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Wu WW, Lu FL, Tang CC, Chao FH, Yu TH. Pediatric palliative care utilization by decedent children: A nationwide population-based study, 2002-2017. J Nurs Scholarsh 2023; 55:1116-1125. [PMID: 37917036 DOI: 10.1111/jnu.12908] [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: 09/01/2022] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE This study aimed (1) to describe how trends in pediatric palliative care (PPC) utilization changed from 2002 to 2017, and (2) to examine factors predicting PPC utilization among decedent children in Taiwan. DESIGN This retrospective, correlational study retrieved 2002-2017 data from three national claims databases in Taiwan. METHODS Children aged 1 through 18 years who died between January 2002 and December 2017 were included. Pediatric palliative care utilization was defined as PPC enrollment and PPC duration, with enrollment described by frequency (n) and percentage (%) and duration described by mean and standard deviation (SD). Logistic regression was used to examine the associations of various demographic characteristics with PPC enrollment; generalized linear regression was used to examine associations of the demographic characteristics with PPC duration. FINDINGS Across the 16-year study period, PPC enrollment increased sharply (15.49 times), while PPC duration decreased smoothly (by 29.41%). Cause of death was a continuous predictor of both PPC enrollment and PPC duration. The children less likely to be enrolled in PPC services were those aged 1 to 6 years, boys, living in poverty, living in rural areas, and diagnosed with life-threatening noncancer diseases. CONCLUSION This study used nationwide databases to investigate PPC enrollment and PPC duration among a large sample of deceased children from 2002 to 2017. The findings not only delineate trends and predictors of PPC enrollment and PPC duration but also highlight great progress in PPC as well as the areas still understudied and underserved. This information could help the pediatric healthcare system achieve the core value of family-centered care for children with life-threatening diseases and their families. CLINICAL RELEVANCE Pediatric palliative care should be widely and continuously implemented in routine pediatric clinical practice to enhance quality of life for children and their families at the end of life.
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Affiliation(s)
- Wei-Wen Wu
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Frank L Lu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Chia-Chun Tang
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Hsin Chao
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Tsung-Hsien Yu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Hrdlickova L, Polakova K, Loucka M. Innovative communication approaches for initializing pediatric palliative care: perspectives of family caregivers and treating specialists. BMC Palliat Care 2023; 22:152. [PMID: 37814302 PMCID: PMC10563209 DOI: 10.1186/s12904-023-01269-3] [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: 05/27/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Effective cooperation between a pediatric palliative care team (PPCT), primary treating specialists, patients and families is crucial for high quality care of children with complex life-limiting conditions. Several barriers among patients, families and treating specialists have been identified in the context of initializing pediatric palliative care. The aim of the study was to assess the experience with initial pediatric palliative care consultations from perspectives of family caregivers and treating physicians with a special focus on two innovative approaches: attendance of the treating specialist and the opportunity for parents to give feedback on the written report from the consultation. METHODS This was a qualitative study using semi-structured interviews with family caregivers of children with malignant and non-malignant disease and their treating specialists. Framework analysis was used to guide the data collection and data analysis. RESULTS In total, 12 family caregivers and 17 treating specialists were interviewed. Four main thematic categories were identified: (1) expectations, (2) content and evaluation, (3) respect and support from the team and (4) consultation outcomes. Parents viewed the consultation as a unique opportunity to discuss difficult topics. They perceived the attendance of the treating specialist at the initial consultation as very important for facilitating communication. Treating specialists valued the possibility to learn more about psychosocial issues of the child and the family while attending the initial palliative care consultation. All participants perceived the written report from the consultation as useful for further medical decisions. Family members appreciated the chance to give feedback on the consultation report. CONCLUSIONS Our study identified several clinically relevant issues that can help initialize pediatric palliative care and establish effective collaboration between families and PPCT and treating specialists. Supporting treating specialists in their ability to explain the role of palliative care is important in order to reduce the risk of misunderstanding or unrealistic expectations. Developing more specific expectations seems to be one of the ways to further increase the effectiveness of initial consultations. The results of the study can be especially helpful for the initial phase of implementing pediatric palliative care and initializing the process of setting up a collaborative relationship with palliative care teams in the hospital.
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Affiliation(s)
- Lucie Hrdlickova
- Department of Pediatric Hematology and Oncology, University Hospital Motol, V Uvalu 84, Prague, 5,150 06, Czech Republic.
- Pediatric Supportive Care Team, University Hospital Motol, Prague, Czech Republic.
- First Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Kristyna Polakova
- Center for Palliative Care, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Loucka
- Center for Palliative Care, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Rico-Mena P, Güeita-Rodríguez J, Martino-Alba R, Chocarro-Gonzalez L, Sanz-Esteban I, Palacios-Ceña D. Understanding pediatric palliative care within interdisciplinary palliative programs: a qualitative study. BMC Palliat Care 2023; 22:80. [PMID: 37355579 DOI: 10.1186/s12904-023-01194-5] [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] [Received: 10/04/2022] [Accepted: 06/07/2023] [Indexed: 06/26/2023] Open
Abstract
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.
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Affiliation(s)
- Patricia Rico-Mena
- Department of Physiotherapy, Chiropody and Dance, Physical Therapy and Health Sciences Research Group, Universidad Europea de Madrid, C. Tajo, S/N, 28670 Villaviciosa de Odón, Madrid, Spain
- International Doctorate School, Rey Juan Carlos University, Madrid, Spain
| | - Javier Güeita-Rodríguez
- Department of Physiotherapy, Occupational Therapy, Rehabilitation, and Physical Medicine, Humanities and Qualitative Research in Health Science Research Group, Universidad Rey Juan Carlos, Madrid, Spain.
| | - Ricardo Martino-Alba
- Pediatric Palliative Care Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | - Ismael Sanz-Esteban
- Department of Physiotherapy, Chiropody and Dance, Physical Therapy and Health Sciences Research Group, Universidad Europea de Madrid, C. Tajo, S/N, 28670 Villaviciosa de Odón, Madrid, Spain
| | - Domingo Palacios-Ceña
- Department of Physiotherapy, Occupational Therapy, Rehabilitation, and Physical Medicine, Humanities and Qualitative Research in Health Science Research Group, Universidad Rey Juan Carlos, Madrid, Spain
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Roberts HJ, Wang Y, Spruit JL, Taylor L, Franson AT. The impact of clinical trial enrollment on specialty palliative care utilization in pediatric patients with high-grade gliomas. Pediatr Blood Cancer 2023; 70:e30115. [PMID: 36458446 DOI: 10.1002/pbc.30115] [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: 09/21/2022] [Revised: 10/19/2022] [Accepted: 11/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Palliative care (PC) provides numerous benefits for children with cancer. Pediatric patients with high-grade glioma (HGG) are particularly well suited for early PC involvement given their high symptom burden and poor prognosis. However, studies continue to reveal that children with cancer, including HGG, have delayed PC involvement. We hypothesized that clinical trial enrollment may lead to a lack of or delay in PC involvement in this population. PROCEDURE For each patient in our cohort of 43 pediatric patients with HGG, demographic, diagnostic, therapeutic, clinical trial enrollment, and PC information were collected. Statistical analysis was performed comparing PC characteristics between patients who did and did not enroll in a clinical trial. RESULTS Seventy-two percent of patients had at least one visit with a PC provider. Fifty-six percent of patients enrolled in a clinical trial with HGG-directed therapy. Seventy-one percent of patients who enrolled in a clinical trial received specialty PC compared to 74% of non-trial participants (p = 1.000). Patients who enrolled in clinical trials received PC earlier in their disease course measured in days before death (mean = 177 days) compared to those who did not enroll (mean = 113 days, p = .180), though not statistically significant. CONCLUSIONS The prevalence of clinical trial enrollment is high in patients with HGG and will likely increase as the genomic/epigenomic landscape of these tumors is better understood. As such, our data reassuringly suggest that trial participation does not interfere with the receipt of specialty PC in this population.
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Affiliation(s)
- Holly J Roberts
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Yujie Wang
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jessica L Spruit
- Stepping Stones Pediatric Palliative Care, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Laura Taylor
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Stepping Stones Pediatric Palliative Care, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Andrea T Franson
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
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5
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Ebelhar J, DeGroote NP, Massie AM, Labudde E, Allen KE, Castellino SM, Wasilewski-Masker K, Brock KE. Differences in palliative opportunities across diagnosis groups in children with cancer. Pediatr Blood Cancer 2023; 70:e30081. [PMID: 36377714 DOI: 10.1002/pbc.30081] [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: 07/14/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Childhood cancer causes significant physical and emotional stress. Patients and families benefit from palliative care (PC) to reduce symptom burden, improve quality of life, and enhance family-centered care. We evaluated palliative opportunities across leukemia/lymphoma (LL), solid tumors (ST), and central nervous system (CNS) tumor groups. PROCEDURE A priori, nine palliative opportunities were defined: disease progression/relapse, hematopoietic stem cell transplant, phase 1 trial enrollment, admission for severe symptoms, social concerns or end-of-life (EOL) care, intensive care admission, do-not-resuscitate (DNR) status, and hospice enrollment. A single-center retrospective review was completed on 0-18-year olds with cancer who died from January 1, 2012 to November 30, 2017. Demographic, disease, and treatment data were collected. Descriptive statistics were performed. Opportunities were evaluated from diagnosis to death and across disease groups. RESULTS Included patients (n = 296) had LL (n = 87), ST (n = 114), or CNS tumors (n = 95). Palliative opportunities were more frequent in patients with ST (median 8) and CNS tumors (median 7) versus LL (median 5, p = .0005). While patients with ST had more progression/relapse opportunities (p < .0001), patients with CNS tumors had more EOL opportunities (p < .0001), earlier PC consultation, DNR status, and hospice enrollment. Palliative opportunities increased toward the EOL in all diseases (p < .0001). PC was consulted in 108 (36%) patients: LL (48%), ST (30%), and CNS (34%, p = .02). CONCLUSIONS All children with cancer incur many events warranting PC support. Patients with ST and CNS tumors had more palliative opportunities than LL, yet received less subspecialty PC. Understanding palliative opportunities within each disease group can guide PC utilization to ease patient and family stress.
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Affiliation(s)
- Jonathan Ebelhar
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
| | - Nicholas P DeGroote
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - A McCauley Massie
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Emily Labudde
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kristen E Allen
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sharon M Castellino
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
| | - Karen Wasilewski-Masker
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
| | - Katharine E Brock
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA.,Department of Pediatrics, Division of Pediatric Palliative Care, Emory University, Atlanta, Georgia, USA
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Salins N, Hughes S, Preston N. Presuppositions, cost–benefit, collaboration, and competency impacts palliative care referral in paediatric oncology: a qualitative study. Palliat Care 2022; 21:215. [DOI: 10.1186/s12904-022-01105-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
Abstract
Background
Although a significant proportion of children with cancer need palliative care, few are referred or referred late, with oncologists and haematologists gatekeeping the referral process. We aimed to explore the facilitators and barriers to palliative care referral.
Methods
Twenty-two paediatric oncologists and haematologists were purposively recruited and interviewed. Data were analysed using reflexive thematic analysis. Findings were interpreted using the critical realist paradigm.
Results
Four themes were generated. 1) Oncologists expressed concern about the competency of palliative care teams. Palliative care often symbolised therapeutic failure and abandonment, which hindered referral. Trustworthy palliative care providers had clinical competence, benevolence, and knowledge of oncology and paediatrics. 2) Making a palliative care referral was associated with stigma, navigating illness-related factors, negative family attitudes and limited resources, impeding palliative care referral. 3) There were benefits to palliative care referral, including symptom management and psychosocial support for patients. However, some could see interactions with the palliative care team as interference hindering future referrals. 4) Suggested strategies for developing an integrated palliative care model include evident collaboration between oncology and palliative care, early referral, rebranding palliative care as symptom control and an accessible, knowledgeable, and proactive palliative care team.
Conclusion
Presuppositions about palliative care, the task of making a referral, and its cost-benefits influenced referral behaviour. Early association with an efficient rebranded palliative care team might enhance integration.
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A multisite randomized controlled trial of an early palliative care intervention in children with advanced cancer: The PediQUEST Response Study Protocol. PLoS One 2022; 17:e0277212. [DOI: 10.1371/journal.pone.0277212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022] Open
Abstract
Background
The Pediatric Quality of Life and Evaluation of Symptoms Technology Response to Pediatric Oncology Symptom Experience (PQ-Response) intervention aims to integrate specialized pediatric palliative care into the routine care of children, adolescents, and young adults (AYAs) with advanced cancer.
