Parents' experiences of initiation of paediatric advance care planning discussions: a qualitative study

A mixed methods exploration of the health and caregiving experiences of fathers of children with a life-limiting condition

BACKGROUND

Fathers of children with a life-limiting condition are underrepresented in the literature. We know little about their experiences of caregiving, the impact of this on their health and their support needs.

AIM

To explore the health and caregiving experiences of fathers of children with a life-limiting condition, both quantitatively and qualitatively.

DESIGN

A convergent mixed methods design comprised of (1) a quantitative survey and (2) semi-structured qualitative interviews prioritising the qualitative data.

SETTING/PARTICIPANTS

Thirty-two fathers of children with a life-limiting condition took part in the survey. They were recruited via social media, three UK children's hospices and one UK children's hospital. Twelve of these fathers went on to take part in a qualitative semi-structured interview.

RESULTS

Thematic analysis resulted in three themes: (1) Everyday precarity; (2) cumulative distress; past, present and future; (3) the scope and severity of the impact of caregiving on fathers; a lack of understanding from others. In the survey, fathers reported high levels of carer strain and distress, alongside high levels of family wellbeing and positive appraisals of caregiving.

CONCLUSION

Fathers' extensive and overwhelming daily routines are inflexible and unstable, leading to multidimensional precarity and a sense of overwhelm. Current care provision does not address the unique and fluctuating support needs of fathers, which are linked to those of their child, and need to be understood in the context of both parenting and caregiving. A process capable of identifying and addressing fathers' support needs to be established.

Influence of pediatric advance care planning on the secondary outcomes of the BOOST pACP trial: determinants of communication between parents and adolescents with cancer

This study explores the impact of a pediatric advance care planning program (BOOST pACP) on adolescents with cancer and their parents, focusing on behavioral determinants such as attitudes, self-efficacy, intention, and behavior regarding the discussion of ACP topics. A multi-center, parallel-group superiority trial was conducted with adolescent-parent dyads recruited from four pediatric oncology wards in Belgium. The intervention group received four structured ACP sessions facilitated by an external professional, while the control group received care as usual. The acquired insights were shared with their oncologist. The behavioral determinants were measured through self-developed questionnaires based on the Theory of Planned Behavior (TPB) at baseline (T0), 3 months (T1), and 7 months (T2). This secondary data analysis used exploratory factor analysis and linear mixed models to assess the impact of the intervention. Forty-nine families were enrolled and randomized to the BOOST pACP group (n=24) or care-as-usual (n=25). At T1, fathers in the intervention group had significantly lower negative attitudes towards discussing ACP topics than their counterparts in the control group; mothers in the intervention group had increased intentions to discuss end-of-life care topics; and adolescents had reduced intentions to discuss ACP topics with their oncologist. No significant differences between intervention and control were observed in self-efficacy and mothers' attitudes.

CONCLUSION

Our RCT suggests a limited effectiveness of a pediatric ACP intervention in changing behavioral determinants associated with ACP communication. As the study was eventually underpowered, these findings underscore the need for a better understanding of the mechanisms driving or hindering outcomes and impact of pediatric ACP and highlight the complexity of influencing ACP behaviors within the pediatric oncology setting.

TRIAL REGISTRATION

ISRCTN, number 33228289 10.1186/ISRCTN33228289. Registration date: 22/01/2021.

WHAT IS KNOWN

• Pediatric advance care planning (pACP) helps families and healthcare professionals discuss future care but is challenging due to evolving decision-making capacity, family dynamics, and parental distress. • Healthcare professionals also report barriers to engage in pACP.

WHAT IS NEW

• This study evaluated the impact of a structured pACP intervention (BOOST pACP) on behavioral determinants of ACP communication from the perspective of the adolescents, mothers, and fathers separately. • Findings highlight the complexity of influencing ACP behaviors and contributes to the important discussion on what ACP for this target group should look like.

Multi-center randomized controlled trial on advance care planning for adolescents with cancer and their parents: Impact on parent-adolescent communication

PURPOSE

This study evaluates whether the Benefits of Obtaining Ownership Systematically Together in pediatric Advance Care Planning (BOOST pACP) intervention improves parent-adolescent communication compared to care as usual.

