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Crain N, Miller J. Palliative Care in the Pediatric Intensive Care Unit. AACN Adv Crit Care 2024; 35:134-145. [PMID: 38848559 DOI: 10.4037/aacnacc2024104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
The purposes of this review are to describe differences between palliative care for adult patients and palliative care for pediatric patients, both generally and in the intensive care unit; to highlight ethical considerations for pediatric intensive care unit patients by using illustrative cases; and to examine the impact of these ethical considerations on decision-making for children and their families.
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Affiliation(s)
- Noreen Crain
- Noreen Crain is Associate Professor of Pediatrics and Anesthesia, Division of Pediatric Critical Care, and Medical Director of Pediatric Palliative Care, University of Virginia Children's Hospital, 1215 Lee St, Charlottesville, VA 22908-0386
| | - Joy Miller
- Joy Miller is Pediatric Nurse Practitioner, Pediatric Palliative Care, University of Virginia Children's Hospital, Charlottesville, Virginia
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Broden EG, Eche-Ugwu IJ, DeCourcey DD, Wolfe J, Hinds PS, Snaman J. "At Least I Can Push this Morphine": PICU Nurses' Approaches to Suffering Among Dying Children. J Pain Symptom Manage 2024:S0885-3924(24)00738-3. [PMID: 38679304 DOI: 10.1016/j.jpainsymman.2024.04.018] [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: 02/23/2024] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024]
Abstract
CONTEXT Parents of children who die in the pediatric intensive care unit (PICU) carry memories of their child's suffering throughout a lifelong grieving experience. Given their prolonged time at the bedside, PICU nurses are poised to attend to dying children's suffering. OBJECTIVES We aimed to explore how PICU nurses identify, assess, and attend to EOL suffering. METHODS Interpretive descriptive qualitative study with thematic analysis of virtual focus groups from a geographically diverse sample of PICU nurses. RESULTS Nurses participated in five focus groups (N = 19). Most identified as White (89%) females (95%) with a range of 1-24 years of PICU experience and involvement in >10 EOL care cases (89%). Nurses described approaches to suffering within five themes: 1) Identifying and easing perceptible elements; 2) Recognizing and responding to subtleties moment-to-moment; 3) Acclimating to family interdependence; 4) Synchronizing nurse in-the-room insight with systemic complexity; and 5) Accounting for ambiguity. Nurses detailed elements of suffering they could "fix" with straightforward, external interventions (e.g., pain medication). More complex tasks like optimizing care within familial and interprofessional team relationships while navigating psychosocial responses from children and families challenged nurses. Nurses attempted to minimize EOL suffering amidst ambiguity and complexity using internal processes including managing the environment and titrating moment-to-moment care. CONCLUSIONS While physical suffering may be remedied with direct nursing care, holistically attending to EOL suffering in the PICU requires both bolstering external processes and strengthening PICU nurses' internal resources. Improving psychosocial training and optimizing interprofessional care systems could better support dying children and their families.
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Affiliation(s)
- Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care (E.G.B., J.S.), Dana-Farber Cancer Institute, Boston Massachussetts; National Clinician Scholars Program (E.G.B.), Yale Schools of Medicine and Public Health, New Haven, Connecticut.
| | - Ijeoma Julie Eche-Ugwu
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services(I.J.E.U.), Dana-Farber Cancer Institute, Boston, Massachussetts
| | - Danielle D DeCourcey
- Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts; Division of Medical Critical Care (D.D.D.), Boston Children's Hospital, Boston, Massachussetts
| | - Joanne Wolfe
- Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts; Department of Pediatrics (J.W.), Massachusetts General Hospital and Department of Pediatrics, Brigham and Women's Hospital, Boston, Massachussetts
| | - Pamela S Hinds
- Department of Nursing Science (P.H.), Professional Practice and Quality, Children's National Hospital, Washington, DC; Department of Pediatrics (P.H.), The George Washington University, Washington, DC
| | - Jennifer Snaman
- Department of Psychosocial Oncology and Palliative Care (E.G.B., J.S.), Dana-Farber Cancer Institute, Boston Massachussetts; Department of Pediatrics (D.D.D., J.W., J.S.), Harvard Medical School Boston, Massachussetts
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Duval C, Porcheret F, Toulouse J, Alexandre M, Roulland C, Viallard ML, Brossier D. Withholding life support for children with severe neurological impairment: Prevalence and predictive factors prior to admission in the PICU. Arch Pediatr 2024; 31:66-71. [PMID: 37989656 DOI: 10.1016/j.arcped.2023.09.014] [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: 12/29/2022] [Revised: 05/17/2023] [Accepted: 09/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Our study aimed to evaluate the prevalence and predictive factors of withholding life support for children suffering from severe neurological impairment before admission to the pediatric intensive care unit (PICU). METHOD Children under 18 years of age with severe neurological impairment, who were hospitalized between January 2006 and December 2016, were included in this retrospective study. They were allocated to a withholding group or a control group, depending on whether life support was withheld or not, before admission to the PICU. RESULTS Overall, 119 patients were included. At admission to the PICU, the rate of withholding life support was 10 % (n = 12). Predictive factors were: (1) a previous stay in the PICU (n = 11; 92 %, p<0.01, odds ratio [OR]: 14 [2-635], p = 0.001); (2) the need for respiratory support (n = 5; 42 %, p = 0.01, OR: 6 [1-27], p = 0.01); (3) the need for feeding support (n = 10; 83 %, p = 0.01, OR: 10 [2-100], p = 0.001); and (4) a higher functional status score (FSS: 16 [12.5-19] vs. 10 [8-13], p<0.01). CONCLUSION The withholding of life support for children suffering from severe neurological impairment appeared limited in our pediatric department. The main predictor was at least one admission to the PICU, which raised the question of the pediatrician's role in the decision to withhold life support.
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Affiliation(s)
- Christophe Duval
- CH Monod, Neonatal Intensive Care Unit, Le Havre, F-76620, France
| | | | - Joseph Toulouse
- CHU de Lyon, Pediatric Neurology Unit, Bron, F-69677, France
| | | | | | - Marcel-Louis Viallard
- Necker Children's University, Neonate & Pediatric Palliative Medicine Team, Paris, F-75015, France
| | - David Brossier
- CHU de Caen, Pediatric Intensive Care Unit, Caen, F-14000, France; CHU de Caen, Pediatric department, Caen, F-14000, France; Université Caen Normandie, medical school, Caen, F-14000, France; Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France.
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Vemuri S, Hynson J, Williams K, O'Neill J, Gillam L. Shepherding parents to prepare for end-of-life decision-making: a critical phenomenological study of the communication approach of paediatricians caring for children with life-limiting conditions in Australia. BMJ Open 2023; 13:e075740. [PMID: 38159953 PMCID: PMC10759114 DOI: 10.1136/bmjopen-2023-075740] [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: 05/17/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND/OBJECTIVES Shared decision-making is widely accepted as the best approach for end-of-life decision-making for children with life-limiting conditions. Both paediatricians and parents find benefit in preparing for such decisions. However, little detail is known about this preparatory process. This study aims to explore how paediatricians prepare parents for end-of-life decision-making for a child with a life-limiting condition using clinical simulation. DESIGN Individual, semistructured, post-simulation qualitative interviews of paediatricians and parent-actors. SETTING Acute intensive and long-term outpatient paediatric care in Victoria, Australia. PARTICIPANTS 18 purposively sampled paediatricians who treat children with life-limiting conditions and the two parent-actors involved in all simulations. Paediatricians were excluded if they assisted in the study design, worked within specialist palliative care teams or did not provide clinical care outside the neonatal period. RESULTS Three key themes in a preparatory process (termed 'shepherding') were identified: (1) paediatricians aim to lead parents along a pathway to future end-of-life decisions, (2) paediatricians prefer to control the pace of these discussions and (3) paediatricians recognise they need to have courage to face risk with this preparation. Paediatricians use a variety of shepherding strategies to influence the pace, content and framing of discussions, which may help prepare parents to make the best end-of-life treatment decisions when the time comes. CONCLUSIONS Shepherding is a newly identified, subtle process intended to influence parents by guiding their understanding of their child's health and potential suffering in advance of decision-making. Shepherding does not fit within current descriptions of physicians' decision-making influence. Paced reflection, thinking and provision of information are shepherding strategies preferred by paediatricians, and these appear the same regardless of whether paediatricians intend to steer parents towards particular treatment decisions or simply prepare them for the process of decision-making. Further study about the intention of this influence and parental perception of this communication is needed.
