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Lusney N, van Breemen C, Lim E, Pawliuk C, Hussein Z. Pediatric Advance Care Planning: A Scoping Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1179. [PMID: 37508676 PMCID: PMC10378635 DOI: 10.3390/children10071179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023]
Abstract
To assess current practice and provide a basis for a provincial template, clinicians at a Canadian pediatric hospice reviewed the literature surrounding pediatric advance care planning (pACP) documentation, process, and implementation for children/youth. The scoping review protocol was developed in accordance with the Joanna Briggs Institute methodology for scoping reviews, and was prospectively registered on the Open Science Framework. MEDLINE, Embase, CINAHL, the Web of Science Core Collection, and Google Scholar, as well as sources of unpublished studies and grey literature, were reviewed. Sixty-four articles met the criteria. Fifteen pACP documentation forms/tools were also identified. Overall, the included articles highlighted that pACP should be a structured, collaborative and iterative process between the family and a trusted or relevant healthcare provider, encompassing medical and non-medical issues. Few articles provided insights into specific elements recommended for advance directive forms. Identified strategies for implementation included a structured, step-by-step pACP interventional tool along with ongoing training, mentorship, and defined organizational structures for the clinician. No single specific ACP tool was acknowledged as the gold standard. Use of a pACP tool, along with ongoing provider education and communication skill development, standardized/accessible documentation, and system-wide quality improvement support, were noted as integral components of pACP.
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Affiliation(s)
- Nadine Lusney
- Canuck Place Children's Hospice, Vancouver, BC V6J 2T2, Canada
| | - Camara van Breemen
- Canuck Place Children's Hospice, Vancouver, BC V6J 2T2, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Edlyn Lim
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Colleen Pawliuk
- Department of Pediatrics, University of British Columbia, Vancouver, BC V6H 3V4, Canada
| | - Zahra Hussein
- Child Health British Columbia, Vancouver, BC V6J 4Y6, Canada
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Thomas C. Basic life support for children and young people with a learning or physical disability and an altered body shape. Nurs Child Young People 2020; 32:24-31. [PMID: 32743996 DOI: 10.7748/ncyp.2020.e1270] [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] [Accepted: 03/26/2020] [Indexed: 11/09/2022]
Abstract
The number of people with complex health needs is increasing and this includes children and young people with a learning or physical disability. People with a learning or physical disability are at an increased risk of developing an altered body shape due to their lack of movement, which typically affects the chest. This has implications for healthcare professionals who may be required to provide basic life support (BLS) to such people. This article considers how the delivery of BLS for children and young people with a learning or physical disability and an altered body shape may need to be modified while still complying with the Resuscitation Council (UK) paediatric and adult BLS guidelines.
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Wosinski B, Newman CJ. Physicians' attitudes when faced with life-threatening events in children with severe neurological disabilities. Dev Neurorehabil 2019; 22:61-66. [PMID: 29648486 DOI: 10.1080/17518423.2018.1461946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Children with severe neurological disabilities are at an increased risk of acute, life-threatening events. We assessed physicians' attitudes when making decisions in these situations. METHODS We surveyed physicians in pediatric intensive care, neurology, and rehabilitation units in Swiss hospitals. The questionnaire explored participants' attitudes toward life-threatening situations in two scenarios: a child with profound intellectual and multiple disabilities (PIMD) and an infant with spinal muscular atrophy (SMA) type I. RESULTS The participation rate was 55% (52/95). There was a consensus favoring non-invasive ventilation and comfort care as well as avoiding tracheostomy and invasive ventilation. For the child with PIMD, 61% of participants opposed cardiopulmonary resuscitation (CPR), 51% for the child with SMA. Physicians with over 20 years of experience were significantly more opposed to providing CPR than less experienced colleagues. CONCLUSIONS Physicians held different views, influenced by personal factors. This highlights the importance of standardizing multidisciplinary processes toward approaching these complex situations.
