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Hodge CH, Kerris EWJ, Freeman MC, Eckman ST, Deeter DM, Even KM. Implementation of an Innovative Palliative Care Screening Tool in the Pediatric Intensive Care Unit: A Pilot Study. J Palliat Med 2024; 27:307-315. [PMID: 37815840 DOI: 10.1089/jpm.2023.0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
Background: Pediatric palliative care (PPC) can improve the quality of care provided to critically ill children with a high risk of morbidity and mortality. Early identification of patients admitted to the pediatric intensive care unit (PICU) who may benefit from PPC involvement is essential. Objectives: To create a brief screening tool, the Pediatric Intensive Care-Pediatric Palliative Care Screen, identifying PICU patients most likely to benefit from PPC involvement and to assess if weekly screening with this screening tool increases the number of PPC consults placed in the PICU. Methods: This is a prospective investigational single-center study in a 24-bed PICU at a U.S. tertiary care children's hospital. Weekly screening was completed by two clinicians for a six-month period between April and October 2022. Results: A total of 162 screens were completed on 124 individual patients; 47 screens were positive (29%), and 115 were negative (71%). Fourteen new PPC consults were placed from the PICU with one PPC consult for every 36.7 compared with one PPC for every 41.4 admissions the previous year. Of the positive screens, 68% had two or more comorbidities at the time of PICU admission versus 26% of negative screens (p < 0.001). Technology dependence (57% vs. 5%, p < 0.001) and presence of congenital defects (26% vs. 10%, p = 0.013) were significantly more common among positive screens. Conclusions: Weekly screening with a short, 7-question screening tool can identify PICU patients most likely to benefit from a PPC consult. Patients with chronic illnesses and baseline comorbidities are most likely to screen positive.
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Affiliation(s)
- Caitlyn H Hodge
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Elizabeth W J Kerris
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Michelle C Freeman
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Susannah T Eckman
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Deana M Deeter
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Katelyn M Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
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Salins N, Rao A, Dhyani VS, Prasad A, Mathew M, Damani A, Rao K, Nair S, Shanbhag V, Rao S, Iyer S, Gursahani R, Mani RK, Simha S. Palliative and end-of-life care practices for critically ill patients and their families in a peri-intensive care setting: A protocol for an umbrella review. Palliat Support Care 2024:1-8. [PMID: 38420705 DOI: 10.1017/s1478951524000130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVES This umbrella review will summarize palliative and end-of-life care practices in peri-intensive care settings by reviewing systematic reviews in intensive care unit (ICU) settings. Evidence suggests that integrating palliative care into ICU management, initiating conversations about care goals, and providing psychological and emotional support can significantly enhance patient and family outcomes. METHODS The Joanna Briggs Institute (JBI) methodology for umbrella reviews will be followed. The search will be carried out from inception until 30 September 2023 in the following databases: Cochrane Library, SCOPUS, Web of Science, CINAHL Complete, Medline, EMBASE, and PsycINFO. Two reviewers will independently conduct screening, data extraction, and quality assessment, and to resolve conflicts, adding a third reviewer will facilitate the consensus-building process. The quality assessment will be carried out using the JBI Critical Appraisal Checklist. The review findings will be reported per the guidelines outlined in the Preferred Reporting Items for Overviews of Reviews statement. RESULTS This umbrella review seeks to inform future research and practice in critical care medicine, helping to ensure that end-of-life care interventions are optimized to meet the needs of critically ill patients and their families.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Arathi Rao
- Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vijay Shree Dhyani
- Evidence Synthesis Specialist, Kasturba Medical College, Manipal, Karnataka, India
| | - Ashmitha Prasad
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
| | - Mebin Mathew
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
| | - Anuja Damani
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Krithika Rao
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shreya Nair
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Vishal Shanbhag
- Department of Critical Care Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shwethapriya Rao
- Department of Critical Care Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth University Medical College, Pune, India
| | - Roop Gursahani
- Department of Neurology, P D Hinduja Hospital, Mahim, Mumbai, India
| | - R K Mani
- Department of Critical care, Yashoda Super Speciality Hospitals, Ghaziabad, India