METHODS

In this multi-center parallel-group superiority trial, adolescent patients (10-18 years old) diagnosed with cancer and their parent(s) were randomized with a 1:1 allocation to a pACP intervention or care as usual. The primary endpoint was the adolescents' assessment of quality of parent-adolescent communication at 3 months, and the secondary was quality of parent-adolescent communication at 7 months.

RESULTS

Forty-nine families were enrolled (28% enrollment rate) between March 2021 and March 2023. No significant differences in parent-adolescent communication were observed between the BOOST and care as usual groups at 3 months (T1) (baseline-adjusted mean difference = 1.4; 95% CI -4.1 to 6.9; p = 0.608), effect size 0.13. Similarly, at 7 months (T2) differences were not significant (baseline-adjusted mean difference = 5.2; 95% CI -0.6 to 11.0; p = 0.077), effect size 0.49 (and 0.67 for father-adolescent communication). No significant differences in anxiety scores of adolescents and parents were found and no adverse events were reported.

CONCLUSION

The BOOST pACP intervention did not significantly improve parent-adolescent communication for adolescents with cancer and their parents at 3 months after baseline. However, the results indicate it might have a clinical impact in later stages of the follow-up period. Limitations of this study are the underpowered sample size and the lack of validated questionnaires for specific ACP communication.

CLINICAL TRIAL REGISTRATION

ISRCTN, number 33228289 https://doi.org/10.1186/ISRCTN33228289.

Healthcare professionals' discussion of loss and grief with parents of children with life-limiting severe neurological impairment: Findings from a scoping review

OBJECTIVES

Parents' experiences of loss and grief in the context of caring for a child with life-limiting severe neurological conditions are complex. Supportive interventions delivered by multidisciplinary teams have the potential to mitigate illness-related and anticipatory grief before and after bereavement. To date, the literature on professionals' discussion of loss and grief with parents has not been synthesized. This systematic review aims to synthesize the evidence to establish what is known about professionals' experience of these discussions with this population, with particular emphasis on timing, frequency, and the setting in which discussions occur.

METHODS

A scoping review was developed, informed by the Preferred Reporting Items for Systematic Reviews and Meta analyses - Scoping Extension guidelines and the PCC (Population, Concept, Context) framework. Three electronic databases (PsycINFO, CINAHL, and PubMED) were searched using medical subject heading (MeSH) terms and keywords search strings in January 2023. The search was not limited to year of publication. Overall, 35 articles were analyzed using a combination of descriptive analysis and thematic synthesis.

RESULTS

Two overarching themes were identified, "loss and grief are part of this context" and "lack of recognition of loss and grief," illustrating that despite the lack of evidence of explicit discussion of these issues, some aspects of loss and grief appeared to guide or implicitly influence healthcare professionals' practice. Failure to acknowledge loss and grief was associated with an increase in parental distress and had implications for future care planning.

SIGNIFICANCE OF RESULTS

Healthcare professionals are well placed to discuss loss and grief with parents of children with life-limiting severe neurological conditions. However, these discussions are only implicitly reported in the literature. Findings suggest that some professionals avoided discussing loss and grief. Bereavement outcomes are not typically considered in findings of the papers reviewed. Based on these findings, future research should focus on what this means for understanding professionals' capacity to engage with loss and grief.

Role of children's hospices in caring for children, young people and families

Children's hospices are central to specialist palliative care provision for the increasing number of children and young people with life-limiting conditions and their families. These hospices provide holistic care through a range of services, including ongoing care from the point of diagnosis, at the end of life and into bereavement. This article outlines the services provided by children's hospices, while dispelling misconceptions that they exclusively provide care at the end of life. It also explains how these services have developed and evolved as a result of technological advances. It is useful for nurses to be aware of the role of children's hospices, so that they can support the effective care of children and young people with life-limiting conditions and their families.

Goals of care conversations and advance care planning for paediatric patients living with serious illness

Goals of care discussions and advance care planning aim to align the values and wishes of patients and their families with the care received. All paediatric health care practitioners who care for fetuses, infants, children or adolescents with serious illnesses have an ethical responsibility to educate themselves about these aspects of care. This statement assists care providers with important conversations. Effective communication is essential to clarify the goals of care and establish agreement on appropriate treatments for achieving those goals, including resuscitative and palliative measures.