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Affiliation(s)
- Benjy Wosinski
- a Paediatrics department , Lausanne University Hospital , Lausanne , Switzerland
| | - Christopher J Newman
- b Paediatric Neurology and Neurorehabilitation Unit , Lausanne University Hospital , Lausanne , Switzerland
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A Retrospective Review of Resuscitation Planning at a Children's Hospital. CHILDREN-BASEL 2018; 5:children5010009. [PMID: 29300339 PMCID: PMC5789291 DOI: 10.3390/children5010009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/18/2017] [Accepted: 12/20/2017] [Indexed: 11/25/2022]
Abstract
Resuscitation plans (RP) are an important clinical indicator relating to care at the end of life in paediatrics. A retrospective review of the medical records of children who had been referred to the Royal Children’s Hospital, Brisbane, Australia who died in the calendar year 2011 was performed. Of 62 records available, 40 patients (65%) had a life limiting condition and 43 medical records (69%) contained a documented RP. This study demonstrated that both the underlying condition (life-limiting or life-threatening) and the setting of care (Pediatric Intensive Care Unit or home) influenced the development of resuscitation plans. Patients referred to the paediatric palliative care (PPC) service had a significantly longer time interval from documentation of a resuscitation plan to death and were more likely to die at home. All of the patients who died in the paediatric intensive care unit (PICU) had a RP that was documented within the last 48 h of life. Most RPs were not easy to locate. Documentation of discussions related to resuscitation planning should accommodate patient and family centered care based on individual needs. With varied diagnoses and settings of care, it is important that there is inter-professional collaboration, particularly involving PICU and PPC services, in developing protocols of how to manage this difficult but inevitable clinical scenario.
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Weise KL, Okun AL, Carter BS, Christian CW, Katz AL, Laventhal NT, Macauley RC, Moon MR, Opel DJ, Statter MB, Feudtner C, Boss RD, Hauer JM, Humphrey LM, Klick J, Linebarger JS, Flaherty EG, Gavril AR, Idzerda SM, Laskey A, Legano LA, Leventhal JM. Guidance on Forgoing Life-Sustaining Medical Treatment. Pediatrics 2017; 140:peds.2017-1905. [PMID: 28847979 DOI: 10.1542/peds.2017-1905] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric health care is practiced with the goal of promoting the best interests of the child. Treatment generally is rendered under a presumption in favor of sustaining life. However, in some circumstances, the balance of benefits and burdens to the child leads to an assessment that forgoing life-sustaining medical treatment (LSMT) is ethically supportable or advisable. Parents are given wide latitude in decision-making concerning end-of-life care for their children in most situations. Collaborative decision-making around LSMT is improved by thorough communication among all stakeholders, including medical staff, the family, and the patient, when possible, throughout the evolving course of the patient's illness. Clear communication of overall goals of care is advised to promote agreed-on plans, including resuscitation status. Perceived disagreement among the team of professionals may be stressful to families. At the same time, understanding the range of professional opinions behind treatment recommendations is critical to informing family decision-making. Input from specialists in palliative care, ethics, pastoral care, and other disciplines enhances support for families and medical staff when decisions to forgo LSMT are being considered. Understanding specific applicability of institutional, regional, state, and national regulations related to forgoing LSMT is important to practice ethically within existing legal frameworks. This guidance represents an update of the 1994 statement from the American Academy of Pediatrics on forgoing LSMT.
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Affiliation(s)
- Kathryn L. Weise
- Department of Bioethics, Cleveland Clinic, and Pediatric Institute, Cleveland Clinic Children's, Cleveland, Ohio
| | | | - Brian S. Carter
- Division of Neonatology and Children’s Mercy Bioethics Center, Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Cindy W. Christian
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Duc JK, Herbert AR, Heussler HS. Paediatric palliative care and intellectual disability—A unique context. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2017; 30:1111-1124. [DOI: 10.1111/jar.12389] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Jacqueline K Duc
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Centre for Children's Health Ethics and LawQueensland Health Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
| | - Anthony Robert Herbert
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Centre for Children's Health Ethics and LawQueensland Health Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
| | - Helen S Heussler
- Paediatric Palliative Care ServiceChildren's Health Queensland Australia
- Faculty of MedicineUniversity of Queensland Brisbane Australia
- Mater Research InstituteUniversity of Queensland Brisbane Australia
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Edwards JD. Palliative Care and End-of-Life Considerations in Children on Chronic Ventilation. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_5] [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: 10/21/2022]
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Wolff A, Griffin H, Flanigan M, Everest S, Thomas D, Whitehouse W. Development and evaluation of a community respiratory physiotherapy service for children with severe neurodisability. BMJ QUALITY IMPROVEMENT REPORTS 2015; 4:u208552.w3411. [PMID: 26734442 PMCID: PMC4693100 DOI: 10.1136/bmjquality.u208552.w3411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/25/2015] [Indexed: 12/02/2022]
Abstract
Children with severe disability often have difficulties with secretion clearance leading to recurrent lower respiratory tract infections and prolonged hospital admissions. A community respiratory physiotherapy service was developed for this client group, including a rapid response for acute respiratory illness, and an evaluation was undertaken, comparing admissions and bed-days in hospital for respiratory tract infections, emergency admissions to hospital for any cause, and admission costs for each child for the 12 months before to the 12 months with the service. Thirty-four children aged 1 to 19 years (median 5) were eligible for the "before and after" evaluation at 28 months; most had severe cerebral palsy 22 (65%), and there were also eight (23%) children with neurodegenerative and four (12%) with neuromuscular conditions. Admissions for respiratory tract infection fell from 43 to 25 (p<0.05), respiratory admission bed-days fell from 383 to 236 (p<0.01), total non-elective admissions fell from 64 to 40 (p<0.01), with admission cost savings of GBP 78,155 (52%) per annum. This small study suggests that a community respiratory physiotherapy service can reduce hospital admissions and bed days for disabled children. The admissions cost savings have enabled the service to "pay for itself".
