Models of Pediatric Palliative Oncology Outpatient Care-Benefits, Challenges, and Opportunities

Needs, status and future directions in palliative care for children with cancer: an insight into the Italian situation

Pediatric palliative care (PPC) is an essential component of holistic care for children with cancer, addressing the physical, emotional, psychosocial and existential needs of children and their families. This narrative review explores the status, challenges, and future directions of PPC for children with cancer, specifically focusing on the Italian context. Despite advancements in legislation, such as Italy's Law 38/2010, access to PPC remains uneven, particularly in underserved regions. Children with cancer experience a high symptom burden, including pain, fatigue, and dyspnea, which is often inadequately managed due to late referrals and misconceptions equating PPC with end-of-life care. Organizational barriers, such as limited trained personnel and inadequate service models are linked to delayed integration. Physician discomfort, family resistance, and uncertainty regarding referral timing also contribute to delayed referral. International studies highlight regional disparities. However, opportunities for improvement exist, including workforce development, targeted education, and public awareness campaigns. Models of care, such as home-based services, telemedicine, and floating clinics, demonstrate potential for addressing gaps and optimizing resource allocation. Data from Italian centers further emphasize the importance of early PPC integration to improve outcomes, reduce unnecessary intensive care interventions, and ensure a better quality of life. This review underscores the need for tailored, multidisciplinary PPC models, proactive screening tools, and sustained policy support to ensure equitable and comprehensive care for all children with cancer.

Exploring the viability of telehealth integration into specialised paediatric palliative care

BACKGROUND

Specialised outpatient paediatric palliative care (SOPPC) is vital for young people with life-limiting conditions and telehealth integration might improve this care.

AIM

Evaluate the acceptance and challenges of implementing teleconsultations among SOPPC healthcare professionals.

METHODS

A questionnaire, tailored to various professions in SOPPC, was developed. After pilot testing, it was distributed to all healthcare professionals in SOPPC in the county of Lower Saxony, Northern Germany. Statistical analyses, using descriptive methods, ensured the reliability of the findings.

FINDINGS

The survey involved 96 participants from SOPPC teams. Teleconsultations were perceived as time-saving (physicians (80%), nursing (68%), psychosocial varied), facilitating patient-centred discussions (physicians (87%), nursing staff (72%), psychosocial had varied responses) and maintaining intensive contact during restrictions (85% agreement). Improved team communication (91%) and patient-family communication (physicians (80%), nursing (68%), psychosocial (62%) were perceived benefits. Concerns included language barriers (84%) and technical readiness (80%). While physicians and nursing professionals saw telehealth enhancing patient safety (64-95%), psychosocial professionals were more skeptical (38-62%).

CONCLUSION

This study highlights telehealth's potential in SOPPC, stressing the need for tailored strategies. While nursing staff and physicians generally accept telehealth, psychosocial professionals express reservations. Overcoming barriers like language and technical readiness is crucial for maximising telehealth benefits.

Outpatient Pediatric Palliative Care Development: Guidance on Building Sustainable Programs

Context: As pediatric palliative care (PPC) expands within institutions and nationally, little guidance is available on building outpatient programs. Objectives: We asked outpatient PPC (OPPC) program leaders in the United States about clinic development experiences to gather advice for growing programs. Methods: As part of a larger OPPC study, 48 freestanding children's hospitals with inpatient PPC programs were invited to complete a survey on OPPC. Self-selected participants were sent a follow-up survey soliciting free-text responses about development experiences. Quantitative data were analyzed with descriptive statistics. Qualitative data underwent inductive content analysis. Results: Thirty-six hospitals completed the initial survey, and 28 (78%) reported practicing clinic-based OPPC. Twenty-two of 28 completed program development questions. More than half (12/22, 55%) recommended a minimum total billable full-time equivalent (FTE) ≥3 before expanding into the outpatient setting. About two-thirds (14/22, 64%) suggested a minimum billable FTE ≥4 for 24/7 coverage. Half (50%) reported that their program grew from subspecialty clinics, most frequently hematology-oncology (10/11, 91%). Half (50%) placed initial limits on referrals, with many restricting schedule availability (7/11, 64%). Six of 12 participants (50%) willing to share more about their development experience completed a follow-up survey, from which three themes emerged: program logistics, expectations and boundaries, and establishing role and workflow. Participants focused advice on slow programmatic growth to optimize sustainability. Conclusion: Program leaders offer tangible guidance informed by their OPPC development experience. Future work is needed to leverage this advice within institutions to promote resilient and sustainable PPC growth.

Association of inpatient and outpatient pediatric palliative care with healthcare utilization and end-of-life outcomes in pediatric oncology

BACKGROUND

Pediatric palliative care (PPC) is associated with improved end-of-life (EOL) outcomes. Inpatient and outpatient PPC have unique roles during the disease course. Yet, it is unknown whether the location of PPC receipt (inpatient vs. outpatient) is associated with healthcare utilization and EOL outcomes for pediatric and adolescent and young adult oncology patients.

PROCEDURE

A retrospective single-institution chart review of pediatric patients (age 0-28) with cancer who died between January 2015 and December 2022 was performed to compare EOL outcomes and healthcare utilization metrics among inpatient PPC, any outpatient PPC, and non-PPC recipients. Demographics and clinical factors were analyzed by PPC receipt location.

RESULTS

Among 450 patients, 292 (64.9%) received PPC (inpatient only 35%, any outpatient 65%). Patients who died without receiving PPC dropped from 69% to 22% following development of an outpatient PPC clinic (p < .001). In the last 6 months, 1 month, and last week of life, inpatient PPC recipients spent more days admitted to the hospital and intensive care unit (all p < .001), and had more intensive medical interventions performed (p < .01). Outpatient PPC recipients were less likely to receive intravenous (IV) chemotherapy (p < .01) or intubation (p = .05), and more likely to receive hospice, die at home, and have an outpatient do-not-resuscitate order (all p < .001).

