding to communication breakdowns. METHODS Semistructured interviews with 80 parents of children with cancer across three academic medical centers during treatment, survivorship, or bereavement. We analyzed transcripts using semantic content analysis. RESULTS Nearly all parents identified negative communication experiences (n = 76). We identified four categories of contributors to negative experiences: individual (n = 68), team (n = 26), organization (n = 46), and greater health care system (n = 8). These experiences involved a variety of health care professionals across multiple specialties. Parents reported 12 personal consequences of communication breakdowns: emotional distress (n = 65), insufficient understanding (n = 48), decreased trust or confidence (n = 37), inconvenience (n = 36), medical harm (n = 23), decreased self-confidence (n = 17), decreased emotional support (n = 13), decreased engagement (n = 9), false hope (n = 9), decreased hope (n = 7), financial insult (n = 7), and decreased access to resources (n = 3). We identified five categories of supportive responses from clinicians: exploring (n = 8), acknowledging (n = 17), informing (n = 27), adapting (n = 27), and advocating (n = 18). Parents often increased their own advocacy on behalf of their child (n = 47). Parents also identified the need for parental engagement in finding solutions (n = 12). Finally, one parent suggested that clinicians should assume that communication will fail and develop contingency plans in advance. CONCLUSION Communication breakdowns in pediatric oncology negatively affect parents and children. Clinicians should plan for communication breakdowns and respond by exploring, acknowledging, informing, adapting, advocating, and engaging parents in finding solutions.
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Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St Louis, MO
| | - Jessica A Zavadil
- Department of Pediatrics, St Louis Children's Hospital, St Louis, MO
| | - Lindsay J Blazin
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Justin N Baker
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN.,Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, TN
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA
| | - James M DuBois
- Department of Medicine, Washington University School of Medicine, St Louis, MO
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24
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Levine DR, Cuviello A, Nelson C, Lu Z, Mandrell BN, Baker JN. Hope-Colored Glasses: Perceptions of Prognosis Among Pediatric Oncology Patients and Their Parents. JCO Oncol Pract 2021; 17:e730-e739. [PMID: 33661701 DOI: 10.1200/op.20.00762] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cancer patients' belief about prognosis can heavily influence medical decision making and goals of care. It is known that parents of children with cancer tend to be optimistic regarding their child's prognosis; however, little is known about pediatric patients' prognostic beliefs, how physicians' prognostic communication is perceived, and how these perceptions are compared with actual prognoses. PATIENTS AND METHODS An original survey was administered to 100 pediatric oncology patients, age 10-18 years, and their parents from 2013 to 2015, at St Jude Children's Research Hospital. Patients were eligible for inclusion if they had an oncologic diagnosis, were between 1 month and 1 year from diagnosis, and were English speaking. Survey responses regarding perceived prognosis were compared with actual prognoses as determined from the medical record review and published literature. Analysis included descriptive statistics and association tests. RESULTS Nearly half of participants (patients = 48.9%, parents = 50.5%) displayed prognostic optimism as compared with the determined objective estimate of curative potential. The majority of both patients (78%) and parents (85%) reported belief in a very high chance of cure, although fewer reported that their physician communicated a very high chance for cure (patients = 57%, parents = 70%), and only 43% were determined to have a very high probability of cure. Significant differences were noted in prognostic optimism by cancer type (P < .0001); patients with solid tumor were more often optimistic (n = 25, 83.3% optimistic; n = 5, 16.7% accurate), and patients with lymphoma were most often accurate (n = 2, 8.7% optimistic; n = 21, 91.3% accurate). CONCLUSION Pediatric oncology patients and parents tend to be optimistic about their chance of cure, as compared to both perceived prognostic communication from physicians and objective estimated prognosis. Understanding the nature of prognostic optimism among patients with cancer and caregivers may empower clinicians to guide realistic decision making while supporting hope.