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Affiliation(s)
- Sidharth Vemuri
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jenny Hynson
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Katrina Williams
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Jenny O'Neill
- Children's Bioethics Centre, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Lynn Gillam
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Children's Bioethics Centre, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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Porter AS, Gouda SR, Broden EG, Snaman JM. "Palliative Intensive Care" at the End of a Child's Life. Hosp Pediatr 2023; 13:e395-e398. [PMID: 37920949 DOI: 10.1542/hpeds.2023-007348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Affiliation(s)
- Amy S Porter
- Boston Children's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer M Snaman
- Boston Children's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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Delgado-Corcoran C, Wawrzynski SE, Flaherty B, Kirkland B, Bodily S, Moore D, Cook LJ, Olson LM. Extracorporeal membrane oxygenation and paediatric palliative care in an ICU. Cardiol Young 2023; 33:1846-1852. [PMID: 36278475 DOI: 10.1017/s1047951122003018] [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] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU. METHODS Retrospective review of clinical characteristics and outcomes of children (aged 0-21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation. MEASUREMENTS AND RESULTS One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation. CONCLUSIONS Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
- University of Utah, College of Nursing, 10 S 2000 E, Salt Lake City, UT, USA
| | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Brandon Kirkland
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Stephanie Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Dominic Moore
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
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Gouda SR, Hoehn KS. Why the Individual Provider Approach to Pediatric Palliative Care Consultation Exacerbates Healthcare Disparities: A Moral Argument for Standard Referral Criteria. THE JOURNAL OF CLINICAL ETHICS 2022. [DOI: 10.1086/jce2022334352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Jewitt N, Mah K, Bonares M, Weingarten K, Ross H, Amin R, Morgan CT, Zimmermann C, Wentlandt K. Pediatric and Adult Cardiologists' and Respirologists' Referral Practices to Palliative Care. J Pain Symptom Manage 2022; 64:461-470. [PMID: 35905938 DOI: 10.1016/j.jpainsymman.2022.07.011] [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: 04/17/2022] [Revised: 07/05/2022] [Accepted: 07/21/2022] [Indexed: 12/24/2022]
Abstract
CONTEXT Children and adults with advanced cardiac or respiratory disease may benefit from specialized palliative care (SPC), but there has been little SPC research in this area. OBJECTIVES To explore pediatric cardiologists' and respirologists' (pediatric clinicians) beliefs about and referral practices to SPC and compare these results to adult cardiologists and respirologists (adult clinicians). METHODS Pediatric and adult clinicians were sent a survey exploring SPC referral practices and beliefs. Responses were summarized with descriptive statistics. Pediatric and adult clinicians' responses were compared using Pearson's chi-square test. RESULTS The response rate was 56% (989/1759); 9% (87/989) were pediatric clinicians. Pediatric clinicians were more likely than adult clinicians to be female, work in an academic center, and experience fewer patient deaths (P<0.001). Pediatric clinicians reported better access to SPC clinical nurse specialists, spiritual care specialists and bereavement counselors (P<0.001), while adult clinicians reported better access to palliative care units (P<0.001). Pediatric clinicians referred to SPC earlier, while adult clinicians tended to refer after disease directed therapies were stopped (P<0.001). More than half of all clinicians felt patients had negative perceptions of the phrase "palliative care". Although most clinicians were satisfied with SPC quality (73-82%), fewer adult clinicians were satisfied with SPC availability (74 vs. 47%; P<0.001). Fewer pediatric clinicians felt that SPC prioritized oncology patients (13 vs. 53%; P<0.001). CONCLUSION There are important differences between pediatric and adult clinicians' beliefs about and referral practices to SPC. This may reflect unique features of pediatric diseases, provider characteristics, care philosophies, or service availability.
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Affiliation(s)
- Natalie Jewitt
- Pediatric Advanced Care Team (PACT), The Hospital for Sick Children, Toronto, Ontario, Canada (N.J., K.W.); Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada (N.J., K.W., R.A., C.T.M.)
| | - Kenneth Mah
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada (K.M., C.Z., K.W.)
| | - Michael Bonares
- Division of Palliative Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (M.B.); Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (M.B., C.Z.)
| | - Kevin Weingarten
- Pediatric Advanced Care Team (PACT), The Hospital for Sick Children, Toronto, Ontario, Canada (N.J., K.W.); Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada (N.J., K.W., R.A., C.T.M.)
| | - Heather Ross
- Peter Munk Cardiac Centre, Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada (H.R.)
| | - Reshma Amin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada (N.J., K.W., R.A., C.T.M.); Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada (R.A.)
| | - Conall Thomas Morgan
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada (N.J., K.W., R.A., C.T.M.); Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada (C.T.M.)
| | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada (K.M., C.Z., K.W.); Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (M.B., C.Z.)
| | - Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada (K.M., C.Z., K.W.); Division of Palliative Care, Department of Community and Family Medicine, University of Toronto, Toronto, Ontario, Canada (K.W.).
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Cuviello A, Pasli M, Hurley C, Bhatia S, Anghelescu DL, Baker JN. Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration. Front Oncol 2022; 12:1017272. [PMID: 36313632 PMCID: PMC9606590 DOI: 10.3389/fonc.2022.1017272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/30/2022] [Indexed: 12/04/2022] Open
Abstract
Context Approximately 40%-60% of deaths in the pediatric intensive care unit (PICU) are in the context of de-escalation of life-sustaining treatments (LSTs), including compassionate extubation, withdrawal of vasopressors, or other LSTs. Suffering at the end of life (EOL) is often undertreated and underrecognized. Pain and poor quality of life are common concerns amongst parents and providers at a child’s EOL. Integration of palliative care (PC) may decrease suffering and improve symptom management in many clinical situations; however, few studies have described medical management and symptom burden in children with cancer in the pediatric intensive care unit (PICU) undergoing de-escalation of LSTs. Methods A retrospective chart review was completed for deceased pediatric oncology patients who experienced compassionate extubation and/or withdrawal of vasopressor support at EOL in the PICU. Demographics, EOL characteristics, and medication use for symptom management were abstracted. Descriptive analyses were applied. Results Charts of 43 patients treated over a 10-year period were reviewed. Most patients (69.8%) were white males who had undergone hematopoietic stem cell transplantation and experienced compassionate extubation (67.4%) and/or withdrawal of vasopressor support (44.2%). The majority (88.3%) had a physician order for scope of treatment (POST – DNaR) in place an average of 13.9 days before death. PC was consulted for all but one patient; however, in 18.6% of cases, consultations occurred on the day of death. During EOL, many patients received medications to treat or prevent respiratory distress, pain, and agitation/anxiety. Sedative medications were utilized, specifically propofol (14%), dexmedetomidine (12%), or both (44%), often with opioids and benzodiazepines. Conclusions Pediatric oncology patients undergoing de-escalation of LSTs experience symptoms of pain, anxiety, and respiratory distress during EOL. Dexmedetomidine and propofol may help prevent and/or relieve suffering during compassionate de-escalation of LSTs. Further efforts to optimize institutional policies, education, and collaborations between pediatric intensivists and PC teams are needed.
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Affiliation(s)
- Andrea Cuviello
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
- *Correspondence: Andrea Cuviello,
| | - Melisa Pasli
- Pediatric Oncology Education Program, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Caitlin Hurley
- Division of Critical Care Medicine, Departments of Pediatric Medicine and Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Shalini Bhatia
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Doralina L. Anghelescu
- Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Justin N. Baker
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
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Spruit JL, Bell CJ. Describing Pediatric Palliative Care Concepts to Patients and Families #442. J Palliat Med 2022; 25:1154-1155. [PMID: 35775900 DOI: 10.1089/jpm.2022.0240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Vemuri S, Hynson J, Williams K, Gillam L. Decision-making approaches for children with life-limiting conditions: results from a qualitative phenomenological study. BMC Med Ethics 2022; 23:52. [PMID: 35578235 PMCID: PMC9112587 DOI: 10.1186/s12910-022-00788-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background For children with life-limiting conditions who are unable to participate in decision-making, decisions are made for them by their parents and paediatricians. Shared decision-making is widely recommended in paediatric clinical care, with parents preferring a collaborative approach in the care of their child. Despite the increasing emphasis to adopt this approach, little is known about the roles and responsibilities taken by parents and paediatricians in this process. In this study, we describe how paediatricians approach decision-making for a child with a life-limiting condition who is unable to participate in decision-making for his/herself. Methods This qualitative phenomenological study involved 25 purposively sampled paediatricians. Verbatim transcripts from individual semi-structured interviews, conducted between mid-2019 and mid-2020, underwent thematic analysis. Interviews were based around a case vignette matched to the clinical experience of each paediatrician. Results Two key themes were identified in the exploration of paediatricians' approach to decision-making for children with life-limiting conditions: (1) there is a spectrum of paediatricians’ roles and responsibilities in decision-making, and (2) the specific influences on paediatricians’ choice of approach for end-of-life decisions. In relation to (1), analysis showed four distinct approaches: (i) non-directed, (ii) joint, (iii) interpretative, and (iv) directed. In relation to (2), the common factors were: (i) harm to the child, (ii) possible psychological harm to parents, (iii) parental preferences in decision-making, and (iv) resource allocation. Conclusions Despite self-reporting shared decision-making practices, what paediatricians often described were physician-led decision-making approaches. Adopting these approaches was predominantly justified by paediatricians’ considerations of harm to the child and parents. Further research is needed to elucidate the issues identified in this study, particularly the communication within and parental responses to physician-led approaches. We also need to further study how parental needs are identified in family-led decision-making approaches. These nuances and complexities are needed for future practice guidance and training around paediatric decision-making. Trial registration: Not applicable. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00788-7.