CONCLUSIONS

PPC receipt substantially increased after the creation of an outpatient PPC clinic, suggesting that outpatient PPC is critical in the provision of PPC to children with cancer. Outpatient PPC was associated with fewer hospital days, IV chemotherapy, and intubation at EOL, while increasing hospice enrollment and home death.

Challenges in Pediatric Home-Based Hospice and Palliative Care: A Case Series

Pediatric home-based hospice and palliative care is a growing and important sub-field within the larger pediatric palliative care landscape. Despite research demonstrating the clinical and systemic efficacy of pediatric home-based hospice and palliative care, there remain barriers to its optimal development, implementation, and dissemination as well as best clinical practice knowledge gaps. This case series presents specific examples of ubiquitous challenges in pediatric home-based hospice and palliative care in hopes of guiding future research, education, advocacy, and program development efforts.

Assessing Telehealth in Palliative Care: A Systematic Review of the Effectiveness and Challenges in Rural and Underserved Areas

The integration of telehealth into palliative care has garnered significant attention due to its potential to enhance both access and quality of care, particularly for patients in rural and underserved areas. This interest stems from the need to address geographical and logistical barriers that traditionally hinder palliative care delivery. Despite its potential benefits, the effectiveness of telehealth and the challenges associated with its implementation remain underexplored, necessitating further investigation. This study aims to critically evaluate the effectiveness of telehealth in palliative care by focusing on several key areas: its impact on access to care, symptom management, patient satisfaction, and cost-effectiveness. To achieve this, a systematic review was conducted, synthesizing data from various studies that investigated telehealth interventions within palliative care settings. The review employed a comprehensive search strategy across electronic databases, concentrating on randomized controlled trials (RTCs) published between 2014 and 2024. To ensure the reliability of the findings, low-quality and unrelated studies were excluded, and the remaining studies were meticulously analyzed for bias and methodological quality. The review's findings indicate that telehealth significantly enhances access to palliative care, allowing patients to receive timely and appropriate care without the need for extensive travel. It also improves symptom management and patient satisfaction, aligning to provide patient-centered care. Additionally, telehealth is cost-effective by reducing expenses associated with travel and in-person visits. These benefits highlight telehealth's potential to address some of the critical challenges in palliative care delivery. Despite its advantages, implementing telehealth in palliative care is not without challenges. Technological barriers, such as inadequate infrastructure and device limitations, pose significant hurdles. Integration issues, including the need for seamless incorporation into existing care systems, and varying levels of digital literacy among patients and caregivers, also impact the effectiveness of telehealth. Addressing these challenges is crucial for optimizing telehealth's implementation. Ensuring that telehealth solutions are accessible, user-friendly, and well-integrated into care practices is essential for fully leveraging its potential benefits.

Is it early enough? The authentic meaning of the pediatric palliative approach between early and late referral in pediatric oncology: a case study

The literature widely supports the benefits of early integration of palliative care into pediatric oncological care; however, many barriers to its successful integration remain. Integrating palliative care as early as possible in the oncology pathway is critical, but other criteria are relevant to positive results. This paper aims to contribute to the early/late referral dualism in pediatric palliative care (PPC) and highlight the importance of a collaborative approach between oncologists and palliative care teams. This study investigates the impact of early versus late referral to PPC, intersecting it with the synergy work between services and the related outcomes. The four pediatric cancer cases were selected based on clinical (e.g., disease duration, multiple treatments, and pain management), management (e.g., involvement of multiple services and multiple home-hospital transitions), and relevance of multidisciplinary team (e.g., difficult clinical decisions and ethical discussions) criteria. A mixed-methods approach was employed, combining qualitative case analysis using clinical diaries, literature review, and practice guidelines development. Critical clinical information, time course, clinician-family communication, and patient involvement were analyzed. The outcomes show how simultaneous care creates continuous discussion and dialogue between professionals. The results indicate the importance of better communication and care coordination to improve patient and family satisfaction, highlighting the uniqueness of the pediatric field and the relationship with children and families. Through the discussion of clinical cases and a literature review, we provide practical guidance for clinicians working in oncology and PPC. These findings underscore the crucial need for a multidisciplinary approach in pediatric oncology, advocating policy changes to support early PPC integration and translate it into complementarity best operating practices. In conclusion, besides assessing the timeliness of referral to the PPC service, the synergy, harmony, and choral work of the professionals involved are equally valuable for a quality-of-life-oriented care plan.

Quality of Outpatient Pediatric Palliative Care Telehealth: A Retrospective Chart Review

CONTEXT

Studies suggest the feasibility and acceptability of telehealth in outpatient pediatric palliative care. However, there is a need for data that describes the implementation and quality of telehealth, relying on objective and validated measures.

OBJECTIVE

We sought to compare the provision of pediatric palliative care by delivery method.

METHODS

We conducted a retrospective electronic health record review of patients seen by our outpatient palliative care team over a two-year period. Demographic, diagnostic, and health utilization data as well as encounter characteristics were compared between patients seen in person (IP), through telehealth (TH), and both (IP/TH).

RESULTS

Three hundred ninety-four patients were evaluated with 889 outpatient pediatric palliative care encounters. Non-English speaking patients were less likely to receive palliative care through TH, as were patients without active patient portals. Median follow-up time was longer for patients seen through TH or IP/TH. Patients with malignancies were seen more frequently IP while children with neurologic diagnoses, technology dependence, and a higher number of complex chronic conditions were seen more frequently via TH. Health outcomes, end of life quality metrics, and encounter-level quality indicators were similar across care delivery methods. Review of systems, pain, and mood management, and advance care planning happened more frequently IP while goals of care discussions and medical decision-making happened more through TH.