Aims
To evaluate whether PQ-Response, compared to usual care, improves patient’s health related quality of life (HRQoL) and symptom burden (aim 1), parent psychological distress and symptom-related stress (aim 2), and family and symptom treatment activation (aim 3).
Design
Multisite, randomized (1:1), controlled, un-blinded, effectiveness trial comparing PediQUEST Response (intervention) vs usual cancer care (control).
Setting
Five US large, tertiary level pediatric cancer centers.
Participants
Children (≥2 years old)/AYAs who receive care at any of the participating sites because of advanced cancer or any progressive/recurrent solid or brain tumor and are palliative care “naïve.” Target: 200 enrolled patient-parent dyads (minimum goal: 136 dyads randomized, N = 68/arm).
Interventions
PediQUEST Response: combines patient-mediated activation (weekly feedback of patient- and parent-reported symptoms and HRQoL to families and providers using the PediQUEST web system) with integration of the palliative care team. Usual Cancer Care: participants receive usual care, which can include palliative care consultation, and use PediQUEST web to answer surveys, with no feedback.
Methods
Following enrollment, patients (if ≥5 years) and one parent receive weekly PediQUEST-Surveys assessing HRQoL (Pediatric Quality of Life Inventory 4.0) and symptom burden (PediQUEST-Memorial Symptom Assessment Scale). After a 2-week run-in period, dyads who answer ≥2 PediQUEST surveys per participant (responders), are randomized (concealed allocation) and followed up for 16-weeks. Parents answer six additional surveys (parent outcomes).
Outcomes
Primary: mean patient HRQoL score over 16-weeks as reported by a) the parent; and b) the patient if ≥5 years-old. Secondary: patient’s symptom burden; parent’s anxiety, depressive symptoms, symptom-related stress; family activation; and symptom treatment activation.
Trial registration
ClinicalTrials.gov (NCT03408314) 1/24/18. https://clinicaltrials.gov/ct2/show/NCT03408314.
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Salek M, Woods C, Gattas M, Gattuso JS, Mandrell B, Baker JN, Kaye EC. Multidisciplinary Clinician Perspectives on Embedded Palliative Care Models in Pediatric Cancer. J Pain Symptom Manage 2022; 64:222-233. [PMID: 35649459 DOI: 10.1016/j.jpainsymman.2022.05.019] [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] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 11/20/2022]
Abstract
CONTEXT Integration of palliative care (PC) into pediatric cancer care is considered best practice by national oncology and pediatric organizations. Optimal strategies for PC integration remain understudied, although growing evidence suggests that embedded models improve quality of care and quality of life for patients and families. OBJECTIVES To describe the perspectives and preferences of multidisciplinary clinicians regarding ideal models for PC integration in pediatric cancer care; to introduce clinicians to the theoretical concept of an embedded care model; to empower clinicians in co-design of a new institutional model through collaborative discussion of anticipated benefits and challenges of embedded model implementation. METHODS Trained facilitators conducted 24 focus groups, stratified by discipline and care team. Focus groups were audio-recorded and transcribed for inductive content analysis using MAXQDA software. RESULTS 174 clinicians participated (25 physicians, 30 advanced practice providers [APPs], 70 nurses, 49 psychosocial clinicians). Clinicians across disciplines verbalized that an embedded PC model would improve access to PC; however, identified benefits and challenges varied by discipline. Benefits included earlier integration of PC (physicians, APPs), normalization of PC as an integral aspect of care by patients/families (nurses, psychosocial), collaboration (physicians, psychosocial clinicians), and communication (APPs, psychosocial). Anticipated challenges included inadequate resources and physician resistance (physicians, APPs, nurses) and multidisciplinary role confusion (APPs, nurses, psychosocial). CONCLUSION Pediatric clinicians recognize the potential value of an embedded PC model. Although some concepts overlapped, multidisciplinary clinicians offered unique beliefs, highlighting the importance of including representative perspectives to ensure that pediatric PC models align with priorities of diverse stakeholders.
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Affiliation(s)
- Marta Salek
- Department of Oncology, St. Jude Children's Research Hospital (M.S., C.W., M.G., B.M., J.N.B., E.C.K.), Memphis, Tennessee, USA.
| | - Cameka Woods
- Department of Oncology, St. Jude Children's Research Hospital (M.S., C.W., M.G., B.M., J.N.B., E.C.K.), Memphis, Tennessee, USA
| | - Melanie Gattas
- Department of Oncology, St. Jude Children's Research Hospital (M.S., C.W., M.G., B.M., J.N.B., E.C.K.), Memphis, Tennessee, USA
| | - Jami S Gattuso
- Division of Nursing Research, Department of Pediatrics (J.S.G.), St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Belinda Mandrell
- Department of Oncology, St. Jude Children's Research Hospital (M.S., C.W., M.G., B.M., J.N.B., E.C.K.), Memphis, Tennessee, USA
| | - Justin N Baker
- Department of Oncology, St. Jude Children's Research Hospital (M.S., C.W., M.G., B.M., J.N.B., E.C.K.), Memphis, Tennessee, USA
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital (M.S., C.W., M.G., B.M., J.N.B., E.C.K.), Memphis, Tennessee, USA
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de Noriega I, Martino Alba R, Herrero Velasco B, Madero López L, Lassaletta Á. Palliative care in pediatric patients with central nervous system cancer: Descriptive and comparative study. Palliat Support Care 2022; 21:1-8. [PMID: 35957581 DOI: 10.1017/s1478951522001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Data regarding the palliative needs of pediatric patients with central nervous system (CNS) cancer are scarce. We aimed to describe the attention provided by a pediatric palliative care (PPC) team to patients with CNS cancer and the differences in care compared to patients who did not receive PPC. METHOD This retrospective study was based on the clinical records of deceased patients with CNS cancer attended by a PPC team over 10 years, analyzing their trajectory and provision of PPC, including medical, psychological, social, and nursing interventions. Furthermore, we compared the last month of life care of deceased patients with CNS cancer in the same institution, based on whether they were attended by the PPC team. RESULTS Of 71 patients, 59 received PPC, with a median of 1.6 months (Interquartile range: 0.6-5.2) from referral to death. Home hospitalization was provided to 84.8%, nursing interventions were registered in 89.8%, psychological characteristics in 84.7%, and social interventions in 88.1%. The most common symptoms were pain, dyspnea, and constipation. When comparing patients from the same hospital who received PPC (n = 36) with those who did not (n = 12), the former spent fewer days in the hospital in their last month and last week (p < 0.01) and were more likely to die at home (50% vs. 0%; p < 0.01). SIGNIFICANCE OF RESULTS Patients with CNS cancer show various medical, social, and psychological needs during end-of-life care. Providing specific PPC interventions decreased the number of days spent at the hospital and increased the rate of death at home.
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Affiliation(s)
- Iñigo de Noriega
- Pediatric Palliative Care Unit, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Ricardo Martino Alba
- Pediatric Palliative Care Unit, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Blanca Herrero Velasco
- Department of Pediatric Oncology, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Luis Madero López
- Department of Pediatric Oncology, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Álvaro Lassaletta
- Department of Pediatric Oncology, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
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Chinyundo K, Casas J, Bank R, Abenawe C, Gaolebale B, Nakirulu A, Maifale-Mburu G, Hesselgrave J, Butia M, Bakulumpagi D, Nassanga I, Higgins J, Hockenberry M. Delphi Method to Develop a Palliative Care Tool for Children and Families in Sub-Saharan Africa. J Pain Symptom Manage 2022; 63:962-970. [PMID: 35202729 DOI: 10.1016/j.jpainsymman.2022.02.021] [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: 12/20/2021] [Revised: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT In sub-Saharan Africa, there is no standardized approach to pediatric palliative care assessment. Because of this, there is a critical demand for evidence-based assessment tools that identify the specialized needs of children and their families requiring palliative care in developing countries. OBJECTIVES To develop a standardized approach to pediatric palliative care (PPC) assessment that includes an individualized plan of care for use in sub-Saharan Africa. METHODS A Delphi method approach used five rounds to explore core elements that define the essential assessment attributes mandatory for providing excellence in PPC. Using the Delphi method, the consensus from 11 PPC experts was obtained during four Delphi rounds regarding the most important questions to include in a PPC assessment tool and plan of care. During the final Delphi round 5, the expert consensus was confirmed in a separate group of 36 childhood cancer/palliative care clinical providers. RESULTS Five core elements were developed as the foundation for a PPC assessment. A symptom assessment tool was developed that includes 15 symptoms that PPC experts agreed occurred more than 65% of the time in their patients. CONCLUSION The Delphi method was an effective tool to develop a consensus on a PPC assessment tool to use with children and their families in sub-Saharan Africa. This standardized approach will enable the collection of data to drive outcomes and research.
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Affiliation(s)
- Kamusisi Chinyundo
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Jessica Casas
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Rhahim Bank
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Cosiate Abenawe
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Babe Gaolebale
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Annet Nakirulu
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Goitseone Maifale-Mburu
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Joy Hesselgrave
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Mercy Butia
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Deogratius Bakulumpagi
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Immaculate Nassanga
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Jennifer Higgins
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
| | - Marilyn Hockenberry
- Global HOPE Botswana (K.C.), Gaborone, Botswana; Baylor College of Medicine (J.C., J.H., M.H.), Houston, Texas, USA; Texas Children's Hospital (J.C., J.H.), Houston, Texas, USA; Global HOPE Malawi (R.B, M.B.), Lilongwe, Malawi; Global HOPE Uganda (A.N., D.B., I.N.), Kampala, Uganda; Princess Marina Hospital (B.G., G.M.M.), Gaborone, Botswana
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11
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Földesi E, Zörgő S, Nyirő J, Péter G, Ottóffy G, Hauser P, Hegedűs K. Medical Communication during the Transition to Palliative Care in Pediatric Oncology in Hungary-The Parents' Perspective. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9050651. [PMID: 35626828 PMCID: PMC9139565 DOI: 10.3390/children9050651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/18/2022] [Accepted: 04/30/2022] [Indexed: 04/09/2023]
Abstract
The transition to palliative care (PC) is a critical aspect of pediatric oncology, and it requires a high level of communication skills from doctors, which could be best judged by the parents of children who have died from cancer. Our aim was to explore the parents' perspectives regarding the timing of the consultation on the implementation of PC, as well as facets of verbal and nonverbal communication in Hungary. Semistructured interviews were conducted with parents who had lost a child to cancer within the past 1-5 years. Interview transcripts (n = 23) were scrutinized with interpretative phenomenological analysis. The parents frequently associated palliation with end-of-life care and they clearly delimited the transition to PC after curative treatments had been exhausted. The parents were ambivalent with regard to the use of the word "death" during this consultation, and they often did not receive information on what to expect (e.g., regarding symptoms) or on who to turn to for further information or support (e.g., concerning bereavement). Although significant progress could be observed in the organization of pediatric palliative care in Hungary, there is still no widely accepted communication method for the transition to sole PC. There is a need for a culturally sensitive approach to refining the recommendations on the word use and communication protocol in pediatric PC in Hungary.
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Affiliation(s)
- Enikő Földesi
- Institute of Behavioural Sciences, Semmelweis University, Nagyvárad tér 4, 1089 Budapest, Hungary; (S.Z.); (J.N.); (K.H.)
- Correspondence:
| | - Szilvia Zörgő
- Institute of Behavioural Sciences, Semmelweis University, Nagyvárad tér 4, 1089 Budapest, Hungary; (S.Z.); (J.N.); (K.H.)
| | - Judit Nyirő
- Institute of Behavioural Sciences, Semmelweis University, Nagyvárad tér 4, 1089 Budapest, Hungary; (S.Z.); (J.N.); (K.H.)
| | - György Péter
- Hemato-Oncology Unit, Heim Pál Children’s Hospital, Üllői út 86, 1089 Budapest, Hungary;
| | - Gábor Ottóffy
- Department of Pediatrics, University of Pécs, József Attila utca 7, 7623 Pécs, Hungary;
| | - Peter Hauser
- 2nd Department of Pediatrics, Semmelweis University, Tűzoltó utca 7–9, 1094 Budapest, Hungary;
- Velkey László Child’s Health Center, Borsod-Abaúj-Zemplén County Central Hospital and University Teaching Hospital, Szentpéteri kapu 72–76, 3526 Miskolc, Hungary
| | - Katalin Hegedűs
- Institute of Behavioural Sciences, Semmelweis University, Nagyvárad tér 4, 1089 Budapest, Hungary; (S.Z.); (J.N.); (K.H.)
