An Automatic Pediatric Palliative Care Consultation for Children Supported on Extracorporeal Membrane Oxygenation: A Survey of Perceived Benefits and Barriers

Increasing Pediatric Palliative Care Consultation for Patients with Heart Disease and Prolonged Cardiac Intensive Care Stay

Introduction

Patients with congenital heart disease are medically complex and experience high rates of morbidity and mortality. Pediatric palliative care (PPC) supports families navigating complex medical scenarios. This study evaluates the effect of quality improvement (QI) interventions towards increasing PPC consultations in patients with heart disease and cardiac intensive care unit (CICU) length of stay (LOS) ≥ 14 days.

Methods

We conducted a mixed methods QI study using CICU team members and family survey assessments of PPC involvement. Patients with CICU LOS ≥14 days were eligible and comprised our study cohort. Interventions included the implementation of a digital prompt screening for eligible patients sent to CICU and PPC providers, as well as the implementation of weekly huddles to discuss consulted and eligible patients. Through the pre- and postintervention phases, family members of consulted patients and CICU team members were surveyed.

Results

Preintervention (January 2020 to December 2021), PPC consultation rates were 35% (n = 34) and increased to 63% (n = 43) postintervention (January 2022 to February 2023) (P < 0.01). The timing of consultation was similar between phases. Survey results from family members (n = 19, 39% of 49 participants) and CICU team members (n = 80, 40% of eligible) revealed predominantly positive perceptions regarding PPC involvement.

Conclusions

QI interventions, including collaborative huddles and digital prompts based on discrete screening criteria, lead to significantly increased rates of PPC consultation in patients with heart disease in the CICU. Survey results support PPC consultation as a positive contribution for families and CICU team members.

A Seat at the Table: Family Conferences for Infants with Neurological Conditions

Objective: We aimed to characterize parents' perspectives on the value of and opportunities to improve conferences between parents of critically ill infants and the health care team. Background: The parent perspective on the value of family conferences in the intensive care unit is not well characterized. Methods: In this descriptive qualitative study, parents of infants with neurological conditions in the intensive care unit at a U.S. academic medical center completed longitudinal semi-structured interviews about their experiences making decisions and communicating with clinicians. Parents were included if they had an upcoming family conference to discuss goals of care or neurological prognosis. This secondary data analysis targets interview content about family conferences. Parent responses were characterized using a conventional content analysis approach. Results: Fifty-two parents of 37 infants completed 123 interviews. Parents described valuing when clinicians (1) provided space to process emotions, (2) prioritized "big picture" discussions about serious decisions, (3) dedicated time to parent questions, and (4) responded to parent concerns and made an effort to foster consensus. Parent-identified opportunities for improvement included: (1) having the team assume responsibility for calling regular meetings, (2) prioritizing attendance of consistent and supportive team members, and (3) summarizing meeting content for parents and documenting discussions for clinicians. Conclusions: These findings demonstrate that parents of infants with neurological conditions value family conferences as an important venue for communicating with the health care team. Future studies should explore the feasibility and impact of regularly scheduled family conferences, attendees dedicated to parent support, and accessible meeting summaries on therapeutic alliance, parent well-being, and communication quality.

Barriers and facilitators influencing referral and access to palliative care for children and young people with life-limiting and life-threatening conditions: a scoping review of the evidence

BACKGROUND

Palliative care is an essential component of children's health services but is accessed by fewer children than could potentially benefit.

AIM

Appraise the evidence to identify factors influencing referral and access to children's palliative care, and interventions to reduce barriers and improve referrals.

DESIGN

Scoping review following the six stages of the Arksey and O'Malley framework. Data were charted using an adapted version of the socioecological framework.

DATA SOURCES

CINAHL, MEDLINE, PsycINFO, EMBASE, Cochrane Library were searched for primary studies of any design and literature/systematic reviews. Studies reporting barriers/facilitators and interventions in relation to referral of children with a life-limiting condition to palliative care, in any setting, were included.

RESULTS

One hundred ninety five articles (primary qualitative and quantitative studies, reviews) were retained (153 reporting barriers/facilitators; 40 interventions; 2 both). Multiple factors were identified as barriers/facilitators: Individual level: underlying diagnosis, prognostic uncertainty, parental attitudes, staff understanding/beliefs; Interpersonal level: family support, patient-provider relationships, interdisciplinary communication; Organisational level: referral protocols, workforce, leadership; Community level: cultural norms, community resources, geography; Society level: policies and legislation, national education, economic environment, medication availability. Most of these factors were bi-directional in terms of influence. Interventions (n = 42) were mainly at the organisational level for example, educational programmes, screening tools/guidelines, workplace champions and new/enhanced services; one-third of these were evaluated.

CONCLUSION

Barriers/facilitators to paediatric palliative care referral are well described. Interventions are less well described and often unevaluated. Multi-modal approaches incorporating stakeholders from all levels of the socioecological framework are required to improve paediatric palliative care referral and access.

Between hope and disillusionment: ECMO seen through the lens of nurses working in a neonatal and paediatric intensive care unit

BACKGROUND

Using extracorporeal membrane oxygenation (ECMO) in paediatric and neonatal intensive care units (PICU/NICU) creates ethical challenges and carries a high risk for moral distress, burn out and team conflicts.

AIM

The study aimed to gain a more comprehensive understanding of the underlying factors affecting moral distress when using ECMO for infants and children by examining the attitudes of ECMO nurses.

METHODS

Four focus groups discussions were conducted with 21 critical care nurses working in a Swiss University Children's Hospital. Purposive sampling was adopted to identify research participants. The data were analysed using reflexive thematic analysis.

RESULTS

Unlike "miracle machine" stories in online media reports, specialized nurses working in PICU/NICU expressed both their hopes and fears towards this technology. Their accounts also contained references to events and factors that triggered experiences of moral distress: the unspeakable nature of the death of a child or infant; the seemingly lack of honest and transparent communication with parents; the apparent loss of situational awareness among doctors; the perceived lack of recognition for the role of nurses and the variability in end-of-life decision-making; the length of time it takes doctors to take important treatment decisions; and the resource intensity of an ECMO treatment.

CONCLUSION

The creation of a multidisciplinary moral community with transparent information among all involved health care professionals and the definition of clear treatment goals as well as the implementation of paediatric palliative care for all paediatric ECMO patients should become a priority if we want to alleviate situations of moral distress.

RELEVANCE FOR CLINICAL PRACTICE

The creation of a multidisciplinary moral community, clear treatment goals and the implementation of palliative care for all paediatric ECMO patients are crucial to alleviate situations of moral distress for nurses, and thus to improve provider well-being and the quality of patient care in PICU/NICU.