CONCLUSION

Despite differences in patients seen and palliative interventions provided in person compared to telehealth, health outcomes, and quality indicators were similar across care delivery methods. These data support the continued practice of telehealth in palliative care and highlight the need for equity in its evolution.

The Scope of Practice of an Embedded Pediatric Palliative Oncology Clinic

CONTEXT

Pediatric palliative care (PPC) improves end-of-life (EOL) outcomes for children with cancer. Though PPC visits are the 'intervention' in studies focused on EOL care, the content of PPC visits within pediatric oncology is poorly understood.

OBJECTIVES

This study aimed to understand the scope of PPC practice during visits for children with cancer and their families.

METHODS

This was a retrospective cohort study of patients 0-27 years with cancer seen in PPC clinic within an academic pediatric oncology center between 2017 and 2022. During each PPC visit, documenting providers chose the domains discussed or managed (goals of care, symptom management, and care coordination with respective subdomains). Data was abstracted from the electronic health record, PPC clinic database, and Cancer Registry. The differences in frequency and addressed domains were analyzed by demographics, visit type, diagnosis group, and proximity to EOL.

RESULTS

Across 351 patients, 1919 outpatient PPC visits occurred. Median domains were higher in visits <90 days vs. 91+ days from EOL (12.0 vs. 10.0; p < 0.0001); pain and hospice collaboration were particularly discussed closer to EOL. Psychological symptoms like anxiety (30.7% vs. 21.1%; p < 0.001) were addressed more in follow-ups than initial visits. Compared to brain tumor or leukemia/lymphoma visits, solid tumor visits addressed more symptom management subdomains, especially pain (79.9%; p < 0.0001).

CONCLUSION

The scope of PPC practice is broad and varied. Each visit encompasses many subdomains, the most common being care coordination with oncology teams and helping patients/families cope with the disease. More domains were addressed in solid tumor visits and near EOL.

The Effect of Psychosocial Support Videos Provided by the Community on Disease Attitudes and Symptoms of Pediatric Oncology Patients: Randomized Controlled Study

OBJECTIVE

This study aimed to evaluate the impact of psychosocial support videos provided by the community on the attitudes of pediatric oncology patients aged between 10 and 18 years toward their illness and treatment-related symptoms.

DATA SOURCES

This prospective randomized controlled study was conducted with 52 pediatric oncology patients aged between 10 and 18. The data were collected using the Information Form, Child Attitude Towards Illness Scale (CATIS), and Memorial Symptom Assessment Scale (MSAS). When the control group received standard care, the intervention group received psychosocial support videos provided by the community at the beginning of the week for 1 month.

CONCLUSION

This study suggests that the implemented intervention positively affected pediatric patients' symptom management, psychological well-being, and attitudes toward their illness. Considering that today's adolescents have grown up in the age of technology and show great interest in technology and media use, it is clear that psychosocial support videos may attract the attention of this age group. Producing and sharing similar content for other children with similar health problems may positively affect the psychosocial health outcomes of pediatric patients.

IMPLICATIONS FOR NURSING PRACTICE

It has been found that it is beneficial to include community-supported psychosocial support in the nursing care of pediatric oncology patients. For this reason, it is recommended that nurses actively participate in developing psychosocial support strategies and take the lead in creating and making the content accessible.

Consultation patterns before and after embedding pediatric palliative care into a pediatric hematology/oncology clinic

INTRODUCTION

Palliative care is a critical component of pediatric oncology care. Embedded pediatric palliative care (PPC) is relatively new in pediatric hematology/oncology (PHO) and may improve access, utilization, and quality of PPC. In June 2020, the Mayo Clinic PPC service transitioned from an afternoon, physically independent clinic to an all-day clinic embedded within PHO.

METHODS

Retrospective chart review was used to quantify consultation rates from PHO to PPC in 12-month study periods before and after establishment of an embedded clinic. Changes in descriptive statistics and consult patterns were calculated. Study periods were compared using either chi-square or Fisher's exact tests for categorical variables and Wilcox rank sum tests for continuous variables.

RESULTS

There was an 89% increase in consultations from PHO to PPC after initiation of an embedded clinic (n = 20 vs. n = 38 per 12 months). The absolute number of completed outpatient consults increased from three (15% of visits) pre-embedment to fourteen (37%) post-embedment (p = .082). The median number of days from first oncology visit to PPC assessment was unchanged after embedment (36 vs. 47 days, p = .98). Consults for solid tumors increased from 22% (n = 4) pre-embedment to 60% (n = 18) post-embedment (p < .05). Consults for symptom management increased from 60% (n = 12) to 87% (n = 33) (p < .05).

CONCLUSIONS

Embedment of PPC into a PHO workspace was associated with an increased number of total consults, outpatient consults, solid tumor consults, and consults for symptom management. Our "partial-PPO" model allowed for provision of PPC in the outpatient oncology setting in a clinic where there is not enough volume to support a full-time oncology-focused clinician team.

Early Versus Late Outpatient Pediatric Palliative Care Consultation and Its Association With End-of-Life Outcomes in Children With Cancer

Background: There is no consensus on what constitutes "early" pediatric palliative care (PPC) referral within pediatric oncology. Few studies report outcomes based on PPC timing. Objectives: Investigate associations between early (<12 weeks) or late (≥12 weeks from diagnosis) outpatient PPC consultation with demographics, advance care planning (ACP), and end-of-life (EOL) outcomes. Design: Retrospective chart and database review of demographic, disease, visit data, and PPC/EOL outcomes. Setting/Subjects: Deceased pediatric patients with cancer 0-27 years of age seen at an embedded consultative PPC clinic. Measurements: Patient demographics, disease characteristics, PPC/EOL outcomes: timing/receipt of ACP, hospice enrollment, do-not-resuscitate (DNR) documentation, hospital days in last 90 days of life, concordance between actual and preferred location of death, receipt of cardiopulmonary resuscitation (CPR) at EOL, and death in the intensive care unit. Results: Thirty-two patients received early and 118 received late PPC. Early outpatient PPC was associated with cancer type (p < 0.01). Early PPC (p = 0.04) and ACP documentation (p = 0.04) were associated with documentation of preferred location of death. Early PPC was associated with a preference for home death (p = 0.02). Timing of outpatient PPC was not associated with ACP documentation or other EOL outcomes. In the entire cohort, 73% of PPC patients received hospice, 74% had a DNR order, 87% did not receive CPR at EOL, and 90% died in their preferred location. Conclusions: When using a cutoff of 12 weeks from diagnosis, outpatient PPC timing was only associated with location of death metrics, likely due to high-quality PPC and EOL care among all patients.