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Affiliation(s)
- Sidharth Vemuri
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia.
| | - Jenny Hynson
- Victorian Paediatric Palliative Care Program, The Royal Children's Hopsital Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Katrina Williams
- Department of Paediatrics, Monash University, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia
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Moynihan KM, Ziniel SI, Johnston E, Morell E, Pituch K, Blume ED. A "Good Death" for Children with Cardiac Disease. Pediatr Cardiol 2022; 43:744-755. [PMID: 34854941 DOI: 10.1007/s00246-021-02781-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/17/2021] [Indexed: 11/25/2022]
Abstract
Children with heart disease often experience symptoms and medically intense end-of-life care. Our study explored bereaved parents' perceptions of a "good death" via a mail survey to 128 parents of children with heart disease who died in two centers. Parental perceptions of end-of-life circumstances were assessed by closed-ended questions including level of agreement with the question: "would you say your child experienced a good death?" and open-ended comments were contributed. Medical therapies at end-of-life and mode of death were retrieved through chart review. Of 50 responding parents, 44 (response rate: 34%) responded to the "good death" question; 16 (36%) agreed strongly, 15 (34%) agreed somewhat, and 30% disagreed (somewhat: 7, 16%; strongly: 6, 14%). Half the children were on mechanical support and 84% intubated at death. Of children with cardiopulmonary resuscitation (CPR) at end-of-life, 71% of parents disagreed with the "good death" question compared with 22% of parents whose child died following discontinuation of life-sustaining therapy or comfort measures (OR 9.1, 95% CI 1.3, 48.9, p < 0.01). Parent-reported circumstances associated with disagreement with the "good death" question included cure-oriented goals-of-care (OR 16.6, 95% CI 3.0, 87.8, p < 0.001), lack of advance care planning (ACP) (OR 12.4 95% CI 2.1, 65.3 p < 0.002), surprise regarding timing of death (OR 11.7, 95% CI 2.6, 53.4 p < 0.002), and experience of pain (OR 42.1, 95% CI 2.3, 773.7 p < 0.02). Despite high medical intensity, many bereaved parents of children with cardiac disease agree a "good death" was experienced. A "good death" was associated with greater preparedness, ACP, non-cure-oriented goals-of-care, pain control, and CPR avoidance.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Avenue, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sonja I Ziniel
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Emily Johnston
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emily Morell
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Kenneth Pituch
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Avenue, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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13
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Delgado-Corcoran C, Wawrzynski SE, Mansfield KJ, Flaherty B, DeCourcey DD, Moore D, Cook LJ, Ullrich CK, Olson LM. An Automatic Pediatric Palliative Care Consultation for Children Supported on Extracorporeal Membrane Oxygenation: A Survey of Perceived Benefits and Barriers. J Palliat Med 2022; 25:952-957. [PMID: 35319287 DOI: 10.1089/jpm.2021.0452] [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: 11/12/2022] Open
Abstract
Background: Pediatric palliative care (PPC) consultation is infrequent among children on extracorporeal membrane oxygenation (ECMO). Objective: Investigate intensive care unit (ICU) team members' perceptions of automatic PPC consultation for children on ECMO in an ICU in the United States. Methods: Cross-sectional survey assessing benefits, barriers to PPC, and consultation processes. Results: Of 291 eligible respondents, 48% (n = 140) completed the survey and 16% (n = 47) answered an open-ended question. Benefits included support in decision-making (n = 98; 70%) and identification of goals of care (n = 89; 64%). Barriers included perception of giving up on families (n = 59; 42%) and poor acceptability by other team members (n = 58; 41%). Respondents endorsed communication with the primary ICU team before (n = 122; 87%) and after (n = 129; 92%) consultation. Open-ended responses showed more positive (79% vs. 13%) than negative statements. Positive statements reflected on expanding PPC to other critically-ill children where negative statements revealed unrecognized value in PPC. Conclusions: Results demonstrate opportunities for education about the scope of PPC and improvements in PPC delivery.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.,Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA.,College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | | | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Christina K Ullrich
- Division of Pediatric Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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14
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Abstract
OBJECTIVES Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs. DATA SOURCES English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed. STUDY SELECTION Original articles, review articles, and commentaries were considered. DATA EXTRACTION Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review. DATA SYNTHESIS Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured. CONCLUSIONS The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.
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15
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Recommendations for analgesia and sedation in critically ill children admitted to intensive care unit. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022. [PMCID: PMC8853329 DOI: 10.1186/s44158-022-00036-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We aim to develop evidence-based recommendations for intensivists caring for children admitted to intensive care units and requiring analgesia and sedation. A panel of national paediatric intensivists expert in the field of analgesia and sedation and other specialists (a paediatrician, a neuropsychiatrist, a psychologist, a neurologist, a pharmacologist, an anaesthesiologist, two critical care nurses, a methodologist) started in 2018, a 2-year process. Three meetings and one electronic-based discussion were dedicated to the development of the recommendations (presentation of the project, selection of research questions, overview of text related to the research questions, discussion of recommendations). A telematic anonymous consultation was adopted to reach the final agreement on recommendations. A formal conflict-of-interest declaration was obtained from all the authors. Eight areas of direct interest and one additional topic were considered to identify the best available evidence and to develop the recommendations using the Evidence-to-Decision framework according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. For each recommendation, the level of evidence, the strength of the recommendation, the benefits, the harms and the risks, the benefit/harm balance, the intentional vagueness, the values judgement, the exclusions, the difference of the opinions, the knowledge gaps, and the research opportunities were reported. The panel produced 17 recommendations. Nine were evaluated as strong, 3 as moderate, and 5 as weak. Conclusion: a panel of national experts achieved consensus regarding recommendations for the best care in terms of analgesia and sedation in critically ill children.
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16
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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17
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Buang SNH, Loh SW, Mok YH, Lee JH, Chan YH. Palliative and Critical Care: Their Convergence in the Pediatric Intensive Care Unit. Front Pediatr 2022; 10:907268. [PMID: 35757116 PMCID: PMC9226486 DOI: 10.3389/fped.2022.907268] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
Palliative care (PC) is an integral component of optimal critical care (CC) practice for pediatric patients facing life-threatening illness. PC acts as an additional resource for patients and families as they navigate through critical illness. Although PC encompasses end of life care, it is most effective when integrated early alongside disease-directed and curative therapies. PC primarily focuses on improving quality of life for patients and families by anticipating, preventing and treating suffering throughout the continuum of illness. This includes addressing symptom distress and facilitating communication. Effective communication is vital to elicit value-based goals of care, and to guide parents through patient-focused and potentially difficult decision-making process which includes advanced care planning. A multidisciplinary approach is most favorable when providing support to both patient and family, whether it is from the psychosocial, practical, emotional, spiritual or cultural aspects. PC also ensures coordination and continuity of care across different care settings. Support for family carries on after death with grief and bereavement support. This narrative review aims to appraise the current evidence of integration of PC into pediatric CC and its impact on patient- and family-centered outcomes. We will also summarize the impact of integration of good PC into pediatric CC, including effective communication with families, advanced care planning, withholding or withdrawal of life sustaining measures and bereavement support. Finally, we will provide a framework on how best to integrate PC in PICU. These findings will provide insights on how PC can improve the quality of care of a critically ill child.
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Affiliation(s)
- Siti Nur Hanim Buang
- Pediatric Palliative Care Service, Department of Pediatric Subspecialities, KK Women's and Children's Hospital, Singapore, Singapore
| | - Sin Wee Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
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18
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Nicoll J, Dryden-Palmer K, Frndova H, Gottesman R, Gray M, Hunt EA, Hutchison JS, Joffe AR, Lacroix J, Middaugh K, Nadkarni V, Szadkowski L, Tomlinson GA, Wensley D, Parshuram CS, Farrell C. Death and Dying in Hospitalized Pediatric Patients: A Prospective Multicenter, Multinational Study. J Palliat Med 2021; 25:227-233. [PMID: 34847737 DOI: 10.1089/jpm.2021.0205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: For hospitalized children admitted outside of a critical care unit, the location, mode of death, "do-not-resuscitate" order (DNR) use, and involvement of palliative care teams have not been described across high-income countries. Objective: To describe location of death, patient and terminal care plan characteristics of pediatric inpatient deaths inside and outside the pediatric intensive care unit (PICU). Design: Secondary analysis of inpatient deaths in the Evaluating Processes of Care and Outcomes of Children in Hospital (EPOCH) randomized controlled trial. Setting/Subjects: Twenty-one centers from Canada, Belgium, the United Kingdom, Ireland, Italy, the Netherlands, and New Zealand. Measurement: Descriptive statistics were used to compare patient and terminal care plan characteristics. A multivariable generalized estimating equation examined if palliative care consult during hospital admission was associated with location of death. Results: A total of 365 of 144,539 patients enrolled in EPOCH died; 219 (60%) died in PICU and 143 (40%) died on another inpatient unit. Compared with other inpatient wards, patients who died in PICU were less likely to be expected to die, have a DNR or palliative care consult. Hospital palliative care consultation was more common in older children and independently associated with a lower adjusted odds (95% confidence interval) of dying in PICU [0.59 (0.52-0.68)]. Conclusion: Most pediatric inpatient deaths occur in PICU where patients were less likely to have a DNR or palliative care consult. Palliative care consultation could be better integrated into end-of-life care for younger children and those dying in PICU.