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12
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Abstract
Purpose of this Review The purpose of this review is to describe the evolution of palliative care in paediatric oncology, the needs of children and their families in a paediatric oncology setting, palliative care referral practices in paediatric oncology, outcomes of palliative care referral in paediatric oncology and models of palliative care in paediatric oncology. Recent Findings Cancer constitutes 5.2% of the palliative care needs in children. Approximately, 90% of children with cancer lives in low and middle-income countries, constituting 84% of the global burden of childhood cancers. Children in low and middle-income countries have low cure rates and high death rates making palliative care relevant in a paediatric oncology setting. Children with cancer experience pain and physical symptoms, low mood, anxiety, and fear. They feel less resilient, experience low self-worth, and have challenges coping with the illness. The families lead very stressful lives, navigating the hospital environment, and dealing with uncertainties of the future. Palliative care referral in children with cancer improves physical symptoms, emotional support, and quality of life. It enables communication between families and health care providers. It improves end-of-life care support to children and their families and facilitates less invasive diagnostic and therapeutic interventions at the end of life. Worldwide children with cancer are infrequently referred to palliative care and referred late in the illness trajectory. Most of the children referred to palliative care receive some form of cancer-directed therapy in their last days. Children in low and low-middle income countries are less likely to access palliative care due to a lack of awareness amongst paediatric oncologists about palliative care and the reduced number of services providing palliative care. A three-tier model is proposed to provide palliative care in paediatric oncology, where most children with palliative care needs are managed by paediatric oncologists and a smaller number with complex physical and psychosocial needs are managed by paediatric palliative care specialists. There are several palliative care models in paediatric oncology practised globally. However, no one model was considered better or superior, and the choice of model depended on the need, preferences identified, and available resources. Summary Children with cancer are sparingly referred to palliative care and referred late and oncologists and haematologists gatekeep the referral process. Knowledge on palliative care referral in paediatric oncology settings might enhance collaboration between paediatric oncology and paediatric palliative care.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - Sean Hughes
- Division of Health Research, Health Innovation One, Lancaster University, Sir John Fisher Drive, Lancaster, LA1 4AT UK
| | - Nancy Preston
- Division of Health Research, Health Innovation One, Lancaster University, Sir John Fisher Drive, Lancaster, LA1 4AT UK
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13
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Walter JK, Hill DL, Schall TE, Szymczak JE, Parikh S, DiDomenico C, Carroll KW, Nye RT, Feudtner C. An Interprofessional Team-Based Intervention to Address Barriers to Initiating Palliative Care in Pediatric Oncology: A Multiple-Method Evaluation of Feasibility, Acceptability, and Impact. J Pain Symptom Manage 2021; 62:1135-1144. [PMID: 34153461 PMCID: PMC8648922 DOI: 10.1016/j.jpainsymman.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Many children with advanced cancer are not referred to palliative care despite both professional recommendations to do so and bereaved parental preference for earlier support from sub-specialty palliative care. OBJECTIVES To assess the feasibility, acceptability, and impact of an adaptive intervention to address individual and team-level barriers to specialty palliative care referrals. METHODS A multiple-method approach assessed feasibility and acceptability among clinicians from pediatric oncology teams at a single institution. Quantitative measures of comfort with palliative care consultations, team cohesion, and team collaboration were conducted before and after the intervention. Number of palliative care consults were examined before, during, and after sessions. Intervention satisfaction surveys and qualitative interviews were conducted after the intervention. RESULTS Twenty-six team members (90% of consented) attended at least one intervention session with 20 (69%) participants completing 75% or more sessions. The intervention was modified in response to participant feedback. After the intervention, participants reported greater team cohesion, comfort discussing palliative care consultation, team collaboration, process satisfaction, and decision satisfaction. Participants agreed that the training was useful, effective, helpful, and worthwhile, that they would use the skills, and that they would recommend the training to other providers. The numbers of palliative care consults increased before intervention sessions were conducted, but did not significantly change during or after the sessions. In the interviews, participants reported overall favorably regarding the intervention with some participants reporting changes in practice. CONCLUSION An adaptive intervention to reduce barriers to initiating palliative care for pediatric oncology teams is feasible and acceptable.
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Affiliation(s)
- Jennifer K Walter
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA.
| | - Theodore E Schall
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania (J.E.S.), Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
| | - Connie DiDomenico
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Division of Pediatric Oncology (C.D.), Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Russell T Nye
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
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14
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Doherty M, Modanloo S, Evans E, Rowe J, Newhook D, Palat G, Archibald D. Exploring Health Professionals' Experiences With a Virtual Learning and Mentoring Program (Project ECHO) on Pediatric Palliative Care in South Asia. Glob Pediatr Health 2021; 8:2333794X211043061. [PMID: 34485624 PMCID: PMC8411613 DOI: 10.1177/2333794x211043061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/12/2021] [Indexed: 01/03/2023] Open
Abstract
Project ECHO (Extension of Community Healthcare Outcomes) is an innovative model
of online education which has been proposed to enhance access to palliative care
in resource-limited settings. There is limited literature describing how health
care providers in low-and middle-income countries benefit from and learn from
this type of training. This qualitative description study explores the learning
experiences of participants in a Project ECHO program on pediatric palliative
care in South Asia through focus group discussions. Discussions were
transcribed, coded, independently verified, and arranged into overarching
themes. We identified learning themes including the importance of creating a
supportive learning community; the opportunity to share ideas and experiences;
gaining knowledge and skills, and access to additional learning materials.
Designing future programs to ensure a supportive and interactive learning
community with attention cultural challenges may enhance learning from future
Project ECHO programs.
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Affiliation(s)
- Megan Doherty
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.,University of Ottawa, Ottawa, ON, Canada.,Two Worlds Cancer Collaboration Foundation Kelowna, BC, Canada
| | - Shokoufeh Modanloo
- Roger Neilson House, Ottawa, ON, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | | | | | - Dennis Newhook
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Gayatri Palat
- Pain Relief and Palliative Care Society, Hyderabad, Telangana, India.,MNJ Institute of Oncology and Regional Cancer Centre
| | - Douglas Archibald
- University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
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15
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Barsky EE, Berbert LM, Dahlberg SE, Truog RD. Attitudes towards involving children in decision-making surrounding lung transplantation. Pediatr Pulmonol 2021; 56:1534-1542. [PMID: 33586869 DOI: 10.1002/ppul.25321] [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: 11/24/2020] [Revised: 01/25/2021] [Accepted: 02/10/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Medical care has shifted from a paternalistic model towards one centered around patient autonomy and shared decision-making (SDM), yet the role of the pediatric patient in decision-making is unclear. Studies suggest that many children with chronic disease are capable of making medical decisions at a young age, yet no standardized approaches have been developed for involving children in these decisions. METHODS This is a single-center survey study investigating the attitudes of pediatric pulmonologists towards involvement of children in decisions regarding lung transplantation, utilizing a hypothetical case scenario with systematic manipulation of age and maturity level. We evaluated physician belief regarding ultimate decision-making authority, reconciliation of parent-child discordance, and utility of ethics and psychiatry consultation services. RESULTS The majority of pediatric pulmonologists at this center believe decision-making authority rests with the parents. The effects of age and maturity are unclear. In instances of parent-child disagreement, physicians are more likely to try to convince parents to defer to the child if the child is both older and more mature. Physicians are divided on the utility of ethics and psychiatry consultations. CONCLUSION Involvement of children with cystic fibrosis in SDM is broadly supported but inconsistently implemented. Despite evidence that children with chronic disease may have decisional capacity at a young age, the majority of physicians still grant decisional authority to parents. There are numerous barriers to involving children in decisions, including legal considerations. The role of age and maturity level in influencing these decisions appears small and warrants further investigation.
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Affiliation(s)
- Emily E Barsky
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura M Berbert
- Biostatistics and Research Design Center of the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Suzanne E Dahlberg
- Division of Adolescent Medicine, Research Design Center of the Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
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16
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Evans AM, Thabrew H, Arroll B, Cole N, Drake R. Audit of Psychosocial and Palliative Care Support for Children Having Allogeneic Stem Cell Transplants at the New Zealand National Allogeneic Transplant Centre. CHILDREN (BASEL, SWITZERLAND) 2021; 8:356. [PMID: 33946879 PMCID: PMC8146388 DOI: 10.3390/children8050356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 11/17/2022]
Abstract
Psychosocial and palliative care support during stem cell transplants (SCT) is known to improve outcomes. AIM evaluate the support provided to children and families at the New Zealand National Allogeneic Stem Cell Transplant unit (NATC). METHOD the psychosocial and palliative care support for children who received SCT between December 2012 and April 2018 was audited. RESULTS of the 101 children who received SCT, 97% were reviewed by the social work team (SW) and 82% by the psychiatric consult liaison team (CLT) at least once during their illness. However, pre-transplant psychological assessment only occurred in 16%, and during the SCT admission, only 55% received SW support, and 67% received CLT support. Eight out of eighty-five families (9%) were offered support for siblings. Eight of the sixteen children who died were referred for pediatric palliative care (PPC) with all supported and half the families who experienced a death (n = 8; 50%) received bereavement follow up. CONCLUSION although the majority received some social work and psychological support, auditing against the standards suggests the consistency of involvement could be improved. Referrals for PPC were inadequate and largely for end-of-life phase. Sibling support, in particular donor siblings, had insufficient psychological assessment and support. Key recommendations are provided to address this underperformance.
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Affiliation(s)
- Amanda M. Evans
- Paediatric Palliative Care Service, Starship Children’s Health, Auckland and Mary Potter Hospice, Wellington 6242, New Zealand
| | - Hiran Thabrew
- Consult Liaison Psychiatry Team, Starship Children’s Health and University of Auckland, Auckland 1010, New Zealand;
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, University of Auckland, Auckland 1010, New Zealand;
| | - Nyree Cole
- Oncology and Haematogy Service, Birmingham Women’s and Children’s, Birmingham B15 2TG, UK;
| | - Ross Drake
- Paediatric Palliative Care and Pain Service, Starship Children’s Health, Auckland 1023, New Zealand;
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17
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Labudde EJ, DeGroote NP, Smith S, Ebelhar J, Allen KE, Castellino SM, Wasilewski‐Masker K, Brock KE. Evaluating palliative opportunities in pediatric patients with leukemia and lymphoma. Cancer Med 2021; 10:2714-2722. [PMID: 33754498 PMCID: PMC8026931 DOI: 10.1002/cam4.3862] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/05/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite favorable prognoses, pediatric patients with hematologic malignancies experience significant challenges that may lead to diminished quality of life or family stress. They are less likely to receive subspecialty palliative care (PC) consultation and often undergo intensive end-of-life (EOL) care. We examined "palliative opportunities," or events when the integration of PC would have the greatest impact, present during a patient's hematologic malignancy course and relevant associations. METHODS A single-center retrospective review was conducted on patients aged 0-18 years with a hematologic malignancy who died between 1/1/12 and 11/30/17. Demographic, disease, and treatment data were collected. A priori, nine palliative opportunity categories were defined. Descriptive statistics were performed. Palliative opportunities were evaluated over temporal quartiles from diagnosis to death. Timing and rationale of pediatric PC consultation were evaluated. RESULTS Patients (n = 92) had a median of 5.0 (interquartile range [IQR] 6.0) palliative opportunities, incurring 522 total opportunities, increasing toward the EOL. Number and type of opportunities did not differ by demographics. PC consultation was most common in patients with lymphoid leukemia (50.9%, 28/55) and myeloid leukemia (48.5%, 16/33) versus lymphoma (0%, 0/4, p = 0.14). Forty-four of ninety-two patients (47.8%) received PC consultation a median of 1.8 months (IQR 4.1) prior to death. Receipt of PC was associated with transplant status (p = 0.0018) and a higher number of prior palliative opportunities (p = 0.0005); 70.3% (367/522) of palliative opportunities occurred without PC. CONCLUSION Patients with hematologic malignancies experience many opportunities warranting PC support. Identifying opportunities for ideal timing of PC involvement may benefit patients with hematologic cancers and their caregivers.