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Affiliation(s)
- Deena R Levine
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Andrea Cuviello
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Catherine Nelson
- Department of Pediatrics, Our Lady of the Lake Regional Medical Center, Baton Rouge, LA
| | - Zhaohua Lu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Belinda N Mandrell
- Division of Nursing Research, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
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25
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Fisher RS, Kenney AE, Fults MZ, Manring S, Rodriguez EM, Desjardins L, Rausch JR, Young-Saleme T, Ranalli MA, Vannatta K, Compas BE, Gerhardt CA. Longitudinal understanding of prognosis among adolescents with cancer. Pediatr Blood Cancer 2021; 68:e28826. [PMID: 33320998 DOI: 10.1002/pbc.28826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/30/2020] [Accepted: 11/02/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Despite calls to increase prognosis communication for adolescents with cancer, limited research has examined their perceptions of prognosis as compared with their parents. We assessed adolescents' understanding of their prognosis relative to parents and oncologists. METHODS Families of adolescents (aged 10-17) were recruited at two pediatric institutions following a new diagnosis or relapse. Seventy-four adolescents, 68 mothers, and 40 fathers participated at enrollment; 76 adolescents, 69 mothers, and 35 fathers participated one year later. The adolescent's primary oncologist reported on prognosis only at enrollment. Participants rated the likelihood of the adolescent's survival in five years, as well as reporting prognosis communication and sources of information. RESULTS Most oncologists (65%) and fathers (63%) discussed prognosis in numerical terms with the adolescent at baseline, which was greater than mother report (49%) of discussions of numerical prognosis with adolescents. Adolescents reported a better prognosis than oncologists, but comparable with mothers at diagnosis and one year. Adolescents' prognosis estimates were stable over time (P > .05). At diagnosis, adolescent-father (P = 0.025) and adolescent-oncologist (P < 0.001) discrepancies were larger for youth with advanced than non-advanced cancer. Adolescents whose parents received numerical prognosis estimates from the oncologist, and whose fathers reported providing numerical prognosis estimates had more accurate understandings of prognosis (P < 0.05). CONCLUSIONS Adolescent prognosis estimates were comparable with those of parents at diagnosis and one year but more favorable than that of oncologists. Although additional research is needed, results suggest discrepancies in prognosis estimates between family members and oncologists, particularly for adolescents with advanced cancer.
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Affiliation(s)
- Rachel S Fisher
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Ansley E Kenney
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Marci Z Fults
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Samantha Manring
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Erin M Rodriguez
- Department of Educational Psychology, The University of Texas at Austin, Austin, Texas
| | | | - Joseph R Rausch
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Tammi Young-Saleme
- Division of Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio
| | - Mark A Ranalli
- Department of Pediatrics, The Ohio State University, Columbus, Ohio.,Division of Hematology/Oncology/Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Kathryn Vannatta
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio.,Department of Psychology, The Ohio State University, Columbus, Ohio
| | - Bruce E Compas
- Psychology and Human Development, Vanderbilt University, Nashville, Tennessee
| | - Cynthia A Gerhardt
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio.,Department of Psychology, The Ohio State University, Columbus, Ohio
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26
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Sisk BA, Friedrich AB, Kaye EC, Baker JN, Mack JW, DuBois JM. Multilevel barriers to communication in pediatric oncology: Clinicians' perspectives. Cancer 2021; 127:2130-2138. [PMID: 33598930 DOI: 10.1002/cncr.33467] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/08/2020] [Accepted: 12/26/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Communication serves several functions in pediatric oncology, but communication deficiencies persist. Little is known about the broad spectrum of barriers contributing to these deficiencies. Identifying these barriers will support new strategies to improve communication. METHODS The authors performed 10 focus groups on perceived communication barriers with nurses, nurse practitioners, physicians, and psychosocial professionals across 2 academic institutions. They analyzed transcripts by adapting a multilevel framework from organizational psychology. RESULTS The authors