| | - Srinagesh Simha
- Department of Pallitaive Medicine, Karunashraya Bangalore Hospice Trust, Bangalore, India
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Ellis D, Mazzola E, Wolfe J, Kelleher C. Comparing Pediatric Surgeons' and Palliative Care Pediatricians' Palliative Care Practices and Perspectives in Pediatric Surgical Patients. J Pediatr Surg 2024; 59:37-44. [PMID: 37827879 DOI: 10.1016/j.jpedsurg.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE The nature of interactions between surgical and pediatric palliative care (PPC) teams caring for seriously ill children is unknown. This study compares pediatric surgeons' and PPC physicians' perspectives and practices regarding PPC in surgical patients. METHODS A survey was administered to members of the American Pediatric Surgical Association and Pediatric Interest Group of the American Academy of Hospice and Palliative Medicine. RESULTS One hundred twenty-four pediatric surgeons (31% female, 17.2 mean years of experience) and 71 PPC physicians (69% female, 10.1 mean years of experience) participated. Forty-three percent of surgeons reported consulting PPC often for children with serious illnesses. However, most PPC physicians (67%), said they are rarely/never consulted by surgeons (p = 0.002). PPC physicians were more likely to report that PPC involvement was too late (43% vs 21%, p = 0.005). More surgeons than PPC physicians felt that an appropriate time for PPC consultation was during serious illness deterioration (30% vs 7%, p = 0.05), whereas PPC physicians preferred consultation at diagnosis (54% vs 34%, p = 0.05). More PPC physicians (67%) than surgeons (17%) agreed that invasive interventions could be considered a form of PPC (p = 0.002). The most reported barrier to PPC consultation by surgeons (29%) was concern that parents would think the surgical team was giving up. PPC physicians were more likely to perceive barriers to consultation by surgeons than surgeons themselves (p < 0.001). CONCLUSION While pediatric surgeons value PPC involvement, surgical culture and misperception of parental resistance to PPC involvement lead to palliative care consultation only when illness acuity and severity are high, the possibility of curability is low, and death seems imminent. Seeking to understand patient and family priorities in care, managing patient and parental psychological distress, and treating non-surgical symptoms are areas where PPC can improve patient care. Barriers to PPC use and self-reported knowledge gaps in PPC provision may be mitigated by formalized PPC training for surgeons and intentional collaboration between the two groups. TYPE OF STUDY Survey. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Danielle Ellis
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA.
| | - Emanuele Mazzola
- Department of Data Science, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Joanne Wolfe
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cassandra Kelleher
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston MA, USA
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Lyons KA, Middleton AA, Farley AA, Henderson NE, Peterson EB. End-of-Life Care Education in Pediatric Critical Care Medicine Fellowship Programs: Exploring Fellow and Program Director Perspectives. J Palliat Med 2023; 26:1217-1224. [PMID: 37093219 DOI: 10.1089/jpm.2022.0397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Background/Objectives: The aim of this study is to describe the current state of end-of-life (EOL) care education within pediatric critical care medicine (PCCM) fellowship programs and explore potential differences in beliefs on EOL care education between program directors (PDs) and fellows. Design: A mixed-methods study based on data obtained through a nationally distributed, web-based cross-sectional survey of PCCM fellowship PDs and PCCM fellows was performed. Setting: Accreditation Council for Graduate Medical Education (ACGME)-accredited PCCM fellowships in the United States. Subjects: PCCM fellows and PDs participated in this study. Measurements and Results: The total number of survey respondents was 124 (94/654 fellows and 30/96 PDs), representing 39% of ACGME-accredited PCCM programs. Bedside teaching and lecture-based modalities were the most commonly used methods to teach EOL care. Most fellows and PDs reported a perceived need for additional EOL education within their respective training programs (fellows 91%, n = 86/94; PDs 67%, n = 20/30). A thematic analysis of curriculum structure questions revealed significant similarities between PDs and fellows, including the perceived need for education in communication, medical management, and cultural awareness. Dealing with uncertainty and resiliency were identified as themes among PDs only, and emotional/moral and legal issues were identified as themes solely by fellows. Conclusions: Our study describes the current state of EOL care education within a sample of PCCM fellowship programs. We highlight the perceived need for additional EOL education and identify areas within EOL care that deserve more focus by PCCM fellows and PDs. Future studies with focus on EOL curriculum development in PCCM EOL training are needed.
