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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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Broden EG, Bailey VK, Beke DM, Snaman JM, Moynihan KM. Dying and Death in a Pediatric Cardiac ICU: Mixed Methods Evaluation of Multidisciplinary Staff Responses. Pediatr Crit Care Med 2024; 25:e91-e102. [PMID: 37678228 DOI: 10.1097/pcc.0000000000003357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Understanding factors influencing quality of pediatric end-of-life (EOL) care is necessary to identify interventions to improve family and staff experiences. We characterized pediatric cardiac ICU (PCICU) staff free-text survey responses to contextualize patterns in quality of dying and death (QODD) scoring. DESIGN This mixed methods study reports on a cross-sectional survey of PCICU staff involved in patient deaths. SETTING Single, quaternary PCICU from 2019-2021. PARTICIPANTS Multidisciplinary staff (bedside nurses, allied health professionals, and medical practitioners) rated QODD and voluntarily added free-text responses. We derived descriptive categories of free-text responses using content analysis. Response sentiment was classified as positive, negative or both positive and negative. We compared category and sentiment frequency by discipline, EOL medical intensity, years of experience and QODD score quartiles. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 60 deaths and 713 completed staff surveys, 269 (38%) contained free-text responses, including 103 of 269 (38%) from nurses. Of six qualitative categories (i.e., relational dynamics, clinical circumstances, family experiences, emotional expressions, temporal conditions, and structural/situational factors), relational dynamics was most frequent (173 responses). When compared by discipline, family experiences were more common in nursing responses than medical practitioners or allied health. High intensity was associated with infrequent discussion of family experience and greater focus on temporal conditions and clinical circumstances. Emotional expressions and temporal conditions were more common in lowest QODD quartile surveys. Although 45% staff responses contained both sentiments, relational dynamics and family experiences were more likely positive. Negative sentiments were more common in the lowest QODD quartile surveys and responses containing temporal conditions or structural/situational factors. CONCLUSIONS Synergistic relationships between the multidisciplinary team and family shaped clinician's positive responses. Attention to team dynamics may be a crucial ingredient in interventions to improve EOL care. Our data support that team-based education initiatives should consider differential foci between disciplines and EOL characteristics.
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Affiliation(s)
- Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
| | - Valerie K Bailey
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, MA
| | - Dorothy M Beke
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, MA
| | - Jennifer M Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Katie M Moynihan
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Cardiovascular and Critical Care Nursing Patient Services, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Jones MT, Albanese E, Boles JC. "They were here, and they still matter": A qualitative study of bereaved parents legacy experiences and perceptions. Palliat Med 2023; 37:1222-1231. [PMID: 37310037 PMCID: PMC10503247 DOI: 10.1177/02692163231180926] [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: 06/14/2023]
Abstract
BACKGROUND Legacy building interventions are used in pediatric healthcare settings to help families cope with difficult healthcare experiences and typically reserved for intentional use at or near the end of a child's life. However, little is known about how bereaved families perceive the concept of legacy that these practices are meant to address. Emerging research challenges the view of legacy as a standardized, handheld keepsake item but rather as a summation of qualities and experiences that affect those left behind. Therefore, more research is needed. AIM To explore the legacy perceptions and experiences of bereaved parents/caregivers in an effort to inform legacy-oriented interventions in pediatric palliative care. DESIGN In this qualitative, phenomenological study grounded in social constructionist epistemology, bereaved parent/caregivers completed a semi-structured interview about their legacy perceptions and experiences. The interviews were audio-recorded, transcribed, and analyzed using an inductive, open coding approach grounded in psychological phenomenology. SETTING/PARTICIPANTS Participants were parents/caregivers and one adult sibling of children (ages 6 months-18 years) that died between 2000 and 2018 at a children's hospital in the Southeastern United States and spoke English as their primary language. RESULTS Sixteen parents/caregivers and one adult sibling were interviewed. Participants' responses converged across three themes: (1) definitions of legacy, including traits and characteristics, impacts on others, and the child's enduring presence; (2) manifestations of legacy, such as tangible items, experiences, traditions, and rituals, and altruism; and (3) factors perceived to affect legacy experiences, including characteristics of the child's death and one's personal grief process. CONCLUSION Bereaved parents/caregivers define and experience their child's legacy in ways and manifestations that conflict with current legacy building interventions used in pediatric healthcare settings. Thus, an immediate shift from standardized legacy-oriented care to individualized assessment and intervention is needed to provide high-quality patient- and family-centered pediatric palliative care.