Embracing paediatric palliative care in paediatric oncology from diagnosis onwards

Paediatric palliative care aims to support children and young people with life-limiting or life-threatening conditions, and their families, from the time of diagnosis. Early integration within oncology has been recognised as having benefits for all involved, whatever the outcome may be. Through improved communication and advance care planning, it enables user-centred care, where concerns about quality of life, preferences and values are given the same relevance as cutting-edge therapy. Challenges to the integration of palliative care within paediatric oncology include raising awareness and providing education, whilst searching for the best care model and adapting to an ever-changing therapeutic scenario.

Top Ten Tips Palliative Care Clinicians Should Know About Delivering Specialty-Aligned Palliative Care

Specialty-aligned palliative care (SAPC) refers to interprofessional palliative care (PC) that is delivered to a specific population of patients in close partnership with other primary or specialty clinicians. As evolving PC models address physical, psychosocial, and spiritual suffering across illnesses and settings, PC clinicians must acquire advanced knowledge of disease-specific symptoms, common treatments, and complications that impact prognosis and outcomes. The tips provided in this article draw on the experience and knowledge of interprofessional PC and other specialist clinicians from diverse institutions across the United States who have developed and studied SAPC services across different disease groups. Recommendations include focusing on approaching specialty team partnerships with humility, curiosity, and diplomacy; focusing on patient populations where PC needs are great; clarifying how work and responsibilities will be divided between PC and other clinicians to the extent possible; using consults as opportunities for bidirectional learning; and adapting workflows and schedules to meet specialty team needs while managing expectations and setting limits as appropriate. Furthermore, to provide effective SAPC, PC clinicians must learn about the specific symptoms, prognoses, and common treatments of the patients they are serving. They must also build trusting relationships and maintain open communication with patients and referring clinicians to ensure integrated and aligned PC delivery.

The Landscape of Outpatient Pediatric Palliative Care: A National Cross-Sectional Assessment

CONTEXT

Inpatient pediatric palliative care (PPC) has grown substantially over the past 20 years; however, PPC in the outpatient setting remains underdeveloped. Outpatient PPC (OPPC) offers opportunities to improve access to PPC as well as facilitate care coordination and transitions for children with serious illness.

OBJECTIVES

This study aimed to characterize the national status of OPPC programmatic development and operationalization in the United States.

METHODS

Utilizing a national report, freestanding children's hospitals with existing PPC programs were identified to query OPPC status. An electronic survey was developed and distributed to PPC participants at each site. Survey domains included hospital and PPC program demographics; OPPC development, structure, staffing, and workflow; metrics of successful OPPC implementation; and other services/partnerships.

RESULTS

Of 48 eligible sites, 36 (75%) completed the survey. Clinic-based OPPC programs were identified at 28 (78%) sites. OPPC programs reported a median age of 9 years [range: 1-18 years] with growth peaks in 2011, 2012 and 2020. OPPC availability was significantly associated with increased hospital size [P = 0.05] and inpatient PPC billable full time equivalent staff [P = 0.01]. Top referral indications included pain management, goals of care, and advance care planning. Funding primarily came from institutional support and billing revenue.

CONCLUSIONS

Although OPPC remains a young field, many inpatient PPC programs are growing into the outpatient setting. Increasingly, OPPC services have institutional support and diverse referral indications from multiple subspecialties. However, despite high demand, resources remain limited. Characterization of the current OPPC landscape is crucial to optimize future growth.

Patterns of Pediatric Palliative and End-of-Life Care in Neonatal Intensive Care Patients in the Southern U.S

CONTEXT

Despite high rates of mortality among infants in the Southern U.S., little is known about the timing of pediatric palliative care (PPC), the intensity of end-of-life care, and whether there are differences among sociodemographic characteristics.

OBJECTIVES

To describe PPC patterns and treatment intensity during the last 48 hours of life among neonatal intensive care unit (NICU) patients in the Southern U.S. who received specialized PPC.

METHODS

Medical record abstraction of infant decedents who received PPC consultation in two NICUs (in Alabama and Mississippi) from 2009 to 2017 (n = 195) including clinical characteristics, palliative and end-of-life care characteristics, patterns of PPC, and intensive medical treatments in the last 48 hours of life.

RESULTS

The sample was racially (48.2% Black) and geographically (35.4% rural) diverse. Most infants died after withdrawal of life-sustaining interventions (58%) and had do not attempt resuscitation orders documented (75.9%); very few infants enrolled in hospice (6.2%). Initial PPC consult occurred a median of 13 days after admission and a median of 17 days before death. Infants with a primary diagnosis of genetic or congenital anomaly received earlier PPC consultation (P = 0.02) compared to other diagnoses. In the last 48 hours of life, NICU patients received intensive interventions including mechanical ventilation (81.5%), CPR (27.7%) and surgeries or invasive procedures (25.1%). Black infants were more likely to receive CPR compared to White infants (P = 0.04).