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Larcher V, Craig F, Bhogal K, Wilkinson D, Brierley J. Making decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice. Arch Dis Child 2015; 100 Suppl 2:s3-23. [PMID: 25802250 DOI: 10.1136/archdischild-2014-306666] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Vic Larcher
- c/o Ethics and Law Advisory Committee RCPCH, London, UK
| | - Finella Craig
- Louis Dundas Centre for Children's Palliative Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Joe Brierley
- c/o Ethics and Law Advisory Committee RCPCH, London, UK Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital, London, UK
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Lotz JD, Jox RJ, Borasio GD, Führer M. Pediatric advance care planning from the perspective of health care professionals: a qualitative interview study. Palliat Med 2015; 29:212-22. [PMID: 25389347 PMCID: PMC4359209 DOI: 10.1177/0269216314552091] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pediatric advance care planning differs from the adult setting in several aspects, including patients' diagnoses, minor age, and questionable capacity to consent. So far, research has largely neglected the professionals' perspective. AIM We aimed to investigate the attitudes and needs of health care professionals with regard to pediatric advance care planning. DESIGN This is a qualitative interview study with experts in pediatric end-of-life care. A qualitative content analysis was performed. SETTING/PARTICIPANTS We conducted 17 semi-structured interviews with health care professionals caring for severely ill children/adolescents, from different professions, care settings, and institutions. RESULTS Perceived problems with pediatric advance care planning relate to professionals' discomfort and uncertainty regarding end-of-life decisions and advance directives. Conflicts may arise between physicians and non-medical care providers because both avoid taking responsibility for treatment limitations according to a minor's advance directive. Nevertheless, pediatric advance care planning is perceived as helpful by providing an action plan for everyone and ensuring that patient/parent wishes are respected. Important requirements for pediatric advance care planning were identified as follows: repeated discussions and shared decision-making with the family, a qualified facilitator who ensures continuity throughout the whole process, multi-professional conferences, as well as professional education on advance care planning. CONCLUSION Despite a perceived need for pediatric advance care planning, several barriers to its implementation were identified. The results remain to be verified in a larger cohort of health care professionals. Future research should focus on developing and testing strategies for overcoming the existing barriers.
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Affiliation(s)
- Julia D Lotz
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University, Munich, Germany
| | - Gian Domenico Borasio
- Service de Soins Palliatifs, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
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Heckford E, Beringer AJ. Advance Care Planning: Challenges and Approaches for Pediatricians. J Palliat Med 2014; 17:1049-53. [PMID: 24955940 DOI: 10.1089/jpm.2013.0374] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Emma Heckford
- Community Children's Health Partnership, North Bristol Trust, Southmead Hospital, Bristol, United Kingdom
| | - Antonia Jane Beringer
- Faculty of Health and Life Sciences, University of the West of England, Bristol, United Kingdom
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Leviton A, Nichol SM, Allred EN, Loddenkemper T. What is quality improvement and why should child neurologists care? J Child Neurol 2012; 27:251-7. [PMID: 21997846 DOI: 10.1177/0883073811419258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
In this article, the authors discuss the 6 domains of care identified by the Institute of Medicine report, Crossing the Chasm, with examples and questions that are especially relevant to physicians caring for children who have neurologic disorders and their families.
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Affiliation(s)
- Alan Leviton
- Departments of Neurology, Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
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