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Affiliation(s)
- Kelly A Lyons
- Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky, USA
| | - Alyssa A Middleton
- Doctor of Social Work Department, Kent School of Social Work, University of Louisville, Louisville, Kentucky, USA
| | - Alyssa A Farley
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Natalie E Henderson
- Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky, USA
| | - Eleanor B Peterson
- Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky, 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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Ellis DI, Nye RT, Wolfe J, Feudtner C. Surgical Intervention in Patients Receiving Pediatric Palliative Care Services. Pediatrics 2023; 151:e2022058905. [PMID: 36606343 PMCID: PMC9890391 DOI: 10.1542/peds.2022-058905] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Many patients receiving pediatric palliative care (PPC) present with surgically treatable problems. The role of surgery in the care of these patients, however, has not yet been defined. We conducted a cohort study of children receiving PPC to assess the incidence, type, and likely purpose of surgical interventions performed after the initiation of PPC. METHODS We performed a cohort analysis of surgical interventions performed on children enrolled in an ongoing, multicenter, prospective cohort study. Patients aged <30 years receiving PPC services were eligible for inclusion in the study. Analyses included descriptive and comparative statistics, as well as logistic regression models. RESULTS After initiation of PPC, 81.1% (n = 488) of patients had undergone at least 1 surgical intervention (range, 1-71) with a median of 4 interventions (interquartile range, 1-9). The most frequent surgical interventions were feeding tubes, endoscopic biopsy, tracheostomy, bone marrow biopsy, tunneled catheters, bronchoscopy, and chest tube placement, followed by sternum closure, abdominal closure, atrial and ventricular septal defect repairs, and heart transplantation. Children who underwent surgical interventions were statistically less likely to die while receiving PPC (29% vs 40%, P < .03). CONCLUSIONS Most children receiving PPC services undergo at least 1 surgical intervention, and many undergo numerous interventions. Undergoing intervention is not futile because surgical intervention is associated with longer survival. Various patient populations that are more likely, as well as less likely, to undergo surgical intervention warrant specific focus.
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Affiliation(s)
| | - Russell T. Nye
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute
- Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chris Feudtner
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Pediatric Advanced Care Team and Department of Medical Ethics, Children’s Hospital of Philadelphia, the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Bogetz JF, Johnston E, Ananth P, Patneaude A, Thienprayoon R, Rosenberg AR. Survey of Pediatric Palliative Care Quality Improvement Training, Activities, and Barriers. J Pain Symptom Manage 2022; 64:e123-e131. [PMID: 35577143 DOI: 10.1016/j.jpainsymman.2022.04.182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/19/2022] [Accepted: 04/30/2022] [Indexed: 11/24/2022]
Abstract
CONTEXT Children with serious illness deserve high-quality pediatric palliative care (PPC). With expansion of PPC provision, it is important to understand the quality improvement (QI) activities of PPC clinicians and programs. OBJECTIVES To describe the 1) background, education/training, and activities in QI and 2) perceived barriers to QI efforts among PPC clinicians and programs nationally. METHODS An electronic survey was sent to members of the Pediatric Palliative Improvement Network, the National Coalition for Hospice and Palliative Care Pediatric Task Force, and the PPC Research Network as part of a study to develop hospital-based, primary PPC quality measures. Surveys queried participants' background, education/training, individual/team QI efforts, and barriers to QI work. Results were summarized descriptively. RESULTS Of the 95 respondents; most were female (84 [88%]) and/or white (84 [88%]). The majority (57 [54%]) were physicians, although participants represented a variety of clinical disciplines, researchers (10 [9%]), and administrators (6 [6%]). One-quarter (25 [26%]) reported having <10 hours total of training in QI, yet two-third (63 [66%]) participated in QI work. About one-third (35 [37%]) reported that their program had no dedicated staff for QI activities, yet over half (56 [59%]) of participants reported that their team participated in QI work. Participants reported that lack of personnel/time, standardized measures/tools, education/training/mentoring in QI, systems to promote QI work, and financing/grants were barriers. CONCLUSION Over half of PPC participants in this study reported involvement in QI activities despite limited staffing/time, QI training, and standardized measures, which presents challenges to this work.