CONCLUSION

Overall, PPC consultation occurred late in NICU hospitalizations, infants received high-intensity medical interventions in the last 48 hours of life, and there are disparities in intensity of treatment interventions at end of life. Further research is needed to explore if these patterns of care reflect parent preferences and goal concordance.

Pediatric palliative care for children with cancer: a concept analysis using Rodgers' evolutionary approach

BACKGROUND

Providing access to pediatric palliative care (PPC) for children living with a serious illness, such as cancer, is of critical importance, although this specialized intervention, as a novel concept, still seems vague and complicated. The present study analyzed the concept of PPC for children with cancer.

METHODS

Rodgers' evolutionary method was employed for the concept analysis. Articles on PPC, particularly those for children suffering from cancer, published between 2010 and 2021 were searched in valid academic research databases. The inclusion criteria for the full-text articles were based on the characteristics, antecedents, and consequences of PPC for children with cancer.

RESULTS

In total, 19 relevant articles were selected and then reviewed and analyzed after applying the inclusion criteria and the final sampling. The analysis of the concept of PPC for children affected with cancer revealed four characteristics, including "PPC as holistic and integrated care", "PPC as patient- and family-centered care", "PPC as early-start continuous care", and "PPC as interdisciplinary and team-based care". Some effective factors could also act as antecedents for this concept, i.e., health care providers' training and expertise as well as human resources and financing. Moreover, improved quality of life, symptom reduction, and coordination between patient care and family support were among the PPC consequences for such children.

CONCLUSIONS

The study results demonstrated that delivering PPC to children with cancer demanded a comprehensive view of its various dimensions. Furthermore, numerous factors need to be delineated for its accurate and complete implementation.

Multidisciplinary Clinician Perspectives on Embedded Palliative Care Models in Pediatric Cancer

CONTEXT

Integration of palliative care (PC) into pediatric cancer care is considered best practice by national oncology and pediatric organizations. Optimal strategies for PC integration remain understudied, although growing evidence suggests that embedded models improve quality of care and quality of life for patients and families.

OBJECTIVES

To describe the perspectives and preferences of multidisciplinary clinicians regarding ideal models for PC integration in pediatric cancer care; to introduce clinicians to the theoretical concept of an embedded care model; to empower clinicians in co-design of a new institutional model through collaborative discussion of anticipated benefits and challenges of embedded model implementation.

METHODS

Trained facilitators conducted 24 focus groups, stratified by discipline and care team. Focus groups were audio-recorded and transcribed for inductive content analysis using MAXQDA software.

RESULTS

174 clinicians participated (25 physicians, 30 advanced practice providers [APPs], 70 nurses, 49 psychosocial clinicians). Clinicians across disciplines verbalized that an embedded PC model would improve access to PC; however, identified benefits and challenges varied by discipline. Benefits included earlier integration of PC (physicians, APPs), normalization of PC as an integral aspect of care by patients/families (nurses, psychosocial), collaboration (physicians, psychosocial clinicians), and communication (APPs, psychosocial). Anticipated challenges included inadequate resources and physician resistance (physicians, APPs, nurses) and multidisciplinary role confusion (APPs, nurses, psychosocial).

CONCLUSION

Pediatric clinicians recognize the potential value of an embedded PC model. Although some concepts overlapped, multidisciplinary clinicians offered unique beliefs, highlighting the importance of including representative perspectives to ensure that pediatric PC models align with priorities of diverse stakeholders.

The Supportive Care Clinic: A Novel Model of Embedded Pediatric Palliative Oncology Care

CONTEXT

Pediatric palliative care (PPC) improves quality of life and end-of-life outcomes for children with cancer, but often occurs late in the disease course. The Supportive Care Clinic (SCC) was launched in 2017 to expand outpatient PPC access.

OBJECTIVES

To describe the inaugural four years (2017-2021) of an academic, consultative, embedded SCC within pediatric oncology.

METHODS

Descriptive statistics (demographic, disease, treatment, visit, and end-of-life) and change over time were calculated.

RESULTS

During the first four years, 248 patients (51.6% male; 58.1% White; 35.5% Black; 13.7% Hispanic/Latino) were seen in SCC, totaling 1,143 clinic visits (median 4, IQR 2,6), including 248 consultations and 895 follow-up visits. Clinic visits grew nearly 300% from year one to four. Primary diagnoses were central nervous system tumor (41.9%), solid tumor (37.5%), and leukemia/lymphoma (17.3%). The first point of PPC contact became SCC (70.6%) for most referred patients. Among the 136 deceased patients (54.8%), 77.9% had a do-not-resuscitate or Physician Orders for Life Sustaining Treatment in place, and 72.8% received hospice care. When known (n = 112), 89.3% died in their preferred location. The time from SCC consultation to death increased from 74 to 226 days over the four years (P < 0.0001). The proportion of SCC consultations that occurred greater than 90 days from death increased from 39.1% in year one to 85.0% in year four.

CONCLUSION

Embedded SCC clinics can be successful, achieve steady growth, improve referrals and timing of PPC, and enhance end-of-life care for children with cancer. Large pediatric cancer centers should include SCC outpatient services.

Pediatric Palliative Care in Oncology: Basic Principles

Simple Summary

About 4 million children with an oncological disease worldwide require palliative care due to the nature of their condition. The WHO defines pediatric palliative care (PPC) as the prevention and relief of suffering in patients with life-threatening or life-limiting disease and their families. PPC relies on the comprehensive and multidisciplinary management of the child and the family’s physical, psychological, spiritual, and social needs. Importantly, PPC begins at the diagnosis of incurability, or supposed incurability, and continues regardless of whether the patient receives any oncological treatment. As such, PPC is a general approach continuing over the entire disease trajectory, which includes, but is not limited to, end-of-life care. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology.