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Affiliation(s)
| | - Nicholas P. DeGroote
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
| | - Susie Smith
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
| | - Jonathan Ebelhar
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Hematology/OncologyEmory UniversityAtlantaGAUSA
| | - Kristen E. Allen
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
| | - Sharon M. Castellino
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Hematology/OncologyEmory UniversityAtlantaGAUSA
| | - Karen Wasilewski‐Masker
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Hematology/OncologyEmory UniversityAtlantaGAUSA
| | - Katharine E. Brock
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Hematology/OncologyEmory UniversityAtlantaGAUSA
- Department of PediatricsDivision of Pediatric Palliative CareEmory UniversityAtlantaGAUSA
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18
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Triggers for Palliative Care Referral in Pediatric Oncology. Cancers (Basel) 2021; 13:cancers13061419. [PMID: 33808881 PMCID: PMC8003810 DOI: 10.3390/cancers13061419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Palliative care (PC) can improve the quality of life for pediatric cancer patients, yet these services remain underutilized, with referrals occurring late in the disease course or not at all. We previously described the patient and family characteristics that diverse pediatric oncology providers agree should be high yield triggers for PC referral in pediatric cancer patients. The current study examined how often those triggers were associated with a completed PC consult for a cohort of 931 patients. We discovered that PC referrals occur very infrequently and patients with stated triggers often do not get referred. These findings help support the need for a screening tool to standardize PC integration and improve care. Abstract Palliative care (PC) integration into the care of pediatric oncology patients is growing in acceptance and has been shown to improve the quality of life of children with cancer. Yet timing for referrals and referral practices remain inconsistent, and PC remains underutilized. We conducted a retrospective chart review of pediatric oncology patients treated at an academic institution between January 2015 to November 2018. Data collected included demographics, disease and therapy characteristics, and consultation notes, specifically documenting existence of predetermined “high yield triggers” for PC consultation. Among 931 eligible patients the prevalence of PC consultation was 5.6% while approximately 94% of patients had at least 1 trigger for PC consultation. The triggers that more often resulted in PC consultation included: symptom management needs (98%; n = 51) high-risk disease (86%; n = 45), poor prognosis (83%; n = 43), multiple lines of therapy (79%; n = 41) and a documented ICU admission (67%; n = 35). Our findings suggest that the high yield triggers for palliative care consultation that pediatric oncologists identify as important are not translating into practice; incorporating these triggers into a screening tool may be the next step to improve early PC integration.
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19
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Massie AM, Ebelhar J, Allen KE, DeGroote NP, Wasilewski-Masker K, Brock KE. Defining and timing of palliative opportunities in children with central nervous system tumors. Neurooncol Pract 2021; 8:451-459. [PMID: 34277023 DOI: 10.1093/nop/npab020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Children with brain and central nervous system (CNS) tumors experience substantial challenges to their quality of life during their disease course. These challenges are opportunities for increased subspecialty palliative care (PC) involvement. Palliative opportunities have been defined in the pediatric oncology population, but the frequency, timing, and factors associated with palliative opportunities in pediatric patients with CNS tumors are unknown. Methods A single-institution retrospective review was performed on children ages 0-18 diagnosed with a CNS tumor who died between January 1, 2012 and November 30, 2017. Nine palliative opportunities were defined prior to data collection (progression, relapse, admission for severe symptoms, intensive care admission, bone marrow transplant, phase 1 trial, hospice, do-not-resuscitate (DNR) order). Demographic, disease, treatment, palliative opportunity, and end-of-life data were collected. Opportunities were evaluated over quartiles from diagnosis to death. Results Amongst 101 patients with a median age at death of eight years (interquartile range [IQR] = 8.0, range 0-22), there was a median of seven (IQR = 6) palliative opportunities per patient, which increased closer to death. PC consultation occurred in 34 (33.7%) patients, at a median of 2.2 months before death, and was associated with having a DNR order (P = .0028). Hospice was involved for 72 (71.3%) patients. Conclusion Children with CNS tumors suffered repeated events warranting PC yet received PC support only one-third of the time. Mapping palliative opportunities over the cancer course promotes earlier timing of PC consultation which can decrease suffering and resuscitation attempts at the end-of-life.
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Affiliation(s)
| | - Jonathan Ebelhar
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
| | - Kristen E Allen
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Nicholas P DeGroote
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Karen Wasilewski-Masker
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Katharine E Brock
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Pediatrics, Division of Pediatric Palliative Care, Emory University, Atlanta, Georgia, USA
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20
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Farooki S, Olaiya O, Tarbell L, Clark NA, Linebarger JS, Stroh J, Ellis K, Lewing K. A quality improvement project to increase palliative care team involvement in pediatric oncology patients. Pediatr Blood Cancer 2021; 68:e28804. [PMID: 33211394 DOI: 10.1002/pbc.28804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pediatric palliative care (PPC) for oncology patients improves quality of life and the likelihood of goal-concordant care. However, barriers to involvement exist. OBJECTIVES We aimed to increase days between PPC consult and death for patients with refractory cancer from a baseline median of 13.5 days to ≥30 days between March 2019 and March 2020. METHODS Outcome measure was days from PPC consult to death; process measure was days from diagnosis to PPC consult. The project team surveyed oncologists to identify barriers. Plan-do-study-act cycles included establishing target diagnoses, offering education, standardizing documentation, and sending reminders. RESULTS The 24-month baseline period included 30 patients who died and 25 newly diagnosed patients. The yearlong intervention period included six patients who died and 16 newly diagnosed patients. Interventions improved outcome and process measures. Targeted patients receiving PPC ≥30 days prior to death increased from 43% to 100%; median days from consult to death increased from 13.5 to 159.5. Targeted patients receiving PPC within 30 days of diagnosis increased from 28% to 63%; median days from diagnosis to consult decreased from 221.5 to 14. Of those without PPC consult ≤ 30 days after diagnosis, 17% had template documentation of the rationale. CONCLUSION Interventions utilized met the global aim, outcome, and process measures. Use of QI methodology empowered providers to involve PPC. Poor template use was a barrier to identifying further drivers. Future directions for this project relate to expanding the target list, creating long-term sustainability, formalizing standards, and surveying patients and families.
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Affiliation(s)
- Sana Farooki
- Department of Pediatrics, Division of Hematology Oncology, Children's Mercy Hospital, Kansas City, Missouri
| | - Oluwaseun Olaiya
- Department of Pediatrics, Division of Hematology Oncology, Children's Mercy Hospital, Kansas City, Missouri
| | - Lisa Tarbell
- Department of Pediatrics, Division of Hematology Oncology, Children's Mercy Hospital, Kansas City, Missouri
| | - Nicholas A Clark
- Department of Pediatrics, Division of Hospital Medicine, Children's Mercy Hospital, Kansas City, Missouri
| | - Jennifer S Linebarger
- Department of Pediatrics, Section of Palliative Care, Children's Mercy Hospital, Kansas City, Missouri
| | - John Stroh
- Department of Pediatrics, Section of Palliative Care, Children's Mercy Hospital, Kansas City, Missouri
| | - Kelstan Ellis
- Department of Pediatrics, Section of Palliative Care, Children's Mercy Hospital, Kansas City, Missouri
| | - Karen Lewing
- Department of Pediatrics, Division of Hematology Oncology, Children's Mercy Hospital, Kansas City, Missouri
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21
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Podda M, Schiavello E, Visconti G, Clerici CA, Armiraglio M, Casiraghi G, Ambroset S, Grossi A, Rizzi B, Lonati G, Massimino M. Customised pediatric palliative care: Integrating oncological and palliative care priorities. Acta Paediatr 2021; 110:682-688. [PMID: 32544257 DOI: 10.1111/apa.15415] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 11/29/2022]
Abstract
AIM To describe the experience involving the early introduction of palliative care (PC) in oncological patients treated within the paediatric oncology unit of the Istituto Nazionale Tumori of Milan and compare this cohort with a cohort of patients resident in the same area treated before the introduction of early palliative care. METHODS A virtual team was assembled in 2015. The PC providers operate outside the hospital. Conference calls were scheduled to discuss patients' problems. This sample was compared with the clinical records of patients residing in the same area who died between 2009 and 2014. RESULTS Between January 2015 and April 2019, 41 patients residing in the Milan area mainly with CNS tumours or sarcomas were referred to the team. Comparing the results with the previous cohort, there was a rise in the number of patients dying at home or in a hospice and the duration of PC increased over time. From 2015, none of the patients died in an intensive care unit. CONCLUSION Patients managed by the virtual team were able to continue their cancer treatments, take part in Phase I trials and receive PC. All patients with a poor prognosis should have PC at an early stage.
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Affiliation(s)
- Marta Podda
- Pediatric Oncology Fondazione IRCCS Istituto Nazionale dei Tumori di Milano Milano Italy
| | - Elisabetta Schiavello
- Pediatric Oncology Fondazione IRCCS Istituto Nazionale dei Tumori di Milano Milano Italy
| | - Giovanna Visconti
- Hospice and Palliative Care Unit Casa Sollievo Bimbi, Associazione VIDAS Milano Italy
| | - Carlo Alfredo Clerici
- Milano ‐ Dipartimento di Oncologia ed Emato‐Oncologia SSD Psicologia ClinicaFondazione IRCCS ‐ Istituto Nazionale dei TumoriUniversità di Milano Milano Italy
| | - Mariangela Armiraglio
- Pediatric Oncology Fondazione IRCCS Istituto Nazionale dei Tumori di Milano Milano Italy
| | - Giovanna Casiraghi
- Pediatric Oncology Fondazione IRCCS Istituto Nazionale dei Tumori di Milano Milano Italy
| | - Sonia Ambroset
- Psychology Unit Casa Sollievo Bimbi, Associazione VIDAS Milano Italy
| | - Alberto Grossi
- Hospice and Palliative Care Unit Casa Sollievo Bimbi, Associazione VIDAS Milano Italy
| | - Barbara Rizzi
- Hospice and Palliative Care Unit Casa Sollievo Bimbi, Associazione VIDAS Milano Italy
| | - Giada Lonati
- Hospice and Palliative Care Unit Casa Sollievo Bimbi, Associazione VIDAS Milano Italy
| | - Maura Massimino
- Pediatric Oncology Fondazione IRCCS Istituto Nazionale dei Tumori di Milano Milano Italy
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22
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Zhang M, Li X. Focuses and trends of the studies on pediatric palliative care:A bibliometric analysis from 2004 to 2018. Int J Nurs Sci 2021; 8:5-14. [PMID: 33575439 PMCID: PMC7859508 DOI: 10.1016/j.ijnss.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/10/2020] [Accepted: 11/26/2020] [Indexed: 10/25/2022] Open
Abstract
Objectives To investigate the focuses and trends of the studies on pediatric palliative care (PPC) and provide directions for future research. Methods Relevant papers about PPC published from 2004 to 2018 were analyzed using bibliometric analysis methods, including co-word analysis, biclustering analysis, and strategic diagram analysis. The included papers were divided into three groups based on the publication time, including 2004-2008, 2009-2013, and 2014-2018. Results A total of 1132 papers were published between 2004 and 2018, and there were 293 papers published between 2004 and 2008, 396 between 2009 and 2013, and 443 between 2014 and 2018. There were 42 high-frequency MeSH terms/MeSH subheadings in papers published between 2004 and 2018, including 12 between 2004 and 2008, 13 between 2009 and 2013, and 17 between 2014 and 2018. Conclusion Studies on PPC were making progress, with the increasing number, expanding scope, and uneven global distribution. Integration palliative care into pediatrics, cancer treatments in pediatric oncology, education methods on PPC, and establishment of professional teams were the major themes during 2004-2008, then the themes changed into establishing interventions to enhance the quality of life of the patients and parents, building professional-family relationship, and investigating attitude of health personnel in PPC during 2009-2013 and subsequently turned into communication skills, end-of-life decision making, and guidelines making on PPC during 2014-2018. Underdeveloped and protential themes including effective approaches to deal with the ethical dilemmas, training programs on communication skills, family support and guideline making are worth studying in the future.