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Affiliation(s)
- Jessica Nicoll
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Janeway Children's Health and Rehabilitation Centre, Discipline of Pediatrics, Memorial University, St. John's Newfoundland and Labrador, Canada.,Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Karen Dryden-Palmer
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Helena Frndova
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronald Gottesman
- Department of Critical Care, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Martin Gray
- Pediatric Intensive Care, St. George's Hospital, Tooting, London, United Kingdom
| | - Elizabeth A Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - James S Hutchison
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jacques Lacroix
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada
| | - Kristen Middaugh
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leah Szadkowski
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
| | - George A Tomlinson
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David Wensley
- Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Chris S Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Farrell
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada
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19
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Grunauer M, Mikesell C, Bustamante G, Aronowitz D, Zambrano K, Icaza-Freire AP, Gavilanes AWD, Barrera R. Availability and Quality of Grief and Bereavement Care in Pediatric Intensive Care Units Around the World, Opportunities for Improvement. Front Pediatr 2021; 9:742916. [PMID: 34869100 PMCID: PMC8634722 DOI: 10.3389/fped.2021.742916] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/22/2021] [Indexed: 11/22/2022] Open
Abstract
Pediatric Intensive Care Units (PICUs) provide multidisciplinary care to critically ill children and their families. Grief is present throughout the trajectory of illness and can peak around the time of death or non-death losses. The objective of this study was to assess how PICUs around the world implement grief and bereavement care (GBC) as part of an integrated model of care. This is a multicenter cross-sectional, prospective survey study. Questionnaires with multiple-choice and open-ended questions focusing on unit infrastructure, personnel, policies, limited patient data, and practices related to GBC for families and health care professionals (HCPs) were completed by on-site researchers, who were HCPs on the direct care of patients. PICU fulfillment of GBC goals was evaluated using a custom scoring based on indicators developed by the Initiative for Pediatric Palliative Care (IPPC). We compared average total and individual items fulfillment scores according to the respective country's World Bank income. Patient characteristics and details of unit infrastructure were also evaluated as potential predictors of total GBC fulfillment scores. Statistical analysis included multilevel generalized linear models (GLM) with a Gaussian distribution adjusted by child age/gender and clustering by center, using high income countries (HICs) as the comparative reference. Additionally, we applied principals of content analysis to analyze and summarize open-ended answers to contextualize qualitative data. The study included 34 PICUs from 18 countries: high-income countries (HICs): 32.4%, upper middle-income countries (UMICs): 44.1%, low middle-income and low-income countries (LMI/LICs): 23.5%. All groups reported some compliance with GBC goals; no group reported perfect fulfillment. We found statistically significant differences in GBC fulfillment scores between HICs and UMICs (specifically, HCP grief support), and between HICs and LMICs (specifically, family grief support and HCP grief support). PICUs world-wide provide some GBC, independent of income, but barriers include lack of financial support, time, and training, overall unit culture, presence of a palliative care consultation service, and varying cultural perceptions of child death. Disparities in GBC for families and HCPs exist and were related to the native countries' income level. Identifying barriers to support families and HCPs, can lead to opportunities of improving GBC in PICUs world-wide.
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Affiliation(s)
- Michelle Grunauer
- School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador
- Pediatric Intensive Care Unit, Hospital de los Valles, Quito, Ecuador
| | - Caley Mikesell
- School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador
| | | | - Danielle Aronowitz
- Department of Surgery, Long Island Jewish Medical Center, Northwell/Hofstra University School of Medicine, New Hyde Park, NY, United States
| | - Kevin Zambrano
- School of Medicine, Universidad San Francisco de Quito, Quito, Ecuador
| | | | | | - Rafael Barrera
- Department of Surgery, Long Island Jewish Medical Center, Northwell/Hofstra University School of Medicine, New Hyde Park, NY, United States
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20
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Grunauer M, Mikesell C, Bustamante Callejas G. Primary palliative care integrated model in paediatric ICU: an international cross-sectional study. BMJ Support Palliat Care 2021:bmjspcare-2020-002627. [PMID: 34610910 DOI: 10.1136/bmjspcare-2020-002627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 08/25/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Numbers are rising of chronically and critically ill, technology-dependent children, who are admitted to paediatric intensive care units (PICUs). An integrated model of care (IMOC), that combines paediatric critical care and primary paediatric palliative care (PPC), in which either approach varies depending on the disease trajectory and is provided by the critical care team, might be a fundamental component of the best available standard of care for patients with life-threatening conditions. The objective of this study is to assess how PICUs around the world, implement an IMOC. METHODS International multicentre cross-sectional observational study. Data was gathered from 34 PICUs from 18 countries in the Americas, Europe, Asia and Africa. Provision of primary PPC was studied for each child admitted at the PICU. We evaluated score differences in each domain of the Initiative for Paediatric Palliative Care (IPPC) curriculum with multilevel generalised linear models. RESULTS High-income country (HIC) units made up 32.4% of the sample, upper-middle income countries (UMICs) 44.1%, lower-middle income/lower income countries (LMIC/LICs) 23.5%. HICs had four statistically significantly higher IPPC scores compared with UMICs (domains: 1 holistic care; 2 family support, 3B family involvement; 6B grief/bereavement healthcare provider support) and two compared with LMIC/LICs (domains: 6A grief/bereavement family support; 6B grief/bereavement healthcare provider support).HICs had a statistically significant overall higher IPPC score than UMICs. Adjusting for patient/centre characteristics, shorter shifts and multiple comorbidities were associated with higher IPPC scores. CONCLUSIONS All centres offered some PPC provision and partially applied an IMOC. These results are encouraging, however, differences related to income and patients/unit evidence opportunities for improvement. TRIAL REGISTRATION NUMBER ISRCTN12556149.
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Affiliation(s)
- Michelle Grunauer
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
| | - Caley Mikesell
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
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21
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Delgado-Corcoran C, Bennett EE, Bodily SA, Wawrzynski SE, Green D, Moore D, Cook LJ, Olson LM. Prevalence of specialised palliative care consultation for eligible children within a paediatric cardiac ICU. Cardiol Young 2021; 31:1458-1464. [PMID: 33597068 PMCID: PMC8547172 DOI: 10.1017/s1047951121000433] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Retrospectively apply criteria from Center to Advance Palliative Care to a cohort of children treated in a cardiac ICU and compare children who received a palliative care consultation to those who were eligible for but did not receive one. METHODS Medical records of children admitted to a cardiac ICU between January 2014 and June 2017 were reviewed. Selected criteria include cardiac ICU length of stay >14 days and/or ≥ 3 hospitalisations within a 6-month period. MEASUREMENTS AND RESULTS A consultation occurred in 17% (n = 48) of 288 eligible children. Children who received a consult had longer cardiac ICU (27 days versus 17 days; p < 0.001) and hospital (91 days versus 35 days; p < 0.001) lengths of stay, more complex chronic conditions at the end of first hospitalisation (3 versus1; p < 0.001) and the end of the study (4 vs.2; p < 0.001), and higher mortality (42% versus 7%; p < 0.001) when compared with the non-consulted group. Of the 142 pre-natally diagnosed children, only one received a pre-natal consult and 23 received it post-natally. Children who received a consultation (n = 48) were almost 2 months of age at the time of the consult. CONCLUSIONS Less than a quarter of eligible children received a consultation. The consultation usually occurred in the context of medical complexity, high risk of mortality, and at an older age, suggesting potential opportunities for more and earlier paediatric palliative care involvement in the cardiac ICU. Screening criteria to identify patients for a consultation may increase the use of palliative care services in the cardiac ICU.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Erin E Bennett
- Division of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital. 1 Children's Way, Little Rock, AR, 72202, USA
| | - Stephanie A Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Danielle Green
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, 84113, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, 84108, USA
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22
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Sabeti F, Mohammadpour M, Pouraboli B, Tahmasebi M, Hasanpour M. Health Care Providers' Experiences of the Non-Pharmacological Pain and Anxiety Management and Its Barriers in the Pediatric Intensive Care Units. J Pediatr Nurs 2021; 60:e110-e116. [PMID: 34412932 DOI: 10.1016/j.pedn.2021.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Children in the intensive care unit experience a high level of pain and anxiety. This study aimed to reveal the health care providers experience of non-pharmacological pain and anxiety management and its barriers in the pediatric intensive care unit. METHODS This qualitative-descriptive study was conducted with thirteen nurses and five physicians in the pediatric intensive care unit in Iran. Individual, in-depth and semi-structured interviews were conducted, which were analyzed by conventional content analysis. RESULTS Five main categories were identified from data analysis: 1) The importance of parents' presence, 2) Disturbance in the presence of parents and communication during the COVID-19 pandemic, 3) Choosing non-pharmacological approaches according to the child's interests and conditions, 4) Building trust in the child through non-pharmacological interventions 5) Barriers to non-pharmacological pain and anxiety management in the pediatric intensive care unit. CONCLUSION Health care providers implement some non-pharmacological methods to manage pain and anxiety in the pediatric intensive care unit. Facilitating the open presence of parents, using innovative methods to communicate with children, and training and psychological support for nurses and parents, especially during the COVID-19 pandemic are recommended.