Abstract

About 4 million children with an oncological disease worldwide require pediatric palliative care (PPC) due to the nature of their condition. PPC is not limited to end-of-life care; it is a general approach continuing over the entire disease trajectory, regardless of whether the patient receives any oncological treatment. This review addresses the value of integrating PPC in treating children with cancer, focusing on the basic principles of PPC and its application in pediatric oncology. Moreover, models for PPC implementation in oncology, end-of-life care, and advanced care planning are discussed.

Palliative Care in Paediatric Oncology: an Update

Purpose of this Review

The purpose of this review is to describe the evolution of palliative care in paediatric oncology, the needs of children and their families in a paediatric oncology setting, palliative care referral practices in paediatric oncology, outcomes of palliative care referral in paediatric oncology and models of palliative care in paediatric oncology.

Recent Findings

Cancer constitutes 5.2% of the palliative care needs in children. Approximately, 90% of children with cancer lives in low and middle-income countries, constituting 84% of the global burden of childhood cancers. Children in low and middle-income countries have low cure rates and high death rates making palliative care relevant in a paediatric oncology setting. Children with cancer experience pain and physical symptoms, low mood, anxiety, and fear. They feel less resilient, experience low self-worth, and have challenges coping with the illness. The families lead very stressful lives, navigating the hospital environment, and dealing with uncertainties of the future. Palliative care referral in children with cancer improves physical symptoms, emotional support, and quality of life. It enables communication between families and health care providers. It improves end-of-life care support to children and their families and facilitates less invasive diagnostic and therapeutic interventions at the end of life. Worldwide children with cancer are infrequently referred to palliative care and referred late in the illness trajectory. Most of the children referred to palliative care receive some form of cancer-directed therapy in their last days. Children in low and low-middle income countries are less likely to access palliative care due to a lack of awareness amongst paediatric oncologists about palliative care and the reduced number of services providing palliative care. A three-tier model is proposed to provide palliative care in paediatric oncology, where most children with palliative care needs are managed by paediatric oncologists and a smaller number with complex physical and psychosocial needs are managed by paediatric palliative care specialists. There are several palliative care models in paediatric oncology practised globally. However, no one model was considered better or superior, and the choice of model depended on the need, preferences identified, and available resources.

Summary

Children with cancer are sparingly referred to palliative care and referred late and oncologists and haematologists gatekeep the referral process. Knowledge on palliative care referral in paediatric oncology settings might enhance collaboration between paediatric oncology and paediatric palliative care.

The Use of Telemedicine for Home-Based Palliative Care for Children With Serious Illness: A Scoping Review

CONTEXT

There is potential value to home-based palliative care for children with serious illness delivered via telemedicine (TM HBPC). Evidence to guide optimal design and delivery of TM HBPC is urgently needed.

OBJECTIVES

To explore the existing literature to identify research on pediatric TM HBPC.

METHODS

Systematic scoping review conducted following preferred reporting items for systematic reviews and meta-analysis for scoping reviews guidelines. PubMed, Embase, Cochrane CENTRAL, CINAHL, Web of Science, PsycINFO, and ERIC were searched (January-April 2020) using keywords and controlled vocabulary. The Reach, Effectiveness, Adoption, Implementation, Maintenance framework was used to identify components in the literature that facilitate or limit dissemination of TM HBPC interventions.

RESULTS

Seventeen articles were included. Most of the literature comprised small descriptive studies, such as case reports, and feasibility trials. Many studies focused on acceptability, and the TM HBPC model was generally acceptable to both clinicians and families. Few studies measured patient access to care, patient, and family centered health or quality of life outcomes. While included studies addressed multiple criteria for each of the Reach, Effectiveness, Adoption, Implementation, Maintenance dimensions, much of the information was qualitative and subjective.

CONCLUSION

TM HBPC is a promising strategy to increase access to palliative care for children with serious illness. However, the current review found a need for more robust information describing implementation and effectiveness of TM HBPC models, adaptation across care settings, and maintenance over time to guide and facilitate broader dissemination.

Relationship of race and ethnicity on access, timing, and disparities in pediatric palliative care for children with cancer

PURPOSE

Pediatric palliative care (PPC) improves quality of life for children and adolescents with cancer. Little is known about disparities between different racial and ethnic groups in the frequency and timing of PPC referrals. We evaluated the impact of race and ethnicity on the frequency and timing of PPC referral after initiation of an embedded PPO clinic where no formal consultation triggers exist.

METHODS

Patients with cancer between 0 and 25 years at diagnosis who experienced a high-risk event between July 2015 and June 2018 were eligible. Demographic, disease, and PPC information were obtained. Descriptive statistics and logistic regression were used to assess likelihood of receiving PPC services by race/ethnicity.

RESULTS

Of 426 patients who experienced a high-risk event, 48% were non-Hispanic White, 31% were non-Hispanic Black, 15% were Hispanic of any race, and 4% were non-Hispanic Asian. No significant differences were found between race/ethnicity and age at diagnosis/death, sex, and diagnosis. PPC consultation (p = 0.03) differed by race. Non-Hispanic Black patients were 1.7 times more likely than non-Hispanic White patients to receive PPC after adjustment (p = 0.01). White patients spent less days in the hospital in the last 90 days of life (3.0 days) compared with Black (8.0), Asian (12.5), or Hispanic patients (14.0, p = 0.009) CONCLUSION: Disparities exist in patients receiving pediatric oncology and PPC services. Cultural tendencies as well as unconscious and cultural biases may affect PPC referral by race and ethnicity. Better understanding of cultural tendencies and biases may improve end-of-life outcomes for children and young adults with cancer.

Palliative home-based care to pediatric cancer patients: characteristics and healthcare delivered

OBJECTIVES

Cancer patients constitute an important group in pediatric palliative care. Though the patients' home is the preferred place of care, little is known about the characteristics of patients attended by units that provide home assistance. Our objective is to describe the characteristics of cancer patients and healthcare delivered by a pediatric palliative care unit with a home hospitalization program.