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Affiliation(s)
- Miao Zhang
- School of Nursing, China Medical University, Shenyang, Liaoning, China
| | - Xiaohan Li
- School of Nursing, China Medical University, Shenyang, Liaoning, China
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23
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Cuviello A, Raisanen JC, Donohue PK, Wiener L, Boss RD. Initiating Palliative Care Referrals in Pediatric Oncology. J Pain Symptom Manage 2021; 61:81-89.e1. [PMID: 32711123 PMCID: PMC9116129 DOI: 10.1016/j.jpainsymman.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Early palliative care (PC) has been shown to improve the quality of life of children with cancer, yet referral practices by pediatric oncology providers remains inconsistent and few patients receive a formal PC consult. OBJECTIVES We sought to describe patient characteristics used by oncologists for PC referral and identify ways to improve PC integration into the care for children with cancer. METHODS This mixed-methods study used semistructured audiotaped interviews to explore the patient or disease characteristics used by pediatric oncology providers to trigger PC referral. Conventional content analysis was applied to interview transcripts. RESULTS About 77 participants with diverse experience were interviewed. More than 75% of participants reported that PC was consulted too late and cited communication and systems issues as the top barriers. Most participants (85%) stated that a screening tool would be helpful to standardize referral practices to PC. Characteristics such as poor prognosis (88%), symptom management (86%), comorbidities (65%), and psychosocial needs (65%) were commonly reported triggers that should initiate PC consultation. However, when presented with case scenarios that included these characteristics, participants did not consistently identify the PC triggers. Nearly 50% of participants stated they had received some formalized PC training; however, only one-third of these participants noted completing a PC rotation. CONCLUSION Our findings suggest that pediatric oncologists are committed to improving the integration of PC for their patients and that standardization of referral practices, through the use of a screening tool, would be of benefit. Additional PC education might reinforce pediatric oncologists' recognition of PC triggers.
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Affiliation(s)
- Andrea Cuviello
- St Jude Children's Research Hospital, Memphis, Tennessee, USA.
| | | | | | - Lori Wiener
- National Institutes of Health, Bethesda, Maryland, USA
| | - Renee D Boss
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA; Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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24
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Ebelhar J, Allen K, DeGroote N, Wasilewski-Masker K, Brock KE. Defining palliative opportunities in pediatric patients with bone and soft tissue sarcomas. Pediatr Blood Cancer 2020; 67:e28363. [PMID: 32706495 DOI: 10.1002/pbc.28363] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pediatric patients with sarcomas experience significant morbidity and compromised quality of life throughout their course. These times could be viewed as opportunities for increased subspecialty palliative care (PC). Systematically defining opportunities for additional PC support has not occurred in pediatric oncology. The frequency, timing, and associated factors for palliative opportunities in pediatric patients with sarcomas are unknown. METHODS A priori, nine palliative opportunities were defined (disease progression or relapse, admission for symptoms, social concerns or end-of-life, intensive care or bone marrow transplant admission, phase 1 trial or hospice enrollment, do-not-resuscitate status). A single-center retrospective review was conducted on patients aged 0-18 years with bone/soft tissue sarcomas who died from January 1, 2012 to November 30, 2017. Demographic, disease, and treatment data were collected. Descriptive statistics were performed. Opportunities were evaluated over quartiles from diagnosis to death. RESULTS Patients (n = 60) had a mean of nine (SD = 4) palliative opportunities with the majority occurring in the last quartile of the disease course. Number and type of opportunities did not differ by demographics or diagnosis. Eighteen patients (30%) received PC consultation a median of 2.2 months (interquartile range [IQR] 11.5) prior to death. Consultation was unrelated to diagnosis or total opportunities. CONCLUSIONS Patients with sarcomas incur repeated events warranting subspecialty PC, which increase toward the end-of-life. Increased PC utilization may help decrease suffering and bolster family coping during these episodes. Additional work should further refine if opportunities differ across cancers, and how to incorporate this framework into clinical oncology care to prevent missed opportunities for PC.
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Affiliation(s)
| | - Kristen Allen
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nicholas DeGroote
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Karen Wasilewski-Masker
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Katharine E Brock
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, Emory University, Atlanta, Georgia.,Pediatric Palliative Care, Children's Healthcare of Atlanta, Atlanta, Georgia
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25
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Association of a pediatric palliative oncology clinic on palliative care access, timing and location of care for children with cancer. Support Care Cancer 2020; 29:1849-1857. [PMID: 32783177 PMCID: PMC7419028 DOI: 10.1007/s00520-020-05671-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/03/2020] [Indexed: 01/26/2023]
Abstract
Background Most pediatric palliative care (PPC) services are inpatient consultation services and do not reach patients and families in the outpatient and home settings, where a vast majority of oncology care occurs. We explored whether an embedded pediatric palliative oncology (PPO) clinic is associated with receipt and timing of PPC and hospital days in the last 90 days of life. Methods Oncology patients (ages 0–25) with a high-risk event (death, relapse/progression, and/or phase I/II clinical trial enrollment) between 07/01/2015 and 06/30/2018 were included. PPO clinic started July 2017. Two cohorts were defined: pre-PPO (high-risk event(s) occurring 07/01/2015–06/30/2017) and post-PPO (high-risk event(s) occurring 07/01/2017–06/30/2018). Descriptive statistics were performed; demographic, disease course, and outcomes variables across cohorts were compared. Results A total of 426 patients were included (pre-PPO n = 235; post-PPO n = 191). Forty-seven patients with events in both pre- and post-PPO cohorts were included in the post-PPO cohort. Mean age at diagnosis was 8 years. Diagnoses were evenly distributed among solid tumors, brain tumors, and leukemia/lymphoma. Post-PPO cohort patients received PPC more often (45.6% vs. 21.3%, p < 0.0001), for a longer time before death than the pre-PPO cohort (median 88 vs. 32 days, p = 0.027), and spent fewer days hospitalized in the last 90 days of life (median 3 vs. 8 days, p = 0.0084). Conclusion A limited-day, embedded PPO clinic was associated with receipt of PPC and spending more time at home in patients with cancer who had high-risk events. Continued improvements to these outcomes would be expected with additional oncology provider education and PPO personnel.
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26
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Taylor J, Booth A, Beresford B, Phillips B, Wright K, Fraser L. Specialist paediatric palliative care for children and young people with cancer: A mixed-methods systematic review. Palliat Med 2020; 34:731-775. [PMID: 32362212 PMCID: PMC7243084 DOI: 10.1177/0269216320908490] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Specialist paediatric palliative care services are promoted as an important component of palliative care provision, but there is uncertainty about their role for children with cancer. AIM To examine the impact of specialist paediatric palliative care for children and young people with cancer and explore factors affecting access. DESIGN A mixed-methods systematic review and narrative synthesis (PROSPERO Registration No. CRD42017064874). DATA SOURCES Database (CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO) searches (2000-2019) identified primary studies of any design exploring the impact of and/or factors affecting access to specialist paediatric palliative care. Study quality was assessed using The Mixed Methods Appraisal Tool. RESULTS An evidence base of mainly low- and moderate-quality studies (n = 42) shows that accessing specialist paediatric palliative care is associated with less intensive care at the end of life, more advance care planning and fewer in-hospital deaths. Current evidence cannot tell us whether these services improve children's symptom burden or quality of life. Nine studies reporting provider or family views identified uncertainties about what specialist paediatric palliative care offers, concerns about involving a new team, association of palliative care with end of life and indecision about when to introduce palliative care as important barriers to access. There was evidence that children with haematological malignancies are less likely to access these services. CONCLUSION Current evidence suggests that children and young people with cancer receiving specialist palliative care are cared for differently. However, little is understood about children's views, and research is needed to determine whether specialist input improves quality of life.
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Affiliation(s)
- Johanna Taylor
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
| | - Alison Booth
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
| | - Bryony Beresford
- Martin House Research Centre, University of York, York, UK
- Social Policy Research Unit, University of York, York, UK
| | - Bob Phillips
- Martin House Research Centre, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
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27
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Cuviello A, Raisanen JC, Donohue PK, Wiener L, Boss RD. Defining the Boundaries of Palliative Care in Pediatric Oncology. J Pain Symptom Manage 2020; 59:1033-1042.e1. [PMID: 31838131 PMCID: PMC8979408 DOI: 10.1016/j.jpainsymman.2019.11.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 11/22/2019] [Accepted: 11/22/2019] [Indexed: 11/29/2022]
Abstract
CONTEXT Although palliative care (PC) continues to be integrated into pediatric oncological care, only a minority of patients with cancer receive a formal PC consult. OBJECTIVES We sought to describe oncologists' current understanding of PC and how primary PC is provided for children with cancer. METHODS This mixed-methods study explored pediatric oncology providers' definitions of PC and self-reported PC practices through semistructured audiotaped interviews. Conventional content analysis was applied to interview transcripts. RESULTS Seventy-seven participants with diverse training backgrounds (30 attending physicians, 21 nurses, 18 fellows, five nurse practitioners, and two child life specialists) completed an interview. Approximately 75% provided a modern definition of PC (e.g., not limited to end-of-life care); all participants acknowledged primary PC skills as part of their daily clinical activities. However, participants expressed wide variation in the comfort and time spent performing primary PC tasks (i.e., symptom management, addressing mental health and psychosocial needs) and over half reported that patients' PC needs are not adequately met. In addition, some reported confusion about the benefits of PC consultation, despite acknowledging that PC needs to be better integrated into the care of pediatric oncology patients. CONCLUSION Our findings demonstrate that although most pediatric oncologists accept a modern definition of PC in theory, how to integrate PC into pediatric oncology practice is less understood. Formalized training and standardization of practice surrounding identification of PC needs in patients who may require secondary or tertiary PC services may help to overcome current barriers for PC integration in pediatric oncology.
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Affiliation(s)
- Andrea Cuviello
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA; National Institutes of Health, Bethesda, Maryland, USA.
| | | | | | - Lori Wiener
- National Institutes of Health, Bethesda, Maryland, USA
| | - Renee D Boss
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA
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28
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Newton K, Sebbens D. The Impact of Provider Education on Pediatric Palliative Care Referral. J Pediatr Health Care 2020; 34:99-108. [PMID: 31590995 DOI: 10.1016/j.pedhc.2019.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/25/2019] [Accepted: 07/13/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Palliative care can significantly benefit children managing a life-limiting illness; unfortunately, services are still generally reserved for end of life. The aim of this project was to demonstrate how established guidelines and provider education could impact referrals. METHODS Educational sessions outlining national referral recommendations were offered to providers in the neonatal intensive care unit, pediatric intensive care unit, and Center for Cancer and Blood Disorders at a tertiary care facility. Presurveys and postsurveys were administered at the time of the intervention, and referral rates for the organization were collected for 2 months before and 2 months after the intervention. RESULTS While there was a clinically significant increase in hospital-wide referral rates, most important was the statistically significant (p < .1) increase in provider comfortability with established guidelines. DISCUSSION Palliative care is essential for optimizing quality of life. Provider knowledge of referral criteria ensures that patients receive this service early in their disease trajectory and can benefit from its inclusion within their care team.
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29
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Cheng BT, Wangmo T. Palliative care utilization in hospitalized children with cancer. Pediatr Blood Cancer 2020; 67:e28013. [PMID: 31612605 DOI: 10.1002/pbc.28013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/10/2019] [Accepted: 09/10/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is growing evidence that palliative care (PC) is associated with increased quality of life in children with cancer. Despite increasing recommendations in support of PC to improve pediatric oncology care, little is known about its patterns of use. METHODS We analyzed the 2005-2011 National Inpatient Sample, a representative, cross-sectional sample of US hospital admissions. Our study cohort comprised 10 960 hospitalizations of children with cancer and high in-hospital mortality risk. Survey-weighted regression models were constructed to determine associations of person- and hospital-level characteristics with PC involvement and healthcare costs. RESULTS Overall, 4.4% of hospitalizations included PC involvement. In regression models invoking stepwise variable selection, a shorter length of stay (PC vs no PC; mean: 23.9 vs 32.6 days), solid cancer (solid vs hematologic vs brain cancer; PC use: 7.4% vs 2.8% vs 5.5%), and older age (PC vs no PC; mean: 10.2 vs 8.9 years) were associated with PC use. PC utilization was also associated with lower overall and daily hospital costs. CONCLUSIONS One in 20 pediatric inpatients with cancer and high mortality risk receives PC, with differential utilization by socio-economic groups. These results have significant implications for public health resource allocation and the delivery of pediatric PC as high-value care. Future research should focus on the development of new tools to help physicians assess when PC is appropriate for their patients.