identified 6 levels of barriers to communication from the clinicians' perspectives: individual, team, organization, collaborating hospital, community, and policy. Individual barriers were subdivided into clinician characteristics, family characteristics, or characteristics of the clinician-family interaction. Within each level and sublevel, several manifestations of barriers were identified. Some barriers, such as a lack of comfort with difficult topics (individual), cultural differences (individual), a lack of a shared team mental model (team), and time pressure (organization), manifested similarly across professions and institutions. Other barriers, such as a need for boundaries (individual), intimidation or embarrassment of family (individual), unclear roles and authority (team), and excessive logistical requirements (policy), manifested differently across professions. With the exception of collaborating hospitals, participants from all professions identified barriers from each level. Physicians did not discuss collaborating hospital barriers. CONCLUSIONS Nurses, nurse practitioners, physicians, and psychosocial professionals experience communication barriers at multiple levels, which range from individual- to policy-level barriers. Yet their unique clinical roles and duties can lead to different manifestations of some barriers. This multilevel framework might help clinicians and researchers to identify targets for interventions to improve communication experiences for families in pediatric oncology. LAY SUMMARY Clinicians and families experience many barriers to communication in pediatric oncology. The authors performed 10 focus groups with 59 clinicians who cared for children with cancer. In these focus groups, barriers to effective communication were discussed. In this article, the authors report on an analysis of the responses. Six levels of barriers to communication were found: individual, team, organization, collaborating hospital, community, and policy. With an understanding of these barriers, interventions can be developed to target these barriers in hopes of improving communication for parents and patients in pediatric oncology.
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Affiliation(s)
- Bryan A Sisk
- Division of Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Annie B Friedrich
- Albert Gnaegi Center for Health Care Ethics, Saint Louis University, St. Louis, Missouri
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Division of Quality of Life and Palliative Care, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jennifer W Mack
- Pediatric Oncology and Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - James M DuBois
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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27
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Morell E, Miller MK, Lu M, Friedman KG, Breitbart RE, Reichman JR, McDermott J, Sleeper LA, Blume ED. Parent and Physician Understanding of Prognosis in Hospitalized Children With Advanced Heart Disease. J Am Heart Assoc 2021; 10:e018488. [PMID: 33442989 PMCID: PMC7955315 DOI: 10.1161/jaha.120.018488] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background The unpredictable trajectory of pediatric advanced heart disease makes prognostication difficult for physicians and informed decision‐making challenging for families. This study evaluated parent and physician understanding of disease burden and prognosis in hospitalized children with advanced heart disease. Methods and Results A longitudinal survey study of parents and physicians caring for patients with advanced heart disease age 30 days to 19 years admitted for ≥7 days was performed over a 1‐year period (n=160 pairs). Percentage agreement and weighted kappa statistics were used to assess agreement. Median patient age was 1 year (interquartile range, 1–5), 39% had single‐ventricle lesions, and 37% were in the cardiac intensive care unit. Although 92% of parents reported understanding their child's prognosis “extremely well” or “well,” 28% of physicians thought parents understood the prognosis only “a little,” “somewhat,” or “not at all.” Better parent‐reported prognostic understanding was associated with greater preparedness for their child's medical problems (odds ratio, 4.7; 95% CI, 1.4–21.7, P=0.02). There was poor parent–physician agreement in assessing functional class, symptom burden, and likelihood of limitations in physical activity and learning/behavior; on average, parents were more optimistic. Many parents (47%) but few physicians (6%) expected the child to have normal life expectancy. Conclusions Parents and physicians caring for children with advanced heart disease differed in their perspectives regarding prognosis and disease burden. Physicians tended to underestimate the degree of parent‐reported symptom burden. Parents were less likely to expect limitations in physical activity, learning/behavior, and life expectancy. Combined interventions involving patient‐reported outcomes, parent education, and physician communication tools may be beneficial.