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Affiliation(s)
- Maile T Jones
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Patient- and Family-Centered Care Department, Nashville, TN, USA
| | - Elena Albanese
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
| | - Jessika C Boles
- Monroe Carell Jr. Children’s Hospital at Vanderbilt, Patient- and Family-Centered Care Department, Nashville, TN, USA
- Department of Psychology and Human Development, Vanderbilt University, Nashville, TN, USA
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Broden EG, Mazzola E, DeCourcey DD, Blume ED, Wolfe J, Snaman JM. The roles of preparation, location, and palliative care involvement in parent-perceived child suffering at the end of life. J Pediatr Nurs 2023; 72:e166-e173. [PMID: 37355461 DOI: 10.1016/j.pedn.2023.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Parents' perceptions of their child's suffering affect their bereavement experience. Identifying factors that shape parental perceptions of suffering could help build effective supportive interventions for children and parents navigating EOL and grief. We aimed to compare parent-perceived child suffering between diagnostic groups and identify related factors. DESIGN AND METHODS We combined databases from 3 surveys of parents whose children who died following cancer, a complex chronic condition (CCC), or advanced heart disease. We built multivariable logistic regression models to identify relationships between parent-perceived child suffering and parent/child, illness experience, and care-related factors. RESULTS Among 277 parents, 41% rated their child's suffering as moderate or high. Fifty-seven percent of parents whose child died from cancer reported that their child suffered "a lot" or "a great deal" at EOL, compared to 33% whose child died from a CCC, and 17% whose child died from heart disease (P < 0.001). Preparation for EOL symptoms was associated with decreased parent-perceived child suffering in multivariable modeling, with parents who were prepared for EOL 68% less likely to rate their child's suffering as high compared to those who felt unprepared (AOR: 0.32, CI [0.13-0.77], P = 0.013). CONCLUSIONS Preparing families for their child's EOL may help mitigate lingering perceptions of suffering. Operationalizing preparation is crucial to optimizing family support during EOL care. IMPLICATIONS TO PRACTICE Preparation for symptoms, and access to resources, including medical/psychosocial interventions and staff, may help ease parental perception of EOL suffering. Clinicians should prioritize preparing families for what to expect during a child's dying process.
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Affiliation(s)
- Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Division of Medical Critical Care, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jennifer M Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Siedner-Weintraub Y, Osman A, Balit CR. Letter to the Editor: End-of-Life Care for Children within a Pediatric Intensive Care Unit. J Palliat Med 2023; 26:458-459. [PMID: 37011290 DOI: 10.1089/jpm.2023.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Affiliation(s)
| | - Ahmed Osman
- Pediatric Intensive Care Unit, University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Corrine R Balit
- Pediatric Intensive Care Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
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McSherry ML, Rissman L, Mitchell R, Ali-Thompson S, Madrigal VN, Lobner K, Kudchadkar SR. Prognostic and Goals-of-Care Communication in the PICU: A Systematic Review. Pediatr Crit Care Med 2023; 24:e28-e43. [PMID: 36066595 DOI: 10.1097/pcc.0000000000003062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Admission to the PICU may result in substantial short- and long-term morbidity for survivors and their families. Engaging caregivers in discussion of prognosis is challenging for PICU clinicians. We sought to summarize the literature on prognostic, goals-of-care conversations (PGOCCs) in the PICU in order to establish current evidence-based practice, highlight knowledge gaps, and identify future directions. DATA SOURCES PubMed (MEDLINE and PubMed Central), EMBASE, CINAHL, PsycINFO, and Scopus. STUDY SELECTION We reviewed published articles (2001-2022) that examined six themes within PGOCC contextualized to the PICU: 1) caregiver perspectives, 2) clinician perspectives, 3) documentation patterns, 4) communication skills training for clinicians, 5) family conferences, and 6) prospective interventions to improve caregiver-clinician communication. DATA EXTRACTION Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology. DATA SYNTHESIS Of 1,420 publications screened, 65 met criteria for inclusion with several key themes identified. Parent and clinician perspectives highlighted the need for clear, timely, and empathetic prognostic communication. Communication skills training programs are evaluated by a participant's self-perceived improvement. Caregiver and clinician views on quality of family meetings may be discordant. Documentation of PGOCCs is inconsistent and most likely to occur shortly before death. Only two prospective interventions to improve caregiver-clinician communication in the PICU have been reported. The currently available studies reflect an overrepresentation of bereaved White, English-speaking caregivers of children with known chronic conditions. CONCLUSIONS Future research should identify evidence-based communication practices that enhance caregiver-clinician PGOCC in the PICU and address: 1) caregiver and clinician perspectives of underserved and limited English proficiency populations, 2) inclusion of caregivers who are not physically present at the bedside, 3) standardized communication training programs with broader multidisciplinary staff inclusion, 4) improved design of patient and caregiver educational materials, 5) the development of pediatric decision aids, and 6) inclusion of long-term post-PICU outcomes as a measure for PGOCC interventions.