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Affiliation(s)
- Brian T Cheng
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tenzin Wangmo
- Institute of Biomedical Ethics, University of Basel, Basel, Switzerland
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30
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Hill DL, Walter JK, Szymczak JE, DiDomenico C, Parikh S, Feudtner C. Seven Types of Uncertainty When Clinicians Care for Pediatric Patients With Advanced Cancer. J Pain Symptom Manage 2020; 59:86-94. [PMID: 31425822 PMCID: PMC6942218 DOI: 10.1016/j.jpainsymman.2019.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022]
Abstract
CONTEXT Clinicians deciding whether to refer a patient or family to specialty palliative care report facing high levels of uncertainty. Most research on medical uncertainty has focused on prognostic uncertainty. As part of a pediatric palliative referral intervention for oncology teams we explored how uncertainty might influence palliative care referrals. OBJECTIVES To describe distinct meanings of the term "uncertainty" that emerged during the qualitative evaluation of the development and implementation of an intervention to help oncologists overcome barriers to palliative care referrals. METHODS We conducted a phenomenological qualitative analysis of "uncertainty" as experienced and described by interdisciplinary pediatric oncology team members in discussions, group activities and semistructured interviews regarding the introduction of palliative care. RESULTS We found that clinicians caring for patients with advanced cancer confront seven broad categories of uncertainty: prognostic, informational, individual, communication, relational, collegial, and inter-institutional. Each of these kinds of uncertainty can contribute to delays in referring patients to palliative care. CONCLUSION Various types of uncertainty arise in the care of pediatric patients with advanced cancer. To manage these forms of uncertainty, providers need to develop strategies and techniques to handle professionally challenging situations, communicate bad news, manage difficult interactions with families and colleagues, and collaborate with other organizations.
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Affiliation(s)
- Douglas L Hill
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Concetta DiDomenico
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Walter JK, Hill DL, DiDomenico C, Parikh S, Feudtner C. A conceptual model of barriers and facilitators to primary clinical teams requesting pediatric palliative care consultation based upon a narrative review. BMC Palliat Care 2019; 18:116. [PMID: 31864331 PMCID: PMC6925857 DOI: 10.1186/s12904-019-0504-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/09/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Despite evidence that referral to pediatric palliative care reduces suffering and improves quality of life for patients and families, many clinicians delay referral until the end of life. The purpose of this article is to provide a conceptual model for why clinical teams delay discussing palliative care with parents. DISCUSSION Building on a prior model of parent regoaling and relevant research literature, we argue for a conceptual model of the challenges and facilitators a clinical team might face in shifting from a restorative-focused treatment plan to a plan that includes palliative aspects, resulting in a subspecialty palliative care referral. Like patients and families, clinicians and clinical teams may recognize that a seriously ill patient would benefit from palliative care and shift from a restorative mindset to a palliative approach. We call this transition "clinician regoaling". Clinicians may experience inhibitors and facilitators to this transition at both the individual and team level which influence the clinicians' willingness to consult subspecialty palliative care. The 8 inhibitors to team level regoaling include: 1) team challenges due to hierarchy, 2) avoidance of criticizing colleagues, 3) structural communication challenges, 4) group norms in favor of restorative goals, 5) diffusion of responsibility, 6) inhibited expression of sorrow, 7) lack of social support, 8) reinforcement of labeling and conflict. The 6 facilitators of team regoaling include: 1) processes to build a shared mental model, 2) mutual trust to encourage dissent, 3) anticipating conflict and team problem solving, 4) processes for reevaluation of goals, 5) sharing serious news as a team, 6) team flexibility. CONCLUSIONS Recognizing potential team level inhibitors to transitioning to palliative care can help clinicians develop strategies for making the transition more effectively when appropriate.
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Affiliation(s)
- Jennifer K. Walter
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Douglas L. Hill
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Concetta DiDomenico
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Shefali Parikh
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
| | - Chris Feudtner
- The Children’s Hospital of Philadelphia, 2716 South St 11th Floor, Philadelphia, PA 19146 USA
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Rost M, De Clercq E, Rakic M, Wangmo T, Elger B. Barriers to Palliative Care in Pediatric Oncology in Switzerland: A Focus Group Study. J Pediatr Oncol Nurs 2019; 37:35-45. [DOI: 10.1177/1043454219871082] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: For children with cancer, early integration of pediatric palliative care in conjunction with curative treatments is recommended. In Switzerland, pediatric palliative care is mostly provided by an interdisciplinary primary oncology team that is mainly composed of nurses. However, only a small fraction of children receive pediatric palliative care and only a minority of them in a timely manner. The main aim was to identify barriers to the provision of pediatric palliative care in Swiss pediatric oncology. Method: This qualitative study consisted of five focus groups. In total, 29 pediatric oncology providers participated (13 nurses, 11 physicians, 4 psycho-oncologists, 1 social worker). Data were analyzed employing applied thematic analysis. Results: Analysis revealed eleven barriers: lack of financial resources, lack of prejob education regarding pediatric palliative care, lack of awareness in politics and policy making, absence of a well-established nationwide bridging care system, insufficient psychosocial and professional supervision for staff, understaffing, inadequate infrastructure of hospitals, asymmetry of factual and emotional knowledge between parents and providers, cultural aspects, irrational parental hopes, and “the unspoken.” Discussion: Awareness should be raised for pediatric palliative care (in particular in demarcation from palliative care in adults) among politics and policy makers which could lead to increased financial resources that, in turn, could be used to improve bridging care, hospital’s infrastructure, and team support. More flexibility for care determining factors is needed, for example, with respect to convening team meetings, short-termed staffing, and reimbursement at the interface between inpatient and outpatient services.
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Cuviello A, Boss R, Shah N, Battles H, Beri A, Wiener L. Utilization of palliative care consultations in pediatric oncology phase I clinical trials. Pediatr Blood Cancer 2019; 66:e27771. [PMID: 31012246 PMCID: PMC7023673 DOI: 10.1002/pbc.27771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/24/2019] [Accepted: 04/08/2019] [Indexed: 11/09/2022]
Abstract
Pediatric phase I clinical oncology trials represent a unique cohort of patients who have not responded to standard therapies and remain highly vulnerable to treatment toxicity and/or disease burden. Incorporating a palliative care consultation into the care plan for those with relapsed/refractory cancer where chance of cure is limited is generally recommended. A retrospective chart review of pediatric phase I trials revealed that palliative care was consulted in <20% of patients, most often for symptom management. Efforts to increase the use of palliative services in this population may enhance quality of life for children and families enrolled in phase I studies.
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Affiliation(s)
- Andrea Cuviello
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, MD, 21287, USA,National Cancer Institute, Center for Cancer Research, Pediatric Oncology Branch, Bethesda, MD 20892
| | - Renee Boss
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, MD, 21287, USA
| | - Nirali Shah
- National Cancer Institute, Center for Cancer Research, Pediatric Oncology Branch, Bethesda, MD 20892
| | - Haven Battles
- National Cancer Institute, Center for Cancer Research, Pediatric Oncology Branch, Bethesda, MD 20892
| | - Andrea Beri
- National Cancer Institute, Center for Cancer Research, Pediatric Oncology Branch, Bethesda, MD 20892
| | - Lori Wiener
- National Cancer Institute, Center for Cancer Research, Pediatric Oncology Branch, Bethesda, MD 20892
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Brock KE, Snaman JM, Kaye EC, Bower KA, Weaver MS, Baker JN, Wolfe J, Ullrich C. Models of Pediatric Palliative Oncology Outpatient Care-Benefits, Challenges, and Opportunities. J Oncol Pract 2019; 15:476-487. [PMID: 31322987 DOI: 10.1200/jop.19.00100] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Although the bulk of current pediatric palliative care (PPC) services are concentrated in inpatient settings, the vast majority of clinical care, symptom assessment and management, decision-making, and advance care planning occurs in the outpatient and home settings. As integrated PPC/pediatric oncology becomes the standard of care, novel pediatric palliative oncology (PPO) outpatient models are emerging. The optimal PPO model is unknown and likely varies on the basis of institutional culture, resources, space, and personnel. METHODS We review five institutions' unique outpatient PPO clinical models with their respective benefits and challenges. This review offers pragmatic guidance regarding PPO clinic development, implementation, and resource allocation. RESULTS Specific examples include a floating clinic model, embedded disease-specific PPC experts, embedded consultative or trigger-based supportive care clinics, and telehealth clinics. CONCLUSION Organizations that have overcome personnel, funding, and logistical challenges can serve as role models for centers developing PPO clinic models. In the absence of a one-size-fits-all model, pediatric oncology and PPC groups can select, tailor, and implement the model that best suits their respective personnel, needs, and capacities. Emerging PPO clinics must balance the challenges and opportunities unique to their organization, with the goal of providing high-quality PPC for children with cancer and their families.
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Affiliation(s)
- Katharine E Brock
- Children's Healthcare of Atlanta, Atlanta, GA.,Emory University, Atlanta, GA
| | - Jennifer M Snaman
- Dana-Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, Boston, MA
| | - Erica C Kaye
- St Jude Children's Research Hospital, Memphis, TN
| | | | | | | | - Joanne Wolfe
- Dana-Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, Boston, MA
| | - Christina Ullrich
- Dana-Farber Cancer Institute, Boston, MA.,Boston Children's Hospital, Boston, MA
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35
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Rossfeld ZM, Miller R, Fosselman DD, Ketner AR, Tumin D, Tobias JD, Humphrey L. Timing of Palliative Consultation for Children During a Fatal Illness. Hosp Pediatr 2019; 9:373-378. [PMID: 30995995 DOI: 10.1542/hpeds.2018-0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The American Academy of Pediatrics recommends palliative care for children at the diagnosis of serious illness. Yet few children who die receive specialty palliative care consultation, and when it is provided, palliative care consultation tends to occur after >75% of the time from diagnosis until death. Focusing on the timing of palliative consultation in relation to the date of diagnosis, we evaluated factors predicting earlier receipt of pediatric palliative care in a cohort of decedents. METHODS We retrospectively identified patients diagnosed with a life-limiting disease who died at our hospital in 2015-2017 after at least 1 inpatient palliative medicine consultation. Our primary outcome was time from palliative-qualifying diagnosis to earliest receipt of specialty palliative care. A survival analysis was used to describe factors associated with earlier receipt of palliative care. RESULTS The analysis included 180 patients (median age at diagnosis <1 month [interquartile range (IQR): 0-77]). The median time to first palliative consultation was 7 days after diagnosis (IQR: 2-63), compared with a median of 50 days between diagnosis and death (IQR: 7-210). On the multivariable analysis, palliative consultation occurred earlier for patients who had cardiovascular diagnoses, had private insurance, and were of African American race. CONCLUSIONS In a cohort of decedents at our institution, palliative consultation occurred much earlier than has been previously reported. We also identify factors associated with delayed receipt of palliative care among children who are dying that reveal further opportunities to improve access to specialty palliative care.
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Affiliation(s)
| | - Rebecca Miller
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Adam R Ketner
- Departments of Pediatrics and
- Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio; and
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Departments of Pediatrics and
| | - Lisa Humphrey
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio;
- Departments of Pediatrics and
- Section of Hospice and Palliative Care and
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36
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Wang S, Wu L, Yang Y, Sheen J. The experience of parents living with a child with cancer at the end of life. Eur J Cancer Care (Engl) 2019; 28:e13061. [DOI: 10.1111/ecc.13061] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/16/2019] [Accepted: 03/25/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Sui‐Ching Wang
- Department of Pediatrics Kaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
| | - Li‐Min Wu
- School of Nursing Kaohsiung Medical University Kaohsiung Taiwan
| | - Yung‐Mei Yang
- School of Nursing Kaohsiung Medical University Kaohsiung Taiwan
| | - Jiunn‐Ming Sheen
- Department of Pediatrics Chiayi Chang Gung Memorial Hospital Puzi City Taiwan
- Department of Pediatrics Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
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37
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Rossfeld ZM, Miller R, Tumin D, Tobias JD, Humphrey LM. Implications of Pediatric Palliative Consultation for Intensive Care Unit Stay. J Palliat Med 2019; 22:790-796. [PMID: 30835155 DOI: 10.1089/jpm.2018.0292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The impact of specialty pediatric palliative care (PPC) on intensive care unit (ICU) length of stay for children is unclear. Objective: To estimate the impact of PPC consultation by analyzing ICU stay as a dynamic outcome over the course of hospitalization. Patients and Methods: Retrospective cohort study of children hospitalized with diagnoses suggested as referral triggers for PPC at a large academic children's hospital. We assessed ICU stay according to PPC consultation and, using a patient-day analysis, applied multivariable mixed effects logistic regression to predict the odds of being in the ICU on a given day. Results: The analytic sample included 777 admissions (11,954 hospital days), of which 100 admissions (13%) included PPC consultation. Principal patient demographics were age 8 ± 6 years, 55% male sex, 71% white race, and 52% commercial insurance. Cardiac diagnoses were most frequent (29%) followed by gastrointestinal (22%) and malignant (20%) conditions. Although total ICU stay was longer for admissions, including PPC consultation (compared to admissions where PPC was not consulted), the odds of being in the ICU on a given day were reduced by 79% after PPC consultation (odds ratio [OR] = 0.21; 95% confidence interval [CI]: 0.13-0.34; p < 0.001) for children with cancer and 85% (OR = 0.15; 95% CI: 0.08-0.26; p < 0.001) for children with nononcologic conditions. Conclusions: Among children hospitalized with a diagnosis deemed eligible for specialty PPC, the likelihood of being in the ICU on a given day was strongly reduced after PPC consultation, supporting the value of PPC.