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Affiliation(s)
- Fahimeh Sabeti
- Pediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Iran
| | - Masoud Mohammadpour
- Pediatric Intensivist, Pediatric Critical Care Division, Departement of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Iran
| | - Batool Pouraboli
- Pediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Iran
| | - Mamak Tahmasebi
- Palliative Medicine Fellowship, Radiotherapy/Oncology Department, Palliative Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran
| | - Marzieh Hasanpour
- Member of Iranian Scientific Association of Medical Education. Pediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Iran.
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23
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Hasanpour M, Pouraboli B, Mohammadpour M, Tahmasebi M, Sabeti F. Challenges of paediatric palliative care in the intensive care unit during the COVID-19 pandemic. Int J Palliat Nurs 2021; 27:303-315. [PMID: 34459244 DOI: 10.12968/ijpn.2021.27.6.303] [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: 11/11/2022]
Abstract
BACKGROUND The integration of paediatric palliative care into the Iranian health system is essential. AIMS The aim of this study was to identify the challenges of palliative care in the paediatric intensive care unit during COVID-19 through the experiences of healthcare providers. METHODS A qualitative study with content analysis approach was conducted. Fifteen physicians and nurses were selected by purposeful sampling. The semi-structured, in-depth interviews were applied in the data collection. FINDINGS Ten main categories were extracted from data analysis, including 'caring in COVID-19', 'communication and family centre care', 'breaking bad news', palliative care training', 'pain and symptom management', 'support of the child, family and clinical team', 'physical environment', 'guidelines', 'specialised staff' and 'home based palliative care'. CONCLUSION Palliative care in the PICU faces several challenges, especially during COVID-19, but the clinical team are making every attempt to improve the comprehensive care of children and their families. Telehealth is important in COVID-19, and education is also a key component to improve palliative care in the PICU in Iran.
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Affiliation(s)
- Marzieh Hasanpour
- Professor of Nursing, NIDCAP Professional, Member of Iranian Scientific Association of Medical Education, International Coordinator of Paediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Batool Pouraboli
- Associate Professor of Nursing, Paediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Mohammadpour
- Assistant Professor, Paediatric Intensivist, Paediatric Critical Care Division, Department of Paediatrics, Children's Medical Centre, Tehran University of Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Mamak Tahmasebi
- Associate Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, School of Medicine, Cancer Institute, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahimeh Sabeti
- Nursing Candidate, Paediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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25
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Variation in Pediatric Palliative Care Allocation Among Critically Ill Children in the United States. Pediatr Crit Care Med 2021; 22:462-473. [PMID: 33116070 DOI: 10.1097/pcc.0000000000002603] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The objectives are as follows: 1) estimate palliative care consult rates and trends among critically ill children and 2) characterize which children receive palliative care consults, including those meeting previously proposed ICU-specific palliative care screening criteria. DESIGN Retrospective cohort. SETTING Fifty-two United States children's hospitals participating in the Pediatric Health Information Systems database. PATIENTS Hospitalized children with nonneonatal ICU admissions from 2007 to 2018. MEASUREMENTS AND MAIN RESULTS The primary outcome was palliative care consultation, as identified by the palliative care International Classification of Disease code. Patient characteristics and outcomes were compared between those with and without palliative care. We used a mixed-effects multivariable model to estimate the independent association between the palliative care and patient characteristics accounting for institution and subject clustering. Hospitalizations were categorized into three mutually exclusive groups for comparative analyses: 1) meeting ICU-specific palliative care criteria, 2) presence of a complex chronic condition not in ICU-specific palliative care criteria, or 3) not meeting ICU-specific palliative care or complex chronic condition criteria. Rates and trends of palliative care consultation were estimated including variation among institutions and variation among subcategories of ICU-specific palliative care criteria. The study cohort included 740,890 subjects with 1,024,666 hospitalizations. About 1.36% of hospitalizations had a palliative care consultation. Palliative care consult was independently associated with older age, female sex, government insurance, inhospital mortality, and ICU-specific palliative care or complex chronic condition criteria. Among the hospitalizations, 30% met ICU-specific palliative care criteria, 40% complex chronic condition criteria, and 30% neither. ICU-specific palliative care patients received more mechanical ventilation and cardiopulmonary resuscitation, had longer hospital and ICU lengths of stay, and had higher inhospital mortality (p < 0.001). Palliative care utilization increased over the study period with considerable variation between the institutions especially in the ICU-specific palliative care cohort and its subgroups. CONCLUSIONS Palliative care consultation for critically ill children in the United States is low. Palliative care utilization is increasing but considerable variation exists across institutions, suggesting inequity in palliative care allocation among this vulnerable population. Future studies should evaluate factors influencing allocation of palliative care among critically ill children in the United States and the drivers of differences between the institutional practices.
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Aziz KB, Boss RD, Yarborough CC, Raisanen JC, Neubauer K, Donohue PK. Intensity of Vasopressor Therapy and In-Hospital Mortality for Infants and Children: An Opportunity for Counseling Families. J Pain Symptom Manage 2021; 61:763-769. [PMID: 32942009 DOI: 10.1016/j.jpainsymman.2020.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Abstract
CONTEXT Most pediatric deaths occur in an intensive care unit, and treatment specific predictors of mortality could help clinicians and families make informed decisions. OBJECTIVE To investigate whether the intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, predicts in-hospital mortality. METHODS Single-center, retrospective medical chart review of children aged 0-17 who were admitted between 2005 and 2015 at a pediatric tertiary care center in the U.S. and received any vasopressor medication-dopamine, dobutamine, epinephrine, vasopressin, norepinephrine, or hydrocortisone. RESULTS During the 10-year period, 1654 patients received at least one vasopressor medication during a hospitalization. Median age at the time of hospitalization was three months, and the median duration of hospitalization was 23 days; 8% of patients had two to five hospitalizations in which they received vasopressors. There were 176 total patients who died while receiving vasopressors; most (93%) died during their first hospitalization. The most common diagnosis was sepsis (34%), followed by congenital heart disease (17%). Dopamine was the most commonly prescribed first-line vasopressor (70%), and hydrocortisone was the most commonly prescribed second-line vasopressor (49%) for all pediatric patients. The incidence of mortality rose sequentially with escalating vasopressor support, increasing from under 10% with the first vasopressor to 48% at the maximum number of agents. The odds of death almost doubled with the addition of each new vasopressor. CONCLUSIONS The intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, is associated with in-hospital mortality; vasopressor escalation should trigger intensive palliative care supports.
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Affiliation(s)
- Khyzer B Aziz
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Renee D Boss
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA
| | | | | | - Kathryn Neubauer
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pamela K Donohue
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Moynihan KM, Heith CS, Snaman JM, Smith-Parrish M, Bakas A, Ge S, Cerqueira AV, Bailey V, Beke D, Wolfe J, Morell E, Gauvreau K, Blume ED. Palliative Care Referrals in Cardiac Disease. Pediatrics 2021; 147:peds.2020-018580. [PMID: 33579811 DOI: 10.1542/peds.2020-018580] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES With evidence of benefits of pediatric palliative care (PPC) integration, we sought to characterize subspecialty PPC referral patterns and end of life (EOL) care in pediatric advanced heart disease (AHD). METHODS In this retrospective cohort study, we compared inpatient pediatric (<21 years) deaths due to AHD in 2 separate 3-year epochs: 2007-2009 (early) and 2015-2018 (late). Demographics, disease burden, medical interventions, mode of death, and hospital charges were evaluated for temporal changes and PPC influence. RESULTS Of 3409 early-epoch admissions, there were 110 deaths; the late epoch had 99 deaths in 4032 admissions. In the early epoch, 45 patients (1.3% admissions, 17% deaths) were referred for PPC, compared with 146 late-epoch patients (3.6% admissions, 58% deaths). Most deaths (186 [89%]) occurred in the cardiac ICU after discontinuation of life-sustaining therapy (138 [66%]). Medical therapies included ventilation (189 [90%]), inotropes (184 [88%]), cardiopulmonary resuscitation (68 [33%]), or mechanical circulatory support (67 [32%]), with no temporal difference observed. PPC involvement was associated with decreased mechanical circulatory support, ventilation, inotropes, or cardiopulmonary resuscitation at EOL, and children were more likely to be awake and be receiving enteral feeds. PPC involvement increased advance care planning, with lower hospital charges on day of death and 7 days before (respective differences $5058 [P = .02] and $25 634 [P = .02]). CONCLUSIONS Pediatric AHD deaths are associated with high medical intensity; however, children with PPC consultation experienced substantially less invasive interventions at EOL. Further study is warranted to explore these findings and how palliative care principles can be better integrated into care.