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Affiliation(s)
- Megan L McSherry
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD
| | - Lauren Rissman
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Riley Mitchell
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD
| | - Sherlissa Ali-Thompson
- Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Vanessa N Madrigal
- Division of Critical Care Medicine, Department of Pediatrics, George Washington University, Washington, DC
- Pediatric Ethics Program, Children's National Hospital, Washington, DC
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University, Baltimore, MD
| | - Sapna R Kudchadkar
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD
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Broden EG, Hinds PS, Werner-Lin AV, Curley MAQ. "I Didn't Want My Baby to Pass, But I Didn't Want Him Suffering Either": Comparing Bereaved Parents' Narratives With Nursing End-of-Life Assessments in the Pediatric Intensive Care Unit. J Hosp Palliat Nurs 2022; 24:271-280. [PMID: 35666188 PMCID: PMC9437116 DOI: 10.1097/njh.0000000000000884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Little is known about how nursing care at the end of a child's life impacts long-term parental bereavement. We aimed to explain, contextualize, and examine comparisons between quantitative trends in children's end-of-life care and parents' qualitative perceptions. We used a mixed methods design, combining quantitative data from the RESTORE clinical trial with qualitative interviews with bereaved parents. Patients who died during RESTORE were included in quantitative analyses. A subset of their parents was interviewed 7 to 11 years later. The quantitative analyses included 104 children. Eight parents were interviewed; 4 had a child die after cancer, and 4 had a child die after a complex chronic illness. Quantitatively, patients' pain and sedation scores were generally comfortable. Children died with multiple invasive devices in place. Parents' descriptions of their child's comfort and critical care requirements differed by illness trajectory (cancer, complex chronic illness). Parents' memories of their child's suffering aligned with peaks in clinical scores, rather than averages. Invasive devices and equipment altered parents' ability to make meaningful final memories with the dying child. Pediatric intensive care clinicians may need to broaden how they attend to dying children's pain and corresponding parental distress, as parents' memories of their dying child's suffering persist for years.
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Green L, Stewart-Lord A, Baillie L. End-of-life and immediate postdeath acute hospital interventions: scoping review. BMJ Support Palliat Care 2022:bmjspcare-2021-003511. [PMID: 35896320 DOI: 10.1136/spcare-2021-003511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/28/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hospital remains the most common place of death in the UK, but there are ongoing concerns about the quality of end-of-life care provision in this setting. Evaluation of interventions in the last days of life or after a bereavement is methodologically and ethically challenging. AIM The aim was to describe interventions at the very end of life and in the immediate bereavement period in acute hospitals, with a particular focus on how these are evaluated. METHOD A scoping review was conducted. Studies were restricted to peer-reviewed original research or literature reviews, published between 2011 and 2021, and written in the English language. Databases searched were CINAHL, Medline and Psychinfo. RESULTS From the search findings, 42 studies were reviewed, including quantitative (n=7), qualitative (n=14), mixed method (n=4) and literature reviews (n=17). Much of the current research about hospital-based bereavement care is derived from the intensive and critical care settings. Three themes were identified: (1) person-centred/family-centred care (memorialisation), (2) institutional approaches (quality of the environment, leadership, system-wide approaches and culture), (3) infrastructure and support systems (transdisciplinary working and staff support). There were limited studies on interventions to support staff. CONCLUSION Currently, there are few comprehensive tools for evaluating complex service interventions in a way that provides meaningful transferable data. Quantitative studies do not capture the complexity inherent in this form of care. Further qualitative studies would offer important insights into the interventions.