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Affiliation(s)
| | - Rebecca Miller
- 2 Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Dmitry Tumin
- 3 Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, North Carolina
| | - Joseph D Tobias
- 2 Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.,4 Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lisa M Humphrey
- 2 Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio.,4 Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio.,5 Section of Hospice and Palliative Care, Nationwide Children's Hospital, Columbus, Ohio
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38
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Cheng BT, Rost M, De Clercq E, Arnold L, Elger BS, Wangmo T. Palliative care initiation in pediatric oncology patients: A systematic review. Cancer Med 2018; 8:3-12. [PMID: 30525302 PMCID: PMC6346252 DOI: 10.1002/cam4.1907] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/06/2018] [Accepted: 11/08/2018] [Indexed: 02/06/2023] Open
Abstract
Palliative care (PC) aims to improve quality of life for patients and their families. The World Health Organization and American Academy of Pediatrics recommend that PC starts at diagnosis for children with cancer. This systematic review describes studies that reported PC timing in the pediatric oncology population. The following databases were searched: PubMed, Web of Science, CINAHL, and PsycInfo databases. Studies that reported time of PC initiation were independently screened and reviewed by 2 researchers. Studies describing pilot initiatives, published prior to 1998, not written in English, or providing no empirical time information on PC were excluded. Extracted data included sample characteristics and timing of PC discussion and initiation. Of 1120 identified citations, 16 articles met the inclusion criteria and comprised the study cohort. Overall, 54.5% of pediatric oncology patients received any palliative service prior to death. Data revealed PC discussion does not occur until late in the illness trajectory, and PC does not begin until close to time of death. Despite efforts to spur earlier initiation, many pediatric oncology patients do not receive any palliative care service, and those who do, predominantly receive it near the time of death. Delays occur both at first PC discussion and at PC initiation. Efforts for early PC integration must recognize the complex determinants of PC utilization across the illness timeline. This systematic review examines the timing of palliative care initiation in pediatric oncology patients to assess the state of palliative care integration. Many pediatric oncology patients do not receive any palliative service, and those who do, typically receive it late in the illness trajectory.
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Affiliation(s)
- Brian T Cheng
- Department of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael Rost
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Louisa Arnold
- Institute of Psychology, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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39
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Rost M, Wangmo T, Rakic M, Acheson E, Rischewski J, Hengartner H, Kühne T, Elger BS. Burden of treatment in the face of childhood cancer: A quantitative study using medical records of deceased children. Eur J Cancer Care (Engl) 2018; 27:e12879. [PMID: 30039619 DOI: 10.1111/ecc.12879] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 03/30/2018] [Accepted: 06/08/2018] [Indexed: 11/30/2022]
Abstract
Lived experiences of childhood cancer patients and their families have been described as interrupted and as a loss of normal life. Apart from symptoms due to the cancer disease, families continuously experience burden of treatment. Since coping capacities are unique to each individual, we captured variables that offer objective measures of treatment burden, with a particular focus on the disruptive effects of treatment on families' lives. Our sample was comprised by 193 children that died of cancer. Medical records were extracted retrospectively. Quantitative data were statistically analysed with respect to variables related to treatment burden. Deceased children with cancer and their families faced a significant burden of treatment. Results revealed that deceased leukaemia patients had a higher number of inpatient stays, spent more time in the hospital both during their illness and during the last month of their life, and were more likely to die in the hospital when compared to deceased patients with CNS neoplasms and with other diagnoses. Our findings highlight the disruptive effects of treatment that are likely to have a great impact on families' daily life, that go beyond exclusively focusing on side effects, and that needs to be taken into account by the treating staff.
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Affiliation(s)
- Michael Rost
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Milenko Rakic
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Elaine Acheson
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Johannes Rischewski
- Pediatric Oncology and Hematology, Children's Hospital, Lucerne, Switzerland
| | | | - Thomas Kühne
- Pediatric Oncology and Hematology, University of Basel Children's Hospital UKBB, Basel, Switzerland
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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40
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Kaye EC, Jerkins J, Gushue CA, DeMarsh S, Sykes A, Lu Z, Snaman JM, Blazin L, Johnson LM, Levine DR, Morrison RR, Baker JN. Predictors of Late Palliative Care Referral in Children With Cancer. J Pain Symptom Manage 2018; 55:1550-1556. [PMID: 29427739 PMCID: PMC6223026 DOI: 10.1016/j.jpainsymman.2018.01.021] [Citation(s) in RCA: 30] [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] [Received: 12/15/2017] [Revised: 01/23/2018] [Accepted: 01/26/2018] [Indexed: 01/15/2023]
Abstract
CONTEXT Early integration of palliative care (PC) in the management of children with high-risk cancer is widely endorsed by patients, families, clinicians, and national organizations. However, optimal timing for PC consultation is not standardized, and variables that influence timing of PC integration for children with cancer remain unknown. OBJECTIVES To investigate associations between demographic, disease, treatment, and end-of-life attributes and timing of PC consultation for children with high-risk cancer enrolled on a PC service. METHODS A comprehensive standardized tool was used to abstract data from the medical records of 321 patients treated at a large academic pediatric cancer center, who died between 2011 and 2015. RESULTS Gender, race, ethnicity, enrollment on a Phase I protocol, number of high-acuity hospitalizations, and receipt of cardiopulmonary resuscitation were not associated with timing of PC involvement. Patients with hematologic malignancy, those who received cancer-directed therapy during the last month of life, and those with advance directives documented one week or less before death had higher odds of late PC referral (malignancy: odds ratio [OR] 3.24, P = 0.001; therapy: OR 4.65, P < 0.001; directive: OR 4.81, P < 0.0001). Patients who received hospice services had lower odds of late PC referral <30 days before death (OR 0.31, P < 0.001). CONCLUSION Hematologic malignancy, cancer-directed therapy at the end of life, and delayed documentation of advance directives are associated with late PC involvement in children who died of cancer. Identification of these variables affords opportunities to study targeted interventions to enhance access to earlier PC resources and services for children with high-risk cancer and their families.
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Affiliation(s)
- Erica C Kaye
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
| | - Jonathan Jerkins
- Le Bonheur Children's Hospital, Memphis, Tennessee, USA; University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Samantha DeMarsh
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, Ohio, USA
| | - April Sykes
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Zhaohua Lu
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer M Snaman
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lindsay Blazin
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Deena R Levine
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - R Ray Morrison
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Justin N Baker
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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41
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Dalberg T, McNinch NL, Friebert S. Perceptions of barriers and facilitators to early integration of pediatric palliative care: A national survey of pediatric oncology providers. Pediatr Blood Cancer 2018; 65:e26996. [PMID: 29418063 DOI: 10.1002/pbc.26996] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/27/2017] [Accepted: 12/30/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The goal of this study was to assess pediatric oncology providers' perceptions of palliative care in order to validate previously identified barriers and facilitators to early integration of a pediatric palliative care team (PCT) in the care of children with cancer. METHODS A 36-question survey based on preliminary, single-institution data was electronically distributed to pediatric oncology physicians, nurse practitioners, nurses, and social workers nationally. The principal outcomes measured included perceived barriers and facilitators to early integration of pediatric palliative care. Data were analyzed using Rv3.1.2 statistical software. RESULTS Most respondents agreed that the PCT does not negatively impact the role of the oncologist; however, there were concerns that optimal patient care may be limited by pediatric oncologists' need to control all aspects of patient care (P < 0.001). Furthermore, oncologists, more than any provider group, identified that the emotional relationship they form with the patients and families they care for, influences what treatment options are offered and how these options are conveyed (P < 0.01). Education and evidence-based research remain important to all providers. Respondents reached consensus that early integration of a PCT would provide more potential benefits than risks and most would not limit access to palliative care based on prognosis. CONCLUSIONS Overall, providers endorse early integration of the PCT for children with cancer. There remains a continued emphasis on provider and patient education. Palliative care is generally accepted as providing a benefit to children with cancer, though barriers persist and vary among provider groups.
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Affiliation(s)
- Todd Dalberg
- Department of Pediatrics, Gillette Children's Specialty Healthcare, St. Paul, Minnesota
| | - Neil L McNinch
- Rebecca D. Considine Research Institute, Akron Children's Hospital, Akron, Ohio
| | - Sarah Friebert
- Department of Pediatrics, Division of Pediatric Palliative Care, Akron Children's Hospital, Akron, Ohio
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42
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Szymczak JE, Schall T, Hill DL, Walter JK, Parikh S, DiDomenico C, Feudtner C. Pediatric Oncology Providers' Perceptions of a Palliative Care Service: The Influence of Emotional Esteem and Emotional Labor. J Pain Symptom Manage 2018; 55:1260-1268. [PMID: 29425881 PMCID: PMC5908218 DOI: 10.1016/j.jpainsymman.2018.01.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 11/30/2022]
Abstract
CONTEXT Pediatric palliative care consults for children with cancer often occur late in the course of disease and close to death, when earlier involvement would reduce suffering. The perceptions that pediatric oncology providers hold about the pediatric palliative care service (PPCS) may shape referral patterns. OBJECTIVES To explore how pediatric oncology providers at one institution perceived the hospital's PPCS and the way these perceptions may influence the timing of consultation. METHODS We conducted semistructured qualitative interviews with pediatric oncology providers at a large children's hospital. Interviews were audio-recorded, transcribed, and analyzed by two coders using a modified grounded theory approach. RESULTS We interviewed 16 providers (10 physicians, one nurse practitioner, two social workers, two psychologists, and one child life specialist). Three core perceptions emerged: 1) the PPCS offers a diverse range of valuable contributions to the care of children with advancing cancer; 2) providers held favorable opinions about the PPCS owing to positive interactions with individual palliative care specialists deemed extraordinarily emotionally skilled; and 3) there is considerable emotional labor involved in calling a PPCS consult that serves as a barrier to early initiation. CONCLUSION The pediatric oncology providers in our study held a highly favorable opinion about their institution's PPCS and agreed that early consultation is ideal. However, they also described that formally consulting PPCS is extremely difficult because of what the PPCS symbolizes to families and the emotional labor that the provider must manage in introducing them. Interventions to encourage the early initiation of palliative care in this population may benefit from a focus on the emotional experiences of providers.
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Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Theodore Schall
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Concetta DiDomenico
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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43
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Lord S, Weingarten K, Rapoport A. Palliative Care Consultation Should Be Routine for All Children Who Enroll in a Phase I Trial. J Clin Oncol 2018; 36:1062-1063. [DOI: 10.1200/jco.2017.76.3938] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sarah Lord
- Sarah Lord, Hospital for Sick Children, Toronto, Ontario, Canada; Kevin Weingarten, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; and Adam Rapoport, Hospital for Sick Children, University of Toronto, and Emily’s House Children’s Hospice, Toronto, Ontario, Canada
| | - Kevin Weingarten
- Sarah Lord, Hospital for Sick Children, Toronto, Ontario, Canada; Kevin Weingarten, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; and Adam Rapoport, Hospital for Sick Children, University of Toronto, and Emily’s House Children’s Hospice, Toronto, Ontario, Canada
| | - Adam Rapoport
- Sarah Lord, Hospital for Sick Children, Toronto, Ontario, Canada; Kevin Weingarten, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; and Adam Rapoport, Hospital for Sick Children, University of Toronto, and Emily’s House Children’s Hospice, Toronto, Ontario, Canada
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The codesign of an interdisciplinary team-based intervention regarding initiating palliative care in pediatric oncology. Support Care Cancer 2018; 26:3249-3256. [PMID: 29627863 DOI: 10.1007/s00520-018-4190-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/29/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Children with advanced cancer are often not referred to palliative or hospice care before they die or are only referred close to the child's death. The goals of the current project were to learn about pediatric oncology team members' perspectives on palliative care, to collaborate with team members to modify and tailor three separate interdisciplinary team-based interventions regarding initiating palliative care, and to assess the feasibility of this collaborative approach. METHODS We used a modified version of experience-based codesign (EBCD) involving members of the pediatric palliative care team and three interdisciplinary pediatric oncology teams (Bone Marrow Transplant, Neuro-Oncology, and Solid Tumor) to review and tailor materials for three team-based interventions. Eleven pediatric oncology team members participated in four codesign sessions to discuss their experiences with initiating palliative care and to review the proposed intervention including patient case studies, techniques for managing uncertainty and negative emotions, role ambiguity, system-level barriers, and team communication and collaboration. RESULTS The codesign process showed that the participants were strong supporters of palliative care, members of different teams had preferences for different materials that would be appropriate for their teams, and that while participants reported frustration with timing of palliative care, they had difficulty suggesting how to change current practices. CONCLUSIONS The current project demonstrated the feasibility of collaborating with pediatric oncology clinicians to develop interventions about introducing palliative care. The procedures and results of this project will be posted online so that other institutions can use them as a model for developing similar interventions appropriate for their needs.