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Affiliation(s)
- Katie M Moynihan
- Departments of Cardiology and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Catherine S Heith
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jennifer M Snaman
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Melissa Smith-Parrish
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Anna Bakas
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Valerie Bailey
- Cardiovascular and Critical Care Nursing Patient Services and
| | - Dorothy Beke
- Cardiovascular and Critical Care Nursing Patient Services and
| | - Joanne Wolfe
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Emily Morell
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Kimberlee Gauvreau
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elizabeth D Blume
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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O'Keefe S, Czaja AS. Validation of Administrative Codes for Palliative Care Consultation Among Critically Ill Children. Hosp Pediatr 2021; 11:179-182. [PMID: 33509843 DOI: 10.1542/hpeds.2020-001263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To determine the validity of palliative care (PC) administrative codes (V66.7 and Z51.5) among critically ill pediatric patients. METHODS In this single-center retrospective cohort study, we included all hospitalizations with a PICU admission between March 2016 and March 2018. Sensitivity, specificity, and positive and negative predictive values of the relevant codes were estimated by using a gold standard of a local PC registry. RESULTS During the study period, 4670 hospitalizations were included. The median admission age was 5 years (interquartile range 1.5-12.9) with 55% having at least 1 complex chronic condition. The median length of PICU stay was 1.8 days (interquartile range 1-3.4) and mortality was low (1.3%). A total 182 (3.9%) hospitalizations had evidence of a PC consultation. Administrative codes for PC had a sensitivity of 11% (95% confidence interval [CI] 6.8%-16.5%) and a specificity of 99.8% (95% CI 99.6%-99.9%). The positive and negative predictive values were 66.7% (95% CI 47.2%-82.7%) and 96.5% (95% CI 95.9%-97.0%), respectively. CONCLUSIONS Among critically ill children, PC administrative codes had high specificity but poor sensitivity. The potential for underascertainment of this resource should be considered in future research using administrative data.
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Affiliation(s)
- Siobhán O'Keefe
- Department of Paediatric Critical Care, Children's Health Ireland, Dublin, Ireland; and
| | - Angela S Czaja
- Section of Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
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Grandjean C, Ullmann P, Marston M, Maitre MC, Perez MH, Ramelet AS. Sources of Stress, Family Functioning, and Needs of Families With a Chronic Critically Ill Child: A Qualitative Study. Front Pediatr 2021; 9:740598. [PMID: 34805041 PMCID: PMC8600118 DOI: 10.3389/fped.2021.740598] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022] Open
Abstract
PICU hospitalization is particularly stressful for families. When it is prolonged and the prognostic is uncertain, it can significantly and negatively affect the whole family. To date, little is known on how families with a chronic critically ill (CCI) child are affected. This national study explored the specific PICU-related sources of stress, family functioning and needs of families of CCI patients during a PICU hospitalization. This descriptive qualitative study was conducted in the eight pediatric intensive care units in Switzerland. Thirty-one families with a child meeting the CCI criteria participated in semi-structured interviews. Interviews, including mothers only (n = 12), fathers only (n = 8), or mother and father dyads (n = 11), were conducted in German, French, or English by two trained researchers/clinical nurses specialists. Interviews were recorded, transcribed verbatim, and analyzed using deductive and inductive content analyses. Five overarching themes emerged: (1) high emotional intensity, (2) PICU-related sources of stress, (3) evolving family needs, (4) multi-faceted family functioning, and (5) implemented coping strategies. Our study highlighted the importance of caring for families with CCI children. Parents reported high negative emotional responses that affect their family functioning. Families experience was highly dependent on how HCPs were able to meet the parental needs, provide emotional support, reinforce parental empowerment, and allow high quality of care coordination.
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Affiliation(s)
- Chantal Grandjean
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Pascale Ullmann
- School of Healthcare, University of Applied Sciences and Arts, Fribourg, Switzerland
| | - Mark Marston
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland.,University Children's Hospital Basel, Basel, Switzerland
| | - Marie-Christine Maitre
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
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Miles AH, Turnbull AE, Sterni LM. The importance of advance care planning for children with chronic respiratory failure. Pediatr Pulmonol 2020; 55:2489-2491. [PMID: 32776702 PMCID: PMC7719584 DOI: 10.1002/ppul.24979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 07/08/2020] [Accepted: 07/21/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Alison H Miles
- Division of Pediatric Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, Maryland
| | - Laura M Sterni
- Eudowood Division of Pediatric Respiratory Sciences, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Interdisciplinary Communication: Documentation of Advance Care Planning and End-of-Life Care in Adolescents and Young Adults With Cancer. J Hosp Palliat Nurs 2020; 21:215-222. [PMID: 30829829 DOI: 10.1097/njh.0000000000000512] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Advance care planning is being increasingly recognized as a component of quality in end-of-life care, but standardized documentation in the electronic health record has not yet been achieved, undermining interdisciplinary communication about care needs and limiting research opportunities.We examined the electronic health records of nine adolescent and young adults with cancer who died after participation in an advance care planning clinical trial (N = 30). In this secondary analysis of this subgroup, disease trajectory and end-of-life information were abstracted from the electronic health record, and treatment preferences from the original study were obtained.All deceased participants older than 18 years had a surrogate decision maker identified in the electronic health record, and all deceased participants had limitations placed on their care, varying from 1.5 hours up to 2 months before death. However, assessment of relations between treatment preferences and end-of-life care was difficult and revealed the presence of circumstances that advance care planning is designed to avoid, such as family conflict. Lack of an integrated health care record regarding advance care planning and end-of-life care makes both care coordination and examination of the association between planning and goal concordant care more difficult.
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Giannini A. Clinical ethics at bedside in Intensive Care Unit: what difference does ethics consultation make? Minerva Anestesiol 2020; 86:598-600. [DOI: 10.23736/s0375-9393.20.14546-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW Children with medical or surgical critical illness or injury require skillful attention to physical, emotional, psychological, and spiritual needs, whereas their families need support and guidance in facing life-threatening or life-changing events and gut-wrenching decisions. This article reviews current evidence and best practices for integrating palliative care into the pediatric intensive care unit (PICU), with a focus on surgical patients. RECENT FINDINGS Palliative care is best integrated in a tiered approach, with primary palliative care provided by the PICU and surgical providers for all patients and families, including basic symptom management, high-quality communication, and end-of-life care. Secondary and tertiary levels of care involve unit or team-based 'champions' with additional expertise, and subspecialty palliative care teams, respectively. PICU and surgical providers should be able to provide primary palliative care, to identify patients and families for whom a palliative care consult would be helpful, and should be comfortable introducing the concept of palliative care to families. SUMMARY This review provides a framework and tools to enable PICU and surgical providers to integrate palliative care best practices into patient and family care.
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Comparison of End-of-Life Care Practices Between Children With Complex Chronic Conditions and Neonates Dying in an ICU Versus Non-ICUs: A Substudy of the Pediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) Project. Pediatr Crit Care Med 2020; 21:e236-e246. [PMID: 32091504 DOI: 10.1097/pcc.0000000000002259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe and compare characteristics of care provided at the end of life for children with chronic complex conditions and neonates who died in an ICU with those who died outside an ICU. DESIGN Substudy of a nation-wide retrospective chart review. SETTING Thirteen hospitals, including 14 pediatric and neonatal ICUs, two long-term institutions, and 10 community-based organizations in the three language regions of Switzerland. PATIENTS One hundred forty-nine children (0-18 yr) who died in the years 2011 or 2012. Causes of death were related to cardiac, neurologic, oncological, or neonatal conditions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and clinical characteristics, therapeutic procedures, circumstances of death, and patterns of decisional processes were extracted from the medical charts. Ninety-three (62%) neonates (median age, 4 d) and children (median age, 23 mo) died in ICU, and 56 (38%) with a median age of 63 months outside ICU. Generally, ICU patients had more therapeutic and invasive procedures, compared with non-ICU patients. Changes in treatment plan in the last 4 weeks of life, such as do-not-resuscitate orders occurred in 40% of ICU patients and 25% of non-ICU patients (p < 0.001). In the ICU, when decision to withdraw life-sustaining treatment was made, time to death in children and newborns was 4:25 and 3:00, respectively. In institutions where it was available, involvement of specialized pediatric palliative care services was recorded in 15 ICU patients (43%) and in 18 non-ICU patients (78%) (p = 0.008). CONCLUSIONS This nation-wide study demonstrated that patients with a complex chronic condition who die in ICU, compared with those who die outside ICU, are characterized by fast changing care situations, including when to withdraw life-sustaining treatment. This highlights the importance of early effective communication and shared decision making among clinicians and families.
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Abstract
OBJECTIVES Describe pediatric palliative care consult in children with heart disease; retrospectively apply Center to Advance Palliative Care criteria for pediatric palliative care consults; determine the impact of pediatric palliative care on end of life. DESIGN A retrospective single-center study. SETTING A 16-bed cardiac ICU in a university-affiliated tertiary care children's hospital. PATIENTS Children (0-21 yr old) with heart disease admitted to the cardiac ICU from January 2014 to June 2017. MEASUREMENTS AND MAIN RESULTS Over 1,000 patients (n = 1, 389) were admitted to the cardiac ICU with 112 (8%) receiving a pediatric palliative care consultation. Patients who received a consult were different from those who did not. Patients who received pediatric palliative care were younger at first hospital admission (median 63 vs 239 d; p = 0.003), had a higher median number of complex chronic conditions at the end of first hospitalization (3 vs 1; p < 0.001), longer cumulative length of stay in the cardiac ICU (11 vs 2 d; p < 0.001) and hospital (60 vs 7 d; p < 0.001), and higher mortality rates (38% vs 3%; p < 0.001). When comparing location and modes of death, patients who received pediatric palliative care were more likely to die at home (24% vs 2%; p = 0.02) and had more comfort care at the end of life (36% vs 2%; p = 0.002) compared to those who did not. The Center to Advance Palliative Care guidelines identified 158 patients who were eligible for pediatric palliative care consultation; however, only 30 patients (19%) in our sample received a consult. CONCLUSIONS Pediatric palliative care consult rarely occurred in the cardiac ICU. Patients who received a consult were medically complex and experienced high mortality. Comfort care at the end of life and death at home was more common when pediatric palliative care was consulted. Missed referrals were apparent when Center to Advance Palliative Care criteria were retrospectively applied.