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Affiliation(s)
- Laura Green
- Faculty of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Adele Stewart-Lord
- Department of Allied Health Sciences, London South Bank University, London, UK
| | - Lesley Baillie
- Florence Nightingale Foundation Chair, London South Bank University, London, UK
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Broden EG, Hinds PS, Werner-Lin A, Quinn R, Asaro LA, Curley MAQ. Nursing Care at End of Life in Pediatric Intensive Care Unit Patients Requiring Mechanical Ventilation. Am J Crit Care 2022; 31:230-239. [PMID: 35466341 DOI: 10.4037/ajcc2022294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Parents' perceptions of critical care during the final days of their child's life shape their grief for decades. Little is known about nursing care needs of children actively dying in the pediatric intensive care unit (PICU). OBJECTIVES To examine associations between patient characteristics, circumstances of death, and nursing care requirements for children who died in the PICU. METHODS A secondary analysis of the data set from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial was conducted. RESULTS This analysis included 104 children; 67 died after withdrawal of life-sustaining treatments; 21, after failed resuscitation; and 16, after brain death. Patients had a median age of 7.5 years, were cognitively appropriate, and were intubated for acute respiratory failure. Daily pain and sedation scores indicated patients' comfort was well managed (mean pain scores: modal, 0; peak, 2; mean sedation scores: modal, -2; peak, -1). Patients with longer PICU stays more often experienced pain and agitation on the day of death. Illness trajectory (acute, complex chronic condition, or cancer) was associated with pain scores (P = .04). Specifically, children with cancer had higher pain scores than children with acute illness trajectories (P = .01). Many patients (62%) had no change in critical care devices in their last days of life (median, 5 devices). Patterns of pain, sedation, comfort medications, and nursing care requirements did not differ by circumstances of death. CONCLUSION Children with cancer and longer PICU stays may need comprehensive comfort management. Invasive devices left in place during withdrawal of life support may have inhibited parents' ability to connect with their child. Future research should incorporate parents' perspectives.
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Affiliation(s)
- Elizabeth G. Broden
- Elizabeth G. Broden is a postdoctoral research fellow in psychosocial oncology and palliative care at Dana-Farber Cancer Institute, Boston, Massachusetts, and a pediatric ICU/CICU nurse at Yale New Haven Children’s Hospital, New Haven, Connecticut
| | - Pamela S. Hinds
- Pamela S. Hinds is the William and Joanne Conway Chair in Nursing Research and executive director of Nursing Science, Professional Practice, and Quality Outcomes, Children’s National Hospital, Washington, DC, and a pediatrics professor, George Washington University, Washington, DC
| | - Allison Werner-Lin
- Allison Werner-Lin is an associate professor, University of Pennsylvania School of Social Policy and Practice, Philadelphia, Pennsylvania, and a senior advisor, National Cancer Institute, Bethesda, Maryland
| | - Ryan Quinn
- Ryan Quinn is a biostatistician, Biostatistics Evaluation Collaboration Consultation and Analysis Lab, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Lisa A. Asaro
- Lisa A. Asaro is a biostatistician, Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Martha A. Q. Curley
- Martha A. Q. Curley is the Ruth M. Colket Endowed Chair in Pediatric Nursing, Research Institute, Children’s Hospital of Philadelphia, Pennsylvania; a professor, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; and a professor, Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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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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11
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Goldberg JM, Duplechain AC, Fraser CE, Boles JC. An Interdisciplinary Hospital-Based Committee to Improve Pediatric Bereavement Care. Hosp Pediatr 2021; 11:1287-1294. [PMID: 34599017 DOI: 10.1542/hpeds.2021-005964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although frequently overshadowed by adult mortality rates and bereavement care needs, the death of a child can significantly jeopardize the physical, psychosocial, and emotional health of surviving parents, caregivers, and family members. Unfortunately, researchers have only recently begun to explore the trajectory of pediatric bereavement care needs. As an ongoing public health concern, health care institutions and related organizations must partner with interdisciplinary care providers and bereaved families to design effective and sustainable bereavement supports in their communities. Therefore, the purpose of this article is to describe the development and accomplishments of an interdisciplinary bereavement committee at a children's hospital within an academic medical center. By relying on available empirical evidence and close collaboration with bereaved parent members, this effort has generated sizeable practice improvements and new service offerings within the organization, local community, and the individual patients and families the institution serves.