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Affiliation(s)
- Jori F Bogetz
- Division of Bioethics and Palliative Care (J.F.B.), Department of Pediatrics, University of Washington School of Medicine; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA.
| | - Emily Johnston
- Division of Pediatric Hematology-Oncology (E.J.), Department of Pediatrics, University of Alabama at Birmingham School of Medicine; Institute for Cancer Outcomes and Survivorship, UAB School of Medicine, Birmingham, Alabama, USA
| | - Prasanna Ananth
- Department of Pediatrics (P.A.), Yale School of Medicine, Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, Connecticut, USA
| | - Arika Patneaude
- Bioethics and Palliative Care (A.P.), Seattle Children's Hospital, Clinical Assistant Professor, University of Washington School of Social Work, Seattle, Washington, USA
| | | | - Rachel Thienprayoon
- University of Cincinnati College of Medicine (R.T.), Department of Anesthesia, Division of Palliative Care, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Abby R Rosenberg
- Division of Hematology and Oncology (A.R.R.), Department of Pediatrics, University of Washington School of Medicine, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
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Kuzlu Ayyildiz T, Kurt A, Topan A, Kulakçı Altıntaş H, Veren F, Üstüner Top F. Difficulties Experienced by Turkish Parents With Children in Pediatric Palliative Care: An Exploratory Qualitative Study. OMEGA-JOURNAL OF DEATH AND DYING 2022:302228221097291. [PMID: 35471123 DOI: 10.1177/00302228221097291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We aimed to identify the difficulties of the parents of pediatric palliative care patients and how they cope with these problems in this qualitative study in Turkey. This study was carried out with 20 parents by in-depth interviews. Content analysis was used for data analysis. Four themes were identified: The problems in the process of acceptance, the difficulties of being at the hospital, the expectations from the health staff, the coping strategies. The families had difficulties in coping with the end-of-life of their children. Future researches may focus on the effectiveness of family-centered care and the experience of parents with its implementation. The findings suggest that social support resources and coping strategies can play an important role in the acceptance of the child's disease process and maintenance of palliative care effectively.
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Affiliation(s)
- Tülay Kuzlu Ayyildiz
- Faculty of Health Sciences, Department of Pediatric Nursing, 53001Zonguldak Bülent Ecevit University, Zonguldak, Turkey
| | - Aylin Kurt
- Faculty of Health Sciences, Department of Pediatric Nursing, 162311Bartın University, Bartın, Turkey
| | - Aysel Topan
- Faculty of Health Sciences, Department of Pediatric Nursing, 53001Zonguldak Bülent Ecevit University, Zonguldak, Turkey
| | - Hülya Kulakçı Altıntaş
- Faculty of Health Sciences, Department of Pediatric Nursing, 53001Zonguldak Bülent Ecevit University, Zonguldak, Turkey
| | - Funda Veren
- Faculty of Health Sciences, Department of Pediatric Nursing, 53001Zonguldak Bülent Ecevit University, Zonguldak, Turkey
| | - Fadime Üstüner Top
- Faculty of Health Sciences, Pediatric Nursing, 187438Giresun University, Giresun, Turkey