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Affiliation(s)
- Emily Morell
- Division of Cardiology Department of Pediatrics Children's Hospital Los Angeles Los Angeles CA
| | | | - Minmin Lu
- Department of Cardiology Boston Children's Hospital Boston MA
| | | | | | | | - Julie McDermott
- Department of Cardiology Boston Children's Hospital Boston MA
| | - Lynn A Sleeper
- Department of Cardiology Boston Children's Hospital Boston MA
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28
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Sisk BA. Improving communication in pediatric oncology: An interdisciplinary path forward. Cancer 2020; 127:1005-1007. [PMID: 33320329 DOI: 10.1002/cncr.33361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/28/2020] [Accepted: 11/14/2020] [Indexed: 11/12/2022]
Affiliation(s)
- Bryan A Sisk
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St Louis, Missouri
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29
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Mack JW, Uno H, Twist CJ, Bagatell R, Rosenberg AR, Marachelian A, Granger MM, Glade Bender J, Baker JN, Park JR, Cohn SL, Fernandez JH, Diller LR, Shusterman S. Racial and Ethnic Differences in Communication and Care for Children With Advanced Cancer. J Pain Symptom Manage 2020; 60:782-789. [PMID: 32360991 PMCID: PMC7523916 DOI: 10.1016/j.jpainsymman.2020.04.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 11/18/2022]
Abstract
CONTEXT Racial and ethnic disparities in end-of-life care are well documented among adults with advanced cancer. OBJECTIVES To examine the extent to which communication and care differ by race and ethnicity among children with advanced cancer. METHODS We conducted a prospective cohort study at nine pediatric cancer centers enrolling 95 parents (42% racial/ethnic minorities) of children with poor prognosis cancer (relapsed/refractory high-risk neuroblastoma). Parents were surveyed about whether prognosis was discussed; likelihood of cure; intent of current treatment; and primary goal of care. Medical records were used to identify high-intensity medical care since the most recent recurrence. Logistic regression evaluated differences between white non-Hispanic and minority (black, Hispanic, and Asian/other race) parents. RESULTS About 26% of parents recognized the child's low likelihood of cure. Minority parents were less likely to recognize the poor prognosis (odds ratio [OR] = 0.19; 95% CI = 0.06-0.63; P = 0.006) and the fact that current treatment was unlikely to offer cure (OR = 0.07; 95% CI = 0.02-0.27; P < 0.0001). Children of minority parents were more likely to experience high-intensity medical care (OR = 3.01; 95% CI = 1.29-7.02; P = 0.01). After adjustment for understanding of prognosis, race/ethnicity was no longer associated with high-intensity medical care (adjusted odds ratio = 2.14; 95% CI = 0.84-5.46; P = 0.11), although power to detect an association was limited. CONCLUSION Parental understanding of prognosis is limited across racial and ethnic groups; racial and ethnic minorities are disproportionately affected. Perhaps as a result, minority children experience higher rates of high-intensity medical care. Work to improve prognostic understanding should include focused work to meet needs of minority populations.
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Affiliation(s)
- Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.
| | - Hajime Uno
- Division of Population Sciences' Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Clare J Twist
- Roswell Park Cancer Institute Buffalo, New York, New York, USA
| | - Rochelle Bagatell
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abby R Rosenberg
- Department of Pediatric Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA; Pediatric Bioethics/Palliative Care, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Araz Marachelian
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - M Meaghan Granger
- Hematology and Oncology Center, Cook Children's Hospital, Fort Worth, Texas, USA
| | - Julia Glade Bender
- Department of Pediatric Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Justin N Baker
- Division of Quality of Life and Palliative Care, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Julie R Park
- Department of Pediatric Hematology/Oncology, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Susan L Cohn
- Department of Pediatrics, Comer Children's Hospital, University of Chicago, Chicago, Illinois, USA
| | - Jorge H Fernandez
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
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30
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Sisk BA, Friedrich A, Blazin LJ, Baker JN, Mack JW, DuBois J. Communication in Pediatric Oncology: A Qualitative Study. Pediatrics 2020; 146:peds.2020-1193. [PMID: 32820068 PMCID: PMC7461134 DOI: 10.1542/peds.2020-1193] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND When children are seriously ill, parents rely on communication with their clinicians. However, in previous research, researchers have not defined how this communication should function in pediatric oncology. We aimed to identify these communication functions from parental perspectives. METHODS Semistructured interviews with 78 parents of children with cancer from 3 academic medical centers at 1 of 3 time points: treatment, survivorship, or bereavement. We analyzed interview transcripts using inductive and deductive coding. RESULTS We identified 8 distinct functions of communication in pediatric oncology. Six of these functions are similar to previous findings from adult oncology: (1) building relationships, (2) exchanging information, (3) enabling family self-management, (4) making decisions, (5) managing uncertainty, and (6) responding to emotions. We also identified 2 functions not previously described in the adult literature: (7) providing validation and (8) supporting hope. Supporting hope manifested as emphasizing the positives, avoiding false hopes, demonstrating the intent to cure, and redirecting toward hope beyond survival. Validation manifested as reinforcing "good parenting" beliefs, empowering parents as partners and advocates, and validating concerns. Although all functions seemed to interact, building relationships appeared to provide a relational context in which all other interpersonal communication occurred. CONCLUSIONS Parent interviews provided evidence for 8 distinct communication functions in pediatric oncology. Clinicians can use this framework to better understand and fulfill the communication needs of parents whose children have serious illness. Future work should be focused on measuring whether clinical teams are fulfilling these functions in various settings and developing interventions targeting these functions.