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Affiliation(s)
- Jessica M Goldberg
- Patient- and Family-Centered Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Anne C Duplechain
- Patient- and Family-Centered Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Camille E Fraser
- Patient- and Family-Centered Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Jessika C Boles
- Patient- and Family-Centered Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee .,Department of Psychology and Human Development, Peabody College Vanderbilt University, Nashville, Tennessee
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12
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Vig PS, Lim JY, Lee RWL, Huang H, Tan XH, Lim WQ, Lim MBXY, Lee ASI, Chiam M, Lim C, Baral VR, Krishna LKR. Parental bereavement - impact of death of neonates and children under 12 years on personhood of parents: a systematic scoping review. BMC Palliat Care 2021; 20:136. [PMID: 34481491 PMCID: PMC8418708 DOI: 10.1186/s12904-021-00831-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Losing a child tragically impacts the well-being and functioning of parents. With these effects extending beyond emotional, physical morbidity and compromising self-perceptions, appropriate, longitudinal, timely and personalised support is key to effective care of bereaved parents. However, in the absence of a comprehensive understanding of parental bereavement, effective support of bereaved parents remains suboptimal. To address this gap, we scrutinise prevailing data on the effects of a child's death, aged 0-12 years, through the lens of the Ring Theory of Personhood (RToP). METHODS To study prevailing accounts of bereaved parents following the death of a child, we adopt Krishna's Systematic Evidence Based Approach (SEBA) to structure our Systematic Scoping Review (SSR in SEBA). RESULTS Three thousand seventy-four abstracts were reviewed, 160 full text articles were evaluated, and 111 articles were included and analysed using thematic and content analysis. Four themes/categories were identified relating to the four rings of the RToP. Findings reveal that static concepts of protective and risk factors for grief are misplaced and that the support of healthcare professionals is key to assisting bereaved parents. CONCLUSION In the absence of consistent support of bereaved parents, this study highlights the need for effective training of healthcare professionals, beginning with an appreciation that every aspect of an individual parent's personhood is impacted by the loss of their child. Acknowledging grief as a complex, evolving and personalised process subjected to parental characteristics, settings, context and available support, this SSR in SEBA calls attention to effective nurturing of the relationship between parents and healthcare professionals, and suggests use of the RToP to assess and direct personalised, timely, specific support of parents in evolving conditions. We believe the findings of this review also call for further studies to support healthcare professionals as they journey with bereaved parents.