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A Single-center Report of the Admission to Intensive Care Unit Effectiveness on Treatment and Survival of Children Diagnosed with Cancer in Iran. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2022. [DOI: 10.5812/ijcm.117517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Childhood cancer is the second leading cause of death in children. Approximately, 40% of children with cancer need to be admitted to the intensive care unit (ICU), which plays a key role in their treatment procedure and overall survival. Objectives: In this study, we aimed at evaluating the impact of ICU admission on pediatric patients’ survival and prognosis at Mahak Pediatric Cancer Treatment and Research Center (MPCTRC), Tehran, Iran. Methods: Amongst a total number of 2693 hospitalized patients who were referred to our center from March 2014 to September 2019, 674 patients younger than 14 years of age who were at least admitted once to the ICU were included in this study. All the collected data were analyzed using IBM-SPSS software version 22. Results: Totally, 48.96% of patients were female and 51.03% of them were male. The most frequent types of cancer were central nervous system tumors (33.23%) and Leukemia (18.99%). Additionally, 43.62% of admitted patients were in the 1 - 4 age group, with the mean age of 1.5 ± 0.30. The mortality rate in ICU was 40.20% and the overall survival (OS) rate was 29.5% ± 2.6. Moreover, the OS in children with solid tumors and non-solid tumors were 27.1% ± 5.5 and 32.6% ± 3.1, respectively. Conclusions: The results of this conducted study provide a complete report on the status of children admitted to the ICU ward in Mahak Hospital. Because of this fact that the most frequent type of cancer was CNS tumors and children with CNS tumors are usually admitted to the ICU in the late stages of their disease, the overall survival rate in our study was 29.80%, which is lower than other studies.
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10
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Grunauer M, Mikesell C, Bustamante Callejas G. Primary palliative care integrated model in paediatric ICU: an international cross-sectional study. BMJ Support Palliat Care 2021:bmjspcare-2020-002627. [PMID: 34610910 DOI: 10.1136/bmjspcare-2020-002627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 08/25/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Numbers are rising of chronically and critically ill, technology-dependent children, who are admitted to paediatric intensive care units (PICUs). An integrated model of care (IMOC), that combines paediatric critical care and primary paediatric palliative care (PPC), in which either approach varies depending on the disease trajectory and is provided by the critical care team, might be a fundamental component of the best available standard of care for patients with life-threatening conditions. The objective of this study is to assess how PICUs around the world, implement an IMOC. METHODS International multicentre cross-sectional observational study. Data was gathered from 34 PICUs from 18 countries in the Americas, Europe, Asia and Africa. Provision of primary PPC was studied for each child admitted at the PICU. We evaluated score differences in each domain of the Initiative for Paediatric Palliative Care (IPPC) curriculum with multilevel generalised linear models. RESULTS High-income country (HIC) units made up 32.4% of the sample, upper-middle income countries (UMICs) 44.1%, lower-middle income/lower income countries (LMIC/LICs) 23.5%. HICs had four statistically significantly higher IPPC scores compared with UMICs (domains: 1 holistic care; 2 family support, 3B family involvement; 6B grief/bereavement healthcare provider support) and two compared with LMIC/LICs (domains: 6A grief/bereavement family support; 6B grief/bereavement healthcare provider support).HICs had a statistically significant overall higher IPPC score than UMICs. Adjusting for patient/centre characteristics, shorter shifts and multiple comorbidities were associated with higher IPPC scores. CONCLUSIONS All centres offered some PPC provision and partially applied an IMOC. These results are encouraging, however, differences related to income and patients/unit evidence opportunities for improvement. TRIAL REGISTRATION NUMBER ISRCTN12556149.