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Is It Time to Move Beyond Observational Studies of the Epidemiology and Mode of PICU Deaths? Pediatr Crit Care Med 2020; 21:505-506. [PMID: 32358336 DOI: 10.1097/pcc.0000000000002262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Menon AP, Mok YH, Loh LE, Lee JH. Pediatric Palliative Transport in Critically Ill Children: A Single Center's Experience and Parents' Perspectives. J Pediatr Intensive Care 2019; 9:99-105. [PMID: 32351763 DOI: 10.1055/s-0039-3401009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 11/03/2019] [Indexed: 12/29/2022] Open
Abstract
The transfer of critically ill children from intensive care units (ICUs) to their homes for palliation is seldom described. We report our 10-year pediatric palliative transport experience and conducted a survey to gain parents' perspectives of their child's transport experience. Over the study period, eight patients were transported from our pediatric ICU to their homes or hospice facilities. There were no intratransport adverse events. Parents who participated in the survey responded positively to the transport experience. The availability of a dedicated critical care transport service allowed for palliative transfers to be performed safely. Facilitating transport to allow withdrawal of life support at home is an acceptable option to families as part of holistic end-of-life care.
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Affiliation(s)
- Anuradha P Menon
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Lik Eng Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore.,Children's Hospital Emergency Transport Service, KK Women's and Children's Hospital, Singapore, Singapore
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Polito A, Combescure C, Levy-Jamet Y, Rimensberger P. Long-stay patients in pediatric intensive care unit: Diagnostic-specific definition and predictors. PLoS One 2019; 14:e0223369. [PMID: 31577836 PMCID: PMC6774522 DOI: 10.1371/journal.pone.0223369] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/19/2019] [Indexed: 11/30/2022] Open
Abstract
Aims To stipulate a new definition for long-stay patients (LSPs) in pediatric intensive care unit (PICU). We defined LSPs as the 10% of patients with the longest PICU length-of-stay (LOS) for each age and diagnostic group. To assess whether the thresholds (days of PICU stay) for the definition of LSPs in PICU significantly differ among diagnostic and age categories. To determine whether independent associations exist between patients’ characteristics at admission and LSPs diagnosis in pre-specified diagnostic and age groups. Methods This was a multicenter retrospective cohort study including all PICUs in Switzerland. Multivariable regression analysis was used to seek for association between patients’ variables at admission and LSPs Results We included 22,284 patients with a median (IQR) age of 12 (1–84) months. Significantly different thresholds across diagnostic and age subgroups are identified. Readmission to PICU, higher PIM2 and NEMS (a score used to quantify nursing workload at intensive care unit level) at admission were associated with higher likelihood of becoming LSPs. Conclusions Our results showed a significantly different definitions of LSPs for specific diagnoses and age categories. Readmission to PICU and higher acuity at admission are associated with longer PICU length-of-stay in the majority of diagnostic groups. A more personalized definition of LSPs in children based on actual patients’ characteristics should probably be used in an effort to optimize care and reduce costs.
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Affiliation(s)
- Angelo Polito
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
- * E-mail:
| | - Christophe Combescure
- Division of Clinical Epidemiology, Faculty of Medicine, University of Geneva, and Geneva University Hospitals, Geneva, Switzerland
| | - Yann Levy-Jamet
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Peter Rimensberger
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
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Moynihan KM, Snaman JM, Kaye EC, Morrison WE, DeWitt AG, Sacks LD, Thompson JL, Hwang JM, Bailey V, Lafond DA, Wolfe J, Blume ED. Integration of Pediatric Palliative Care Into Cardiac Intensive Care: A Champion-Based Model. Pediatrics 2019; 144:peds.2019-0160. [PMID: 31366685 PMCID: PMC6855829 DOI: 10.1542/peds.2019-0160] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 01/04/2023] Open
Abstract
Integration of pediatric palliative care (PPC) into management of children with serious illness and their families is endorsed as the standard of care. Despite this, timely referral to and integration of PPC into the traditionally cure-oriented cardiac ICU (CICU) remains variable. Despite dramatic declines in mortality in pediatric cardiac disease, key challenges confront the CICU community. Given increasing comorbidities, technological dependence, lengthy recurrent hospitalizations, and interventions risking significant morbidity, many patients in the CICU would benefit from PPC involvement across the illness trajectory. Current PPC delivery models have inherent disadvantages, insufficiently address the unique aspects of the CICU setting, place significant burden on subspecialty PPC teams, and fail to use CICU clinician skill sets. We therefore propose a novel conceptual framework for PPC-CICU integration based on literature review and expert interdisciplinary, multi-institutional consensus-building. This model uses interdisciplinary CICU-based champions who receive additional PPC training through courses and subspecialty rotations. PPC champions strengthen CICU PPC provision by (1) leading PPC-specific educational training of CICU staff; (2) liaising between CICU and PPC, improving use of support staff and encouraging earlier subspecialty PPC involvement in complex patients' management; and (3) developing and implementing quality improvement initiatives and CICU-specific PPC protocols. Our PPC-CICU integration model is designed for adaptability within institutional, cultural, financial, and logistic constraints, with potential applications in other pediatric settings, including ICUs. Although the PPC champion framework offers several unique advantages, barriers to implementation are anticipated and additional research is needed to investigate the model's feasibility, acceptability, and efficacy.
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Affiliation(s)
- Katie M. Moynihan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
| | - Jennifer M. Snaman
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Erica C. Kaye
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Wynne E. Morrison
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Aaron G. DeWitt
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Loren D. Sacks
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Jess L. Thompson
- Department of Cardiothoracic Surgery, Children’s Heart Center, University of Oklahoma, Oklahoma City, Oklahoma; and
| | - Jennifer M. Hwang
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Pediatrics, Perelman School of Medicine, The University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Valerie Bailey
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts
| | - Deborah A. Lafond
- PANDA Palliative Care Team, Children’s National and School of Medicine, The George Washington University, Washington, District of Columbia
| | - Joanne Wolfe
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth D. Blume
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
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The role of the neuropediatrician in pediatric intensive care unit: Diagnosis, therapeutics and major participation in collaborative multidisciplinary deliberations about life-sustaining treatments' withdrawal. Eur J Paediatr Neurol 2019; 23:171-180. [PMID: 30262235 DOI: 10.1016/j.ejpn.2018.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/03/2018] [Accepted: 09/04/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND In Pediatric Intensive Care Unit (PICU) two types of population require the intervention of neuropediatricians (NP): chronic brain diseases' patients who face repetitive and prolonged hospitalizations, and patients with acute brain failure facing the risk of potential neurologic sequelae, and both conditions may result in a limitation of life-sustaining treatments (LLST) decision. OBJECTIVE To assess NP's involvement in LLST decisions within the PICU of a tertiary hospital. METHOD Retrospective study of medical reports of patients hospitalized during 2014 in the Necker-Hospital PICU. Patients were selected using keywords ("cardiorespiratory arrest", "death", "withdrawal of treatment", "palliative care", "acute brain failure", or "chronic neurological disease"), and/or if they were assessed by a NP during the hospitalization. Demographic and medical data were analysed, including the NP's assessment and data about Collaborative Multidisciplinary Deliberation (CMD) to discuss potential LLST. RESULTS Among 1160 children, 274 patients were included and 142 (56%) were assessed by a NP during their hospitalization for diagnosis (n = 55) and/or treatment (n = 95) management. NP was required for 59%-100% of patients with neurological acute failure, and for 14-44% of patients with extra neurological failure. A LLST decision was taken after a CMD for 27 (9.8%) of them, and a NP was involved in 19/27 (70%) of these decisions that occurred during the hospitalization (n = 19) or before (n = 8).12 patients died thereafter the LLST decision (40% of the 30 dead patients). CONCLUSION NP are clearly involved in the decision-process of LLST for patients admitted in PICU, claiming for close collaboration to improve current practices and the quality of the care provided to children.
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de Saint Blanquat L, Viallard ML. Réflexions éthiques et démarche palliative intégrée dans les réanimations pédiatriques françaises en 2017. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
En réanimation pédiatrique, 40 % des décès surviennent à la suite d’une décision de limitation ou d’arrêt de traitement (LAT). Ces situations sont sources de questionnements éthiques complexes au sein de l’équipe soignante. La législation française et les recommandations des sociétés savantes donnent un cadre aux réanimateurs pédiatres pour les prises de décisions de LAT. Les enquêtes de pratiques nous montrent qu’ils se sont approprié certains éléments de la procédure collégiale comme la nécessité de la concertation pluriprofessionnelle, l’information et la communication avec les parents. Néanmoins, certains points tels que la présence du consultant, la réalité de la collégialité avec l’expression de toutes les personnes soignantes présentes sont encore insuffisamment appliqués. La place des parents dans les décisions doit être également réfléchie. La collaboration entre les équipes de réanimation pédiatrique et de médecine palliative est une possibilité pour améliorer sensiblement la qualité des soins et de l’accompagnement proposés. Cette collaboration élargit également les possibilités de la réflexion éthique nécessaire dans les situations de fin de vie complexes. L’intégration dans l’enseignement de la réanimation des principes de la médecine palliative est en cours de réflexion.