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A randomised trial of early palliative care for maternal stress in infants prenatally diagnosed with single-ventricle heart disease. Cardiol Young 2018; 28:561-570. [PMID: 29316996 DOI: 10.1017/s1047951117002761] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Children with single-ventricle disease experience high mortality and complex care. In other life-limiting childhood illnesses, paediatric palliative care may mitigate maternal stress. We hypothesised that early palliative care in the single-ventricle population may have the same benefit for mothers. In this pilot randomised trial of early palliative care, mothers of infants with prenatal single-ventricle diagnoses completed surveys measuring depression, anxiety, coping, and quality of life at a prenatal visit and neonatal discharge. Infants were randomised to receive early palliative care - structured evaluation, psychosocial/spiritual, and communication support before surgery - or standard care. Among 56 eligible mothers, 40 enrolled and completed baseline surveys; 38 neonates were randomised, 18 early palliative care and 20 standard care; and 34 postnatal surveys were completed. Baseline Beck Depression Inventory-II and State-Trait Anxiety Index scores exceeded normal pregnant sample scores (mean 13.76±8.46 versus 7.0±5.0 and 46.34±12.59 versus 29.8±6.35, respectively; p=0.0001); there were no significant differences between study groups. The early palliative care group had a decrease in prenatal to postnatal State-Trait Anxiety Index scores (-7.6 versus 0.3 in standard care, p=0.02), higher postnatal Brief Cope Inventory positive reframing scores (p=0.03), and a positive change in PedsQL Family Impact Module communication and family relationships scores (effect size 0.46 and 0.41, respectively). In conclusion, these data show that mothers of infants with single-ventricle disease experience significant depression and anxiety prenatally. Early palliative care resulted in decreased maternal anxiety, improved maternal positive reframing, and improved communication and family relationships.
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Kaye EC, Gushue CA, DeMarsh S, Jerkins J, Sykes A, Lu Z, Snaman JM, Blazin L, Johnson LM, Levine DR, Morrison RR, Baker JN. Illness and end-of-life experiences of children with cancer who receive palliative care. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26895. [PMID: 29218773 PMCID: PMC6159948 DOI: 10.1002/pbc.26895] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 10/19/2017] [Accepted: 10/24/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The field of pediatric palliative oncology is newly emerging. Little is known about the characteristics and illness experiences of children with cancer who receive palliative care (PC). METHODS A retrospective cohort study of 321 pediatric oncology patients enrolled in PC who died between 2011 and 2015 was conducted at a large academic pediatric cancer center using a comprehensive standardized data extraction tool. RESULTS The majority of pediatric palliative oncology patients received experimental therapy (79.4%), with 40.5% enrolled on a phase I trial. Approximately one-third received cancer-directed therapy during the last month of life (35.5%). More than half had at least one intensive care unit hospitalization (51.4%), with this subset demonstrating considerable exposure to mechanical ventilation (44.8%), invasive procedures (20%), and cardiopulmonary resuscitation (12.1%). Of the 122 patients who died in the hospital, 44.3% died in the intensive care unit. Patients with late PC involvement occurring less than 30 days before death had higher odds of dying in the intensive care unit over the home/hospice setting compared to those with earlier PC involvement (OR: 4.7, 95% CI: 2.47-8.97, P < 0.0001). CONCLUSIONS Children with cancer who receive PC experience a high burden of intensive treatments and often die in inpatient intensive care settings. Delayed PC involvement is associated with increased odds of dying in the intensive care unit. Prospective investigation of early PC involvement in children with high-risk cancer is needed to better understand potential impacts on cost-effectiveness, quality of life, and delivery of goal concordant care.
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Affiliation(s)
| | - Courtney A. Gushue
- Le Bonheur Children’s Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Samantha DeMarsh
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, OH
| | - Jonathan Jerkins
- Le Bonheur Children’s Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - April Sykes
- St. Jude Children’s Research Hospital, Memphis, TN
| | - Zhaohua Lu
- St. Jude Children’s Research Hospital, Memphis, TN
| | - Jennifer M. Snaman
- Dana-Farber Cancer Institute, Boston, MA
- Boston Children’s Hospital, Boston, MA
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Abstract
The Affordable Care Act (ACA) expanded access to high-quality end-of-life care for Americans with serious illness, including cancer. Before the ACA was enacted in 2010, nearly 715,000 patients died in hospitals annually, despite evidence that most Americans prefer to die at home. Moreover, fewer than half of Medicare beneficiaries used hospice before death, despite evidence that hospice services improve cancer patients' quality of life near death and caregivers' bereavement outcomes. The ACA-stipulated programs and subsequent efforts were designed to address these deficiencies in access to high-quality end-of-life care. However, important gaps in coverage persist. In this article, we highlight the impact of the ACA on end-of-life care for individuals with and without cancer.
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Affiliation(s)
- Ravi B. Parikh
- Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Alexi A. Wright
- Harvard Medical School, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
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48
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Rost M, Acheson E, Kühne T, Ansari M, Pacurari N, Brazzola P, Niggli F, Elger BS, Wangmo T. Palliative care in Swiss pediatric oncology settings: a retrospective analysis of medical records. Support Care Cancer 2018; 26:2707-2715. [PMID: 29478188 DOI: 10.1007/s00520-018-4100-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/07/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE This study examined the provision of palliative care and related decision-making in Swiss pediatric oncology settings. The aim was to determine if and when children who died from cancer received palliative care, whether there were differences by cancer diagnosis, and inclusion of children in decision-making regarding palliative care. METHODS Using a standardized data extraction form, a retrospective review of medical records of deceased pediatric patients was conducted. The form captured information on demographics, diagnosis, relapse(s), treatments, decision-making during palliative care, and circumstances surrounding a child's death. RESULTS For 170 patients, there was information on whether the child received palliative care. Among those, 38 cases (22%) did not receive palliative care. For 16 patients, palliative care began at diagnosis. The mean duration of palliative care was 145 days (Mdn = 89.5, SD = 183.4). Decision to begin palliative care was discussed solely with parent(s) in 60.9% of the cases. In 39.1%, the child was involved. These children were 13.6 years of age (SD = 4.6), whereas those not included were 7.16 years old (SD = 3.9). Leukemia patients were less likely to receive palliative care than the overall sample, and patients with CNS neoplasms received palliative care for a longer time than other patients. CONCLUSIONS There are still high numbers of late or non-referrals, and even children older than 12 years were not involved in decision-making regarding palliative care. These results do not align with international organizational guidelines which recommend that palliative care should begin at diagnosis.
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Affiliation(s)
- Michael Rost
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, -4056, Basel, CH, Switzerland.
| | - Elaine Acheson
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, -4056, Basel, CH, Switzerland
| | - Thomas Kühne
- Pediatric Oncology and Hematology, University of Basel Children's Hospital UKBB Basel, Basel, Switzerland
| | - Marc Ansari
- Department of Pediatric, Oncology and Hematology Unit, Geneva University Hospital, Geneva, Switzerland
| | - Nadia Pacurari
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, -4056, Basel, CH, Switzerland
| | - Pierluigi Brazzola
- Ospedale Regionale di Bellinzona e Valli, Pediatria, Bellinzona, Switzerland
| | - Felix Niggli
- Depatment of Pediatric Oncology, University Children's Hospital, Zurich, Switzerland
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, -4056, Basel, CH, Switzerland.,Center for Legal Medicine, University of Geneva, Geneva, Switzerland
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, -4056, Basel, CH, Switzerland
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Haines ER, Frost AC, Kane HL, Rokoske FS. Barriers to accessing palliative care for pediatric patients with cancer: A review of the literature. Cancer 2018; 124:2278-2288. [DOI: 10.1002/cncr.31265] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 12/23/2017] [Accepted: 12/28/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Emily R. Haines
- Department of Health Policy and Management, Gillings School of Global Public Health; The University of North Carolina at Chapel Hill; Chapel Hill North Carolina
- End-of-Life, Hospice, and Palliative Care Program; RTI International; Research Triangle Park North Carolina
| | - A. Corey Frost
- Child and Adolescent Research and Evaluation Program; RTI International; Research Triangle Park North Carolina
| | - Heather L. Kane
- Child and Adolescent Research and Evaluation Program; RTI International; Research Triangle Park North Carolina
| | - Franziska S. Rokoske
- End-of-Life, Hospice, and Palliative Care Program; RTI International; Research Triangle Park North Carolina
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50
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Archambault-Grenier MA, Roy-Gagnon MH, Gauvin F, Doucet H, Humbert N, Stojanovic S, Payot A, Fortin S, Janvier A, Duval M. Survey highlights the need for specific interventions to reduce frequent conflicts between healthcare professionals providing paediatric end-of-life care. Acta Paediatr 2018; 107:262-269. [PMID: 28793184 DOI: 10.1111/apa.14013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/28/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
AIMS This study explored how paediatric healthcare professionals experienced and coped with end-of-life conflicts and identified how to improve coping strategies. METHODS A questionnaire was distributed to all 2300 professionals at a paediatric university hospital, covering the frequency of end-of-life conflicts, participants, contributing factors, resolution strategies, outcomes and the usefulness of specific institutional coping strategies. RESULTS Of the 946 professionals (41%) who responded, 466 had witnessed or participated in paediatric end-of-life discussions: 73% said these had led to conflict, more frequently between professionals (58%) than between professionals and parents (33%). Frequent factors included professionals' rotations, unprepared parents, emotional load, unrealistic parental expectations, differences in values and beliefs, parents' fear of hastening death, precipitated situations and uncertain prognosis. Discussions with patients and parents and between professionals were the most frequently used coping strategies. Conflicts were frequently resolved by the time of death. Professionals mainly supported designating one principal physician and nurse for each patient, two-step interdisciplinary meetings - between professionals then with parents - postdeath ethics meetings, bereavement follow-up protocols and early consultations with paediatric palliative care and clinical ethics services. CONCLUSION End-of-life conflicts were frequent and predominantly occurred between healthcare professionals. Specific interventions could target most of the contributing factors.
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Affiliation(s)
| | - Marie-Hélène Roy-Gagnon
- Centre de Recherche; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON Canada
| | - France Gauvin
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Soins Palliatifs Pédiatriques; CHU Sainte-Justine; Montréal QC Canada
| | - Hubert Doucet
- Comité de Bioéthique; CHU Sainte-Justine; Montréal QC Canada
| | - Nago Humbert
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Soins Palliatifs Pédiatriques; CHU Sainte-Justine; Montréal QC Canada
| | - Sanja Stojanovic
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Centre de Réadaptation Marie-Enfant; CHU Sainte-Justine; Montréal QC Canada
| | - Antoine Payot
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Soins Palliatifs Pédiatriques; CHU Sainte-Justine; Montréal QC Canada
- Comité de Bioéthique; CHU Sainte-Justine; Montréal QC Canada
- Unité de Consultation en Éthique Clinique; CHU Sainte-Justine; Montréal QC Canada
| | - Sylvie Fortin
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Comité de Bioéthique; CHU Sainte-Justine; Montréal QC Canada
- Unité de Consultation en Éthique Clinique; CHU Sainte-Justine; Montréal QC Canada
| | - Annie Janvier
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Éthique Clinique; CHU Sainte-Justine; Montréal QC Canada
- Soins Intensifs Néonataux; CHU Sainte-Justine; Montréal QC Canada
| | - Michel Duval
- Service d'Hématologie-Oncologie; Centre de Cancérologie Charles-Bruneau; Montréal QC Canada
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Soins Palliatifs Pédiatriques; CHU Sainte-Justine; Montréal QC Canada
- Unité de Consultation en Éthique Clinique; CHU Sainte-Justine; Montréal QC Canada
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