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Affiliation(s)
- Michelle Grunauer
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
| | - Caley Mikesell
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
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11
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Basu MR, Partin L, Revette A, Wolfe J, DeCourcey DD. Clinician Identified Barriers and Strategies for Advance Care Planning in Seriously Ill Pediatric Patients. J Pain Symptom Manage 2021; 62:e100-e111. [PMID: 33823242 DOI: 10.1016/j.jpainsymman.2021.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Parents desire more opportunities for advance care planning (ACP), however, large-scale adoption of ACP for seriously ill children remains unrealized. Little is known about current approaches to ACP and strategies to circumvent existing barriers to ACP provision. OBJECTIVE To explore multidisciplinary clinician perceptions about perceived barriers and strategies to improve ACP provision. DESIGN Qualitative study including focus groups conducted with multidisciplinary clinicians at two centers from December 2018-April 2019. Iterative multi-stage thematic analyses were utilized to identify key contexts and themes pertaining to current approaches to ACP, as well as clinician perspectives on ACP barriers and improvement strategies. RESULTS Thirty-five clinicians (physicians, nurses, and psychosocial clinicians) participated in identifying both clinician and perceived patient and family barriers to initiating and engaging in ACP discussions, including mixed messaging, lack of knowledge of patient and family goals, prognostic uncertainty, poor prognostic awareness, unstandardized documentation, and family dynamics. Clinicians also identified strategies to overcome these barriers and to facilitate ACP discussions, including enhancing multidisciplinary communication, creation of a shared ACP communication framework, and formal training in ACP communication to normalize ACP throughout a child's disease trajectory. CONCLUSION Despite ubiquitous recognition of the importance of ACP communication, various clinician- and parent-level barriers were identified which impede ACP in children with serious illness and their families. Improvement strategies should focus on formal clinician training on how to conduct and document longitudinal ACP discussions to ensure care is aligned with family goals and values.
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Affiliation(s)
- Meera R Basu
- Department of Pediatrics, Boston Children's Hospital (M.R.B., L.P., J.W., D.D.D.), Boston, Massachusetts.
| | - Lindsay Partin
- Department of Pediatrics, Boston Children's Hospital (M.R.B., L.P., J.W., D.D.D.), Boston, Massachusetts
| | - Anna Revette
- Survey and Data Management Core, Dana Farber Cancer Institute (A.R.), Boston, Massachusetts
| | - Joanne Wolfe
- Department of Pediatrics, Boston Children's Hospital (M.R.B., L.P., J.W., D.D.D.), Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute (J.W.), Boston, Massachusetts
| | - Danielle D DeCourcey
- Department of Pediatrics, Boston Children's Hospital (M.R.B., L.P., J.W., D.D.D.), Boston, Massachusetts
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12
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Sabeti F, Mohammadpour M, Pouraboli B, Tahmasebi M, Hasanpour M. Health Care Providers' Experiences of the Non-Pharmacological Pain and Anxiety Management and Its Barriers in the Pediatric Intensive Care Units. J Pediatr Nurs 2021; 60:e110-e116. [PMID: 34412932 DOI: 10.1016/j.pedn.2021.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Children in the intensive care unit experience a high level of pain and anxiety. This study aimed to reveal the health care providers experience of non-pharmacological pain and anxiety management and its barriers in the pediatric intensive care unit. METHODS This qualitative-descriptive study was conducted with thirteen nurses and five physicians in the pediatric intensive care unit in Iran. Individual, in-depth and semi-structured interviews were conducted, which were analyzed by conventional content analysis. RESULTS Five main categories were identified from data analysis: 1) The importance of parents' presence, 2) Disturbance in the presence of parents and communication during the COVID-19 pandemic, 3) Choosing non-pharmacological approaches according to the child's interests and conditions, 4) Building trust in the child through non-pharmacological interventions 5) Barriers to non-pharmacological pain and anxiety management in the pediatric intensive care unit. CONCLUSION Health care providers implement some non-pharmacological methods to manage pain and anxiety in the pediatric intensive care unit. Facilitating the open presence of parents, using innovative methods to communicate with children, and training and psychological support for nurses and parents, especially during the COVID-19 pandemic are recommended.
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Affiliation(s)
- Fahimeh Sabeti
- Pediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Iran
| | - Masoud Mohammadpour
- Pediatric Intensivist, Pediatric Critical Care Division, Departement of Pediatrics, Children's Medical Center, Tehran University of Medical Sciences, Iran
| | - Batool Pouraboli
- Pediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Iran
| | - Mamak Tahmasebi
- Palliative Medicine Fellowship, Radiotherapy/Oncology Department, Palliative Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran
| | - Marzieh Hasanpour
- Member of Iranian Scientific Association of Medical Education. Pediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Iran.