METHODS

Retrospective study based on clinical records of deceased patients attended by the pediatric palliative care unit of Madrid over 10 years. Data collected included general characteristics, type of cancer, whether they received home assistance, place of death, healthcare delivered (hospitalizations, devices, oncological treatments…), and symptom prevalence.

RESULTS

After excluding 47 patients, the clinical records of 144 patients were analyzed. The median age at referral was 9.4 years (IQR: 5.6-14.1), 61.2% were males; 44.2% had solid non-CNS tumors, 35.4% CNS tumors, and 20.4% hematological malignancies; 137 received home care with 89 not requiring further hospital admissions and 70.1% dying at home. The median follow-up time was 1.6 months (IQR: 0.5-2.9). The most used devices were venous ports (71.4%) and oxygen (49.4%); 53.5% of the patients received oncological support therapies. The most common symptoms were pain (91.8%) dyspnea (49.0%) and fatigue (46.9%).

CONCLUSIONS

Home assistance was provided in a high number of patients, with a large proportion needing one or no hospital admissions and 70.1% of them dying at home. Further studies characterizing these patients and the factors which promote early access to palliative care are needed.

Providing Palliative and Hospice Care to Children, Adolescents and Young Adults with Cancer

OBJECTIVES

To describe palliative, concurrent, and hospice care in pediatric oncology in the United States (US), we present a clinical scenario illustrating palliative and hospice care, including eligibility for concurrent care, insurance coverage and billing, barriers to accessing quality pediatric palliative and hospice care, and implications for oncology nursing practice.

DATA SOURCES

Peer-reviewed articles, clinical practice guidelines, professional organizations, and expert clinical opinion examining pediatric oncology, palliative care, and hospice care.

CONCLUSION

Understanding the goals of palliative and hospice care and the differences between them is important in providing holistic, goal-directed care.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses play a pivotal role in supporting the goals of pediatric palliative care and hospice care and in educating patients and their families. Nurses form trusting relationships with pediatric oncology patients and their families and are in a position to advocate for best palliative care practices as disease progresses to end of life, including when appropriate concurrent care or hospice.

Defining and timing of palliative opportunities in children with central nervous system tumors

Background

Children with brain and central nervous system (CNS) tumors experience substantial challenges to their quality of life during their disease course. These challenges are opportunities for increased subspecialty palliative care (PC) involvement. Palliative opportunities have been defined in the pediatric oncology population, but the frequency, timing, and factors associated with palliative opportunities in pediatric patients with CNS tumors are unknown.

Methods

A single-institution retrospective review was performed on children ages 0-18 diagnosed with a CNS tumor who died between January 1, 2012 and November 30, 2017. Nine palliative opportunities were defined prior to data collection (progression, relapse, admission for severe symptoms, intensive care admission, bone marrow transplant, phase 1 trial, hospice, do-not-resuscitate (DNR) order). Demographic, disease, treatment, palliative opportunity, and end-of-life data were collected. Opportunities were evaluated over quartiles from diagnosis to death.

Results

Amongst 101 patients with a median age at death of eight years (interquartile range [IQR] = 8.0, range 0-22), there was a median of seven (IQR = 6) palliative opportunities per patient, which increased closer to death. PC consultation occurred in 34 (33.7%) patients, at a median of 2.2 months before death, and was associated with having a DNR order (P = .0028). Hospice was involved for 72 (71.3%) patients.

Conclusion

Children with CNS tumors suffered repeated events warranting PC yet received PC support only one-third of the time. Mapping palliative opportunities over the cancer course promotes earlier timing of PC consultation which can decrease suffering and resuscitation attempts at the end-of-life.

Feasibility, Acceptability, and Education of Pediatric Oncology Providers Before and After an Embedded Pediatric Palliative Oncology Clinic

PURPOSE

Most pediatric palliative care (PPC) education is trainee-directed, didactic, or simulation-based and therefore limited in scope, realism, and audience. We explored whether an embedded pediatric palliative oncology (PPO) clinic is associated with improved pediatric oncology provider palliative care comfort, knowledge, and attitudes toward PPC and if the model is feasible for both clinical care and education of providers of all levels.

METHODS

Oncology providers (oncologists, advanced practice providers, and fellows) were enrolled in this study. Based on interaction with the PPO clinic, two cohorts were defined: PPO providers (n = 11, 37.9%) and non-PPO providers (n = 18, 62.1%). Providers in both groups responded to qualitative and quantitative questionnaires about the feasibility and acceptability of PPO clinic, their attitudes toward PPC, and knowledge and comfort in PPC concepts at baseline and 1 year. Descriptive statistics were performed; demographic and outcome variables across cohorts by PPO grouping and experience were compared.

RESULTS

All 29 pediatric oncology providers reported acceptability of a PPO clinic and favorable attitudes about PPC. The most feasible clinic model was oncology followed by PPO visits. Non-PPO group and less experienced (≤ 10 years) providers had greater improvement in knowledge and comfort with PPC skills than PPO group or more experienced providers. Providers lacked comfort in non-pain symptom management skills.

CONCLUSION

This embedded PPO clinic model was feasible, acceptable, and highly rated by responding oncology clinicians, but was insufficient as a sole method of educating multidisciplinary oncology providers. Methods of combining clinical and formal education are needed to impart sustained educational change.