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Affiliation(s)
- Bryan A. Sisk
- Division of Hematology and Oncology, Department of
Pediatrics and
| | - Annie Friedrich
- Albert Gnaegi Center for Health Care Ethics, Saint
Louis University, St Louis, Missouri
| | - Lindsay J. Blazin
- Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, Tennessee
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care
and,Department of Oncology, St. Jude Children’s
Research Hospital, Memphis, Tennessee
| | - Jennifer W. Mack
- Division of Population Sciences, McGraw Patterson
Center for Population Sciences and Department of Pediatric Oncology, Dana-Farber
Cancer Institute, Boston, Massachusetts; and,Division of Hematology/Oncology, Boston
Children’s Hospital, Boston, Massachusetts
| | - James DuBois
- Division of General Medical Sciences, Department of
Medicine, School of Medicine, Washington University in St Louis, St Louis,
Missouri
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31
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Lichtenthal WG, Roberts KE, Catarozoli C, Schofield E, Holland JM, Fogarty JJ, Coats TC, Barakat LP, Baker JN, Brinkman TM, Neimeyer RA, Prigerson HG, Zaider T, Breitbart W, Wiener L. Regret and unfinished business in parents bereaved by cancer: A mixed methods study. Palliat Med 2020; 34:367-377. [PMID: 32020837 PMCID: PMC7438163 DOI: 10.1177/0269216319900301] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prior research has demonstrated that the presence of regret and unfinished business is associated with poorer adjustment in bereavement. Though there is a growing literature on these constructs among caregivers of adult patients, the literature on regret and unfinished business in bereaved parents has been limited. AIM The aim of this study was to examine regret and unfinished business in parents bereaved by cancer, as well as their associations with caregiving experiences and prolonged grief. DESIGN This was a cross-sectional mixed methods study that utilized self-report questionnaires with open-ended items. SETTING/PARTICIPANTS The multisite study took place at a tertiary cancer hospital and pediatric cancer clinical research institution. Participants were 118 parents (mothers = 82, fathers = 36) who lost a child aged 6 months to 25 years to cancer between 6 months and 6 years prior. RESULTS Results showed that 73% of the parents endorsed regret and 33% endorsed unfinished business, both of which were more common among mothers than fathers (p ⩽ 0.05). Parents were on average moderately distressed by their regrets and unfinished business, and both regret-related and unfinished business-related distress were associated with distress while caregiving and prolonged grief symptoms. CONCLUSION Findings have implications for how providers work with families, including increasing treatment decision-making support, supporting parents in speaking to their child about illness, and, in bereavement, validating choices made. Grief interventions that use cognitive-behavioral and meaning-centered approaches may be particularly beneficial.
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Affiliation(s)
- Wendy G Lichtenthal
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medicine, New York, NY, USA
| | - Kailey E Roberts
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Elizabeth Schofield
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Justin J Fogarty
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Taylor C Coats
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | | | | | - Talia Zaider
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medicine, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medicine, New York, NY, USA
| | - Lori Wiener
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD, USA
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