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13
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Communication and Cultural Sensitivity for Families and Children With Life-Limiting Diseases: An Informed Decision-Making Ethical Case in Community-Based Palliative Care. J Hosp Palliat Nurs 2021; 22:270-275. [PMID: 32412925 DOI: 10.1097/njh.0000000000000654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The health care decisions of families of children who have life-limiting genetic diseases are impacted by multiple factors including religious and ethical values, education and knowledge, emotional trauma, availability of support, and accessibility of care. Palliative care nurses must practice the highest standards by delivering nonbiased, nonjudgmental support to patients and families; however, nurses may experience moral distress if their personal values conflict with a family's decisions and needs. This case focuses on a family receiving community-based palliative care for a child with a genetic life-limiting disease. They had a family history of this disease, which had caused the deaths of previous children, and the mother had a current unplanned pregnancy. The care team overcame language barriers and cultural obstacles to establish a trusting relationship with the vulnerable pregnant mother. They were able to support her decision to terminate her pregnancy safely by helping her to navigate a complex health care system. Using 5 crucial pillars to assist health care members with the delivery of nonjudgmental family-centered palliative care is recommended: (1) identification of biases, (2) utilization of a culturally safe approach, (3) effective communication, (4) assessment and support, and (5) knowledge of community resources.
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14
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Variation in Pediatric Palliative Care Allocation Among Critically Ill Children in the United States. Pediatr Crit Care Med 2021; 22:462-473. [PMID: 33116070 DOI: 10.1097/pcc.0000000000002603] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The objectives are as follows: 1) estimate palliative care consult rates and trends among critically ill children and 2) characterize which children receive palliative care consults, including those meeting previously proposed ICU-specific palliative care screening criteria. DESIGN Retrospective cohort. SETTING Fifty-two United States children's hospitals participating in the Pediatric Health Information Systems database. PATIENTS Hospitalized children with nonneonatal ICU admissions from 2007 to 2018. MEASUREMENTS AND MAIN RESULTS The primary outcome was palliative care consultation, as identified by the palliative care International Classification of Disease code. Patient characteristics and outcomes were compared between those with and without palliative care. We used a mixed-effects multivariable model to estimate the independent association between the palliative care and patient characteristics accounting for institution and subject clustering. Hospitalizations were categorized into three mutually exclusive groups for comparative analyses: 1) meeting ICU-specific palliative care criteria, 2) presence of a complex chronic condition not in ICU-specific palliative care criteria, or 3) not meeting ICU-specific palliative care or complex chronic condition criteria. Rates and trends of palliative care consultation were estimated including variation among institutions and variation among subcategories of ICU-specific palliative care criteria. The study cohort included 740,890 subjects with 1,024,666 hospitalizations. About 1.36% of hospitalizations had a palliative care consultation. Palliative care consult was independently associated with older age, female sex, government insurance, inhospital mortality, and ICU-specific palliative care or complex chronic condition criteria. Among the hospitalizations, 30% met ICU-specific palliative care criteria, 40% complex chronic condition criteria, and 30% neither. ICU-specific palliative care patients received more mechanical ventilation and cardiopulmonary resuscitation, had longer hospital and ICU lengths of stay, and had higher inhospital mortality (p < 0.001). Palliative care utilization increased over the study period with considerable variation between the institutions especially in the ICU-specific palliative care cohort and its subgroups. CONCLUSIONS Palliative care consultation for critically ill children in the United States is low. Palliative care utilization is increasing but considerable variation exists across institutions, suggesting inequity in palliative care allocation among this vulnerable population. Future studies should evaluate factors influencing allocation of palliative care among critically ill children in the United States and the drivers of differences between the institutional practices.
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15
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Tume LN, Menzies JC, Ray S, Scholefield BR. Research Priorities for U.K. Pediatric Critical Care in 2019: Healthcare Professionals' and Parents' Perspectives. Pediatr Crit Care Med 2021; 22:e294-e301. [PMID: 33394942 DOI: 10.1097/pcc.0000000000002647] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Paediatric Intensive Care Society Study Group conducted a research prioritization exercise with the aim to identify and agree research priorities in Pediatric Critical Care in the United Kingdom