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Affiliation(s)
- Prachi Simran Vig
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Jia Yin Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Randal Wei Liang Lee
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Huixin Huang
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Xiu Hui Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Wei Qiang Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Marie Bernadette Xin Yi Lim
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Alexia Sze Inn Lee
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Crystal Lim
- Medical Social Services, Singapore General Hospital, Outram Road, Block 3 Level 1, Singapore, 169608 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
| | - Vijayendra Ranjan Baral
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Division of Neonatal and Developmental Medicine, Singapore General Hospital, Outram Road, Block 5 Level 4, Singapore, 169608 Singapore
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 11, Singapore, 119228 Singapore
- Division of Palliative and Supportive Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
- Centre for Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597 Singapore
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436 Singapore
- Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA UK
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Bogetz JF, Revette A, DeCourcey DD. Clinical Care Strategies That Support Parents of Children With Complex Chronic Conditions. Pediatr Crit Care Med 2021; 22:595-602. [PMID: 33813549 DOI: 10.1097/pcc.0000000000002726] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Children with complex chronic conditions often receive inpatient and end-of-life care in the ICU, yet little is known about the clinical care strategies that best support this unique group of parents. This study aimed to elucidate supportive clinical care strategies identified by bereaved parents of children with complex chronic conditions. DESIGN Qualitative analysis of 21 open-response items from the cross-sectional "Survey of Caring for Children with Complex Chronic Conditions" querying communication, decision-making, and end-of-life experiences. SETTING Large tertiary care children's hospital. PATIENTS Parents of children with complex chronic conditions who received care at a large academic institution and died between 2006 and 2015. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS An iterative multistage thematic analysis of responses was used to identify key themes pertaining to clinical care strategies that support parents of children with complex chronic conditions. Open-ended responses were analyzed from 110 of 114 (96%) of survey respondents. The majority of parents had children with congenital/chromosomal complex chronic conditions who died 3.9 years (interquartile range, 2.2-6.7 yr) prior to their parents' study participation. Although informational themes related to clear honest communication, consistent messaging, and enhanced care coordination were identified, parents emphasized the relational aspects of clinical care including inclusivity of their expertise about their child's needs, recognition of their unique experience as parents, and maintenance of connection with clinicians through bereavement. CONCLUSIONS Clinical care strategies that support parents of children with complex chronic conditions reflect the unique needs of this group of children. Relational strategies such as including parents as experts in their child's care were paramount to parents of children with complex chronic conditions throughout their child's medical journey and at end of life.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatric, University of Washington, Seattle, WA
- Treuman Katz Center for Bioethics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
- Palliative Care Resilience Research Lab, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Anna Revette
- Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, MA
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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Nadkarni V, Kissoon N. Dr. Patrick Kochanek: A "Wild Ride" Olé!… 20 Years of Editorial Genius, Drive, and Vision. Pediatr Crit Care Med 2021; 22:5-7. [PMID: 33410644 DOI: 10.1097/pcc.0000000000002636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Vinay Nadkarni
- Secretary, SCCM
- Department of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Niranjan Kissoon
- Past President and Pediatric Critical Care Medicine Journal Liaison, WFPICCS
- Senior Medical Director, Acute and Critical Care Programs, British Columbia Children's Hospital, Vancouver, BC, Canada
- Associate Head and Professor, University of British Columbia, Vancouver, BC, Canada
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Abstract
OBJECTIVE To characterise the parenting priorities of mothers and fathers of infants hospitalised with CHD and generate recommendations to support parenting during infant hospitalisation. STUDY DESIGN Through online crowdsourcing, an innovative research methodology to create an online community to serve as a research sample, 79 parents of young children with CHD responded to questions about parenting during hospitalisation via private social networking site. Responses were analysed using qualitative research methods. RESULTS Three broad themes were identified: (1) establishing a bond with my baby, (2) asserting the parental role, and (3) coping with fear and uncertainty. Parents value provider support in restoring normalcy to the parenting experience during infant hospitalisation. CONCLUSIONS Care teams can support parenting during infant hospitalisation by promoting parents' roles as primary caretakers and decision-makers and attending to the emotional impact of infant hospitalisation on the family.
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Palumbo K, Koncicki ML. Pediatric Palliative Care and the PICU: Where We Have Been and Where We Are Going. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00230-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Brown KL, De Luca D. Focus on paediatrics. Intensive Care Med 2020; 46:1254-1257. [PMID: 32232504 PMCID: PMC7223899 DOI: 10.1007/s00134-020-06017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/17/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Katherine L Brown
- Heart and Lung Division and Biomedical Research Centre, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK. .,Institute of Cardiovascular Science University College, Zayed Rare Diseases Research Building, Guildford Street, London, WC1N 1DZ, UK.
| | - Daniele De Luca
- Pédiatrie et Réanimation Néonatale, Hôpital Antoine Béclère, GHU Paris Saclay, APHP, Paris, France.,Physiopathologie et Innovation Thérapeutique Unit, INSERM Unit U999, Université Paris Saclay, Faculté de Médecine Paris Sud, Saint-Aubin, France
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