Les objectifs des échanges sur les soins et de la planification préalable des soins chez les patients d'âge pédiatrique atteints d'une maladie grave

Les échanges sur les soins et la planification préalable des soins visent à faire concorder les valeurs et les désirs des patients et de leur famille avec les soins qu'ils reçoivent. Tous les professionnels de la santé qui soignent des fœtus, des nourrissons, des enfants ou des adolescents atteints de maladies graves ont la responsabilité éthique de s'éduquer à l'égard de ces aspects des soins. Le présent document de principes aide les professionnels de la santé à entamer ces discussions importantes. Des communications efficaces sont essentielles pour clarifier les objectifs des soins et s'entendre sur les traitements adaptés à la réalisation de ces objectifs, y compris les mesures de réanimation et les mesures palliatives.

Understanding pediatric palliative care within interdisciplinary palliative programs: a qualitative study

PURPOSE

To describe the process of delivery of pediatric palliative care from the perspective of a pediatric interdisciplinary team and the children's parents.

METHODS

A qualitative descriptive case study was conducted. Purposeful sampling took place within a specialized pediatric palliative care Unit in Madrid (Spain), located at the Niño Jesus Hospital. The study participants included a specialized pediatric palliative care team from Madrid's pediatric palliative care program, other professional teams involved in interdisciplinary care and parents of children under pediatric palliative care. Data were collected via semi-structured interviews, focus groups and researchers' field notes. A thematic analysis was performed.

RESULTS

This study included 28 participants (20 women, 8 men), of whom 18 were professionals who belonged to the pediatric palliative care interdisciplinary team, 4 professionals were from other units that collaborated with the pediatric palliative care, and 6 were parents (5 women, 1 man). The mean age of the pediatric palliative care members was 38.2 years (SD ± 7.9), that of the collaborating professionals was 40.5 (SD ± 6.8), and that of the parents was 44.2 (SD ± 5.4). Two main themes emerged: a) Pediatric palliative care has a distinct identity, associated with life. It represents the provision of special care in highly complex children, in the context of the home, far from the hospital environment; b) The team is key: its interdisciplinary organization provides a more comprehensive view of the child and their family, fosters communication among professionals, and improves coordination with other services involved in the care of children. The mindset shift experienced by ID-PPC professionals towards a palliative approach makes them more sensitive to the needs of their patients and leads them to develop specific skills in areas such as communication, decision-making, and adaptability that were identified as differentiating aspects of pediatric palliative care.

CONCLUSIONS

Describing pediatric palliative care from the professional and parental perspective helps to establish realistic and comprehensive goals for the care of children and their parents. The findings of this study may help with the establishment of a pediatric palliative care team, as a necessary organizational change in a health care system that cares for children with complex and life-threatening conditions. Promoting training in pediatric palliative care, prioritizing more horizontal organizations, providing tools and spaces for coordination and communication between professionals from different services, together with the creation of a position of case coordinator in the care process of children could enhance the understanding of pediatric palliative care services.

Advance care plan discussion among parents of children with cerebral palsy

AIM

To evaluate parental perception of advance care plan (ACP) discussions in families of Malaysian children with bilateral cerebral palsy (CP) classified in Gross Motor Function Classification System levels IV or V for (1) acceptance of the ACP discussion, (2) feedback on the usefulness of ACP discussion, and (3) exploration of possible factors related to parental acceptance of ACP.

METHOD

This was a prospective pre- and post-ACP discussion questionnaire study for parents of children with bilateral CP.

RESULTS

Sixty-nine patients were recruited to the study; 64 (93%) had at least one additional comorbidity. The median age was 8 years (interquartile range 5 years 1 month-11 years 6 months). Fifty-seven (82.6%) parents found the ACP discussion acceptable, and most reported positive feedback on various components of the discussion (88.4-97.1%). One-third of participants were not comfortable discussing end-of-life care plans. On multivariate analysis, parents who were comfortable discussing end-of-life care plans were more likely to find the ACP discussion acceptable (odds ratio 27.78, 95% confidence interval 2.9-265.1, p = 0.004).

INTERPRETATION

Most parents of Malaysian children with bilateral CP reported the ACP discussion as both acceptable and beneficial. Parents need to be comfortable about discussing end-of-life care plans for their child to enable the ACP discussion to be an acceptable experience.