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Lazzarin P, Marinelli E, Orzalesi M, Brugnaro L, Benini F. Rights of the Dying Child: The Nurses' Perception. J Palliat Med 2018; 21:1713-1717. [PMID: 30256694 DOI: 10.1089/jpm.2017.0660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIM The Charter of the Rights of the Dying Child was formulated as a professional guide for caring the child in the final stages. The study examines the nurses' degree of agreement with the Charter's principles and their perception of the implementation of those principles in hospital. MATERIALS AND METHODS A multicenter, cross-sectional study to observe the nurses' positions about the 10 rights outlined in the Charter, using an online questionnaire in 5 pediatric hospitals in northern Italy. RESULTS A total of 119 nurses (44.9%) completed the questionnaire. The majority (range: 86.6-100%) expressed their agreement with the Charter's principles (Likert ≥4). Lower ratings were reported in Charter's principles implementation items (range: 42.9-89.1%). Being older and working in a smaller hospital lead the nurses to overlook the child's right to be informed and to be given the opportunity to make decisions about his/her own life and death (p = 0.02, p < 0.01). Postgraduate training induced greater awareness of the dying child (p = 0.01). CONCLUSIONS This study highlights the value of the Charter of the Rights of the Dying Child as a reference guideline for nurses working in pediatric hospitals. Better training is important to improve the nurse's communication skills and the pediatric palliative care should be offered to all families that have a child with incurable disease mostly in the end of life.
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Affiliation(s)
- Pierina Lazzarin
- 1 Veneto Regional Center for Pediatric Palliative Care and Pain Control, Department of Women's and Children's Health, Padua General Hospital , Padua, Italy
| | - Elena Marinelli
- 2 Pediatric Intensive Care Unit, Department of Women's and Children's Health, Padua General Hospital , Padua, Italy
| | - Marcello Orzalesi
- 3 Fondazione Maruzza Lefebvre D'Ovidio Onlus (Maruzza Foundation) , Rome, Italy
| | - Luca Brugnaro
- 4 Education and Training Department, Padua General Hospital , Padua, Italy
| | - Franca Benini
- 1 Veneto Regional Center for Pediatric Palliative Care and Pain Control, Department of Women's and Children's Health, Padua General Hospital , Padua, Italy
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Abstract
OBJECTIVES To describe important considerations during the process of caring for critically ill children who may be potential organ donors and supporting the family during the death of their child. DESIGN Literature review and expert commentary. MEASUREMENT AND MAIN RESULTS Medical literature focusing on pediatric donation, best pediatric donation practices, donor management, and factors influencing donation were reviewed. Additional pediatric data were obtained and reviewed from the U.S. Organ Procurement and Transplantation Network. Achieving successful organ donation requires the coordinated efforts of the critical care team, organ donation organization, and transplant team to effectively manage a potential donor and recover suitable organs for transplantation. Collaboration between these teams is essential to ensure that all potential organs are recovered in optimal condition, to reduce death and morbidity in children on transplantation waiting lists as well as fulfilling the family's wishes for their dying child to become a donor. CONCLUSIONS Organ donation is an important component of end-of-life care and can help the healing process for families and medical staff following the death of a child. The process of pediatric organ donation requires healthcare providers to actively work to preserve the option of donation before the death of the child and ensure donation occurs after consent/authorization has been obtained from the family. Medical management of the pediatric organ donor requires the expertise of a multidisciplinary medical team skilled in the unique needs of caring for children after neurologic determination of death and those who become donors following circulatory death after withdrawal of life-sustaining medical therapies.
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Abstract
OBJECTIVES To propose a model describing levels of integration of palliative care into the care of ICU patients. DATA SOURCES Literature review and author opinion. CONCLUSIONS All critical care team members should demonstrate and foster their core competencies in caring for patients with complex illness and uncertain prognosis, including at the end of life. We describe these core competencies of the ICU team member as "primary" palliative care skills. Some ICU team members will have special expertise in end-of-life care or symptom management and decision-making support and will serve as local experts within the ICU team as a resource to other team members. We call this skillset "secondary" palliative care. Some patients will benefit from the full range of expertise provided by a separate consulting team, with additional training, focused on caring for patients with palliative care needs across the full spectrum of patient locations within a health system. We term the skillset provided by such outside consultants "tertiary" palliative care. Solutions for meeting patients' palliative care needs will be unique within each system and individual institution, depending on available resources, history, and structures in place. Providers from multiple professions will usually contribute to meeting patient needs.
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Nguyen LT, Cooperberg DB, Spear ML. Introduction of triggers for palliative care consultation improves utilization and satisfaction within a level four NICU. J Perinatol 2018; 38:574-579. [PMID: 29740184 DOI: 10.1038/s41372-018-0067-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/19/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We sought to explore the beliefs regarding palliative care team utilization, as well as increase consultation and awareness of the palliative care team's role in the NICU. STUDY DESIGN The study design in this Level 4 NICU included observational time series with multiple planned sequential interventions. Medical chart review was conducted to determine eligibility, and statistical process control charts were used to show performance over time. RESULTS Prior to implementation of the triggers, 26% received consultation, which increased to 46% after implementation. There was an increase in level of understanding, knowledge of team's role, and improved utilization. The time until initial consultation decreased from ~1.5 months to 1 week. CONCLUSIONS We observed a 20% increase in consultations. Key interventions included continual education, reminders, and clear postage of the trigger list. Written guidelines increase awareness of a palliative care team's role within a NICU, and provider satisfaction.
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Affiliation(s)
- Linda T Nguyen
- Pediatrics, Drexel University of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA.
| | - David B Cooperberg
- Pediatrics, Drexel University of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Michael L Spear
- Pediatrics, Drexel University of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA, USA
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Grunauer M, Mikesell C. A Review of the Integrated Model of Care: An Opportunity to Respond to Extensive Palliative Care Needs in Pediatric Intensive Care Units in Under-Resourced Settings. Front Pediatr 2018; 6:3. [PMID: 29410951 PMCID: PMC5787068 DOI: 10.3389/fped.2018.00003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/08/2018] [Indexed: 01/27/2023] Open
Abstract
It is estimated that 6.3 million children who die annually need pediatric palliative care (PPC) and that only about 10% of them receive the attention they need because about 98% of them live in under-resourced settings where PPC is not accessible. The consultative model and the integrated model of care (IMOC) are the most common strategies used to make PPC available to critically ill children. In the consultative model, the pediatric intensive care unit (PICU) team, the patient, or their family must request a palliative care (PC) consultation with the external PC team for a PICU patient to be evaluated for special care needs. While the consultation model has historically been more popular, issues related to specialist availability, referral timing, staff's personal biases, misconceptions about PC, and other factors may impede excellent candidates from receiving the attention they need in a timely manner. Contrastingly, in the IMOC, family-centered care, PC tasks, and/or PC are a standard part of the treatment automatically available to all patients. In the IMOC, the PICU team is trained to complete critical and PC tasks as a part of normal daily operations. This review investigates the claim that the IMOC is the best model to meet extensive PPC needs in PICUs, especially in low-resource settings; based on an extensive review of the literature, we have identified five reasons why this model may be superior. The IMOC appears to: (1) improve the delivery of PPC and pediatric critical care, (2) allow clinicians to better respond to the care needs of patients and the epidemiological realities of their settings in ways that are consistent with evidence-based recommendations, (3) facilitate the universal delivery of care to all patients with special care needs, (4) maximize available resources, and (5) build local capacity; each of these areas should be further researched to develop a model of care that enables clinicians to provide pediatric patients with the highest attainable standard of health care. The IMOC lays out a pathway to provide the world's sickest, most vulnerable children with access to PPC, a human right to which they are entitled by international legal conventions.
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Affiliation(s)
- Michelle Grunauer
- Escuela de Medicina, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador
- Pediatric Intensive Care Unit, Hospital de los Valles, Quito, Ecuador
| | - Caley Mikesell
- Escuela de Medicina, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador
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García-Salido A, Santos-Herranz P, Puertas-Martín V, García-Teresa MÁ, Martino-Alba R, Serrano-González A. Estudio retrospectivo de pacientes derivados de cuidados intensivos pediátricos a cuidados paliativos: por qué y para qué. An Pediatr (Barc) 2018; 88:3-11. [DOI: 10.1016/j.anpedi.2016.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/26/2016] [Accepted: 11/28/2016] [Indexed: 11/16/2022] Open
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García-Salido A, Santos-Herranz P, Puertas-Martín V, García-Teresa MÁ, Martino-Alba R, Serrano-González A. Retrospective study of children referred from paediatric intensive care to palliative care: Why and for what. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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