Palliative Care in High and Low Resource Countries

Palliative Care (PC) is defined by the World Health Organization (WHO) as a support provided by multiple disciplines in order to improve the quality of life of both patients and their caregivers, throughout the disease course, from diagnosis to end-of-life. PC aims to prevent and treat symptoms and side effects of the disease and its treatment. PC is well developed in most high- -income countries; however in most low-income settings, where approximately 80% of patients with cancer requiring PC care for advanced disease live, PC services are still uncommon. Health indicators monitoring global PC development are policy, education, use of medicines, service provision and professional activity. Globally, PC development may be categorized as Group 1 (no known hospice-PC activity), Group 2 (capacity-building activity), Groups 3a Isolated PC provided, 3b Generalized PC provided, 4a hospice-PC services at a stage of integration into regular service provision, and 4b hospice-PC services at a stage of advanced integration into regular service provision. Spirituality is an essential element of patient-centered PC. The use of Complementary and Traditional Medicine (CTM) in Middle Eastern countries is widespread. There are wide discrepancies in cancer care and PC in many regions of the world. The Individualized Care Planning and Coordination (ICPC) Model is designed to facilitate the advance care planning with continuity of all the measures like symptom control or emotional, social and spiritual care of both the patient and the family during the disease steps like relapse or end of life.

Defining palliative opportunities in pediatric patients with bone and soft tissue sarcomas

BACKGROUND

Pediatric patients with sarcomas experience significant morbidity and compromised quality of life throughout their course. These times could be viewed as opportunities for increased subspecialty palliative care (PC). Systematically defining opportunities for additional PC support has not occurred in pediatric oncology. The frequency, timing, and associated factors for palliative opportunities in pediatric patients with sarcomas are unknown.

METHODS

A priori, nine palliative opportunities were defined (disease progression or relapse, admission for symptoms, social concerns or end-of-life, intensive care or bone marrow transplant admission, phase 1 trial or hospice enrollment, do-not-resuscitate status). A single-center retrospective review was conducted on patients aged 0-18 years with bone/soft tissue sarcomas who died from January 1, 2012 to November 30, 2017. Demographic, disease, and treatment data were collected. Descriptive statistics were performed. Opportunities were evaluated over quartiles from diagnosis to death.

RESULTS

Patients (n = 60) had a mean of nine (SD = 4) palliative opportunities with the majority occurring in the last quartile of the disease course. Number and type of opportunities did not differ by demographics or diagnosis. Eighteen patients (30%) received PC consultation a median of 2.2 months (interquartile range [IQR] 11.5) prior to death. Consultation was unrelated to diagnosis or total opportunities.

CONCLUSIONS

Patients with sarcomas incur repeated events warranting subspecialty PC, which increase toward the end-of-life. Increased PC utilization may help decrease suffering and bolster family coping during these episodes. Additional work should further refine if opportunities differ across cancers, and how to incorporate this framework into clinical oncology care to prevent missed opportunities for PC.

Association of a pediatric palliative oncology clinic on palliative care access, timing and location of care for children with cancer

Background

Most pediatric palliative care (PPC) services are inpatient consultation services and do not reach patients and families in the outpatient and home settings, where a vast majority of oncology care occurs. We explored whether an embedded pediatric palliative oncology (PPO) clinic is associated with receipt and timing of PPC and hospital days in the last 90 days of life.

Methods

Oncology patients (ages 0–25) with a high-risk event (death, relapse/progression, and/or phase I/II clinical trial enrollment) between 07/01/2015 and 06/30/2018 were included. PPO clinic started July 2017. Two cohorts were defined: pre-PPO (high-risk event(s) occurring 07/01/2015–06/30/2017) and post-PPO (high-risk event(s) occurring 07/01/2017–06/30/2018). Descriptive statistics were performed; demographic, disease course, and outcomes variables across cohorts were compared.

Results

A total of 426 patients were included (pre-PPO n = 235; post-PPO n = 191). Forty-seven patients with events in both pre- and post-PPO cohorts were included in the post-PPO cohort. Mean age at diagnosis was 8 years. Diagnoses were evenly distributed among solid tumors, brain tumors, and leukemia/lymphoma. Post-PPO cohort patients received PPC more often (45.6% vs. 21.3%, p < 0.0001), for a longer time before death than the pre-PPO cohort (median 88 vs. 32 days, p = 0.027), and spent fewer days hospitalized in the last 90 days of life (median 3 vs. 8 days, p = 0.0084).

Conclusion

A limited-day, embedded PPO clinic was associated with receipt of PPC and spending more time at home in patients with cancer who had high-risk events. Continued improvements to these outcomes would be expected with additional oncology provider education and PPO personnel.

Behind the Scenes: Care Coordination Time in an Outpatient Pediatric Palliative Oncology Clinic

Background: Integrated pediatric palliative oncology (PPO) outpatient models are emerging to assist oncologists, children, and families throughout their course with cancer. Significant time is devoted to care coordination ("nonbillable" time), but the scope, time per patient, and ratio of nonbillable to billable (NB:B) minutes are unknown. This information is crucial to designing new PPO outpatient clinics and advocating for appropriate personnel, physician time, and resources. Our objectives were to quantify nonbillable time and evaluate demographic or disease-based associations. Methods: A single-institution one-day PPO clinic was started in July 2017. All encounters were tracked for 11 months. Administrative and PPO inpatient time were excluded. Billable and nonbillable minutes were recorded daily. Ratios of NB:B minutes by patient demographics and clinical factors were calculated using descriptive statistics and multivariate modeling. Results: Ninety-five patients were included [solid tumors (42, 44%), brain tumors (33, 35%), and leukemia/lymphoma (20, 21%)]. PPO completed billable visits on 52 of 95 (55%) patients and assisted without billing in the care of 43 patients (45%). Twenty-four (25%) patients were deceased. Overall NB:B ratio was 1.04 and differed among diagnoses (leukemia/lymphoma 2.5, solid tumor 0.9, and brain tumor 0.8). Deceased patients had a higher ratio of NB:B minutes than alive patients (1.9 vs. 0.8, p = 0.012). Billable and nonbillable minutes both increased over time. Conclusions: Care coordination in a PPO clinic is time intensive and grows with clinic volume. When devising a PPO outpatient program, this NB:B ratio should be accounted for in clinician time and personnel devoted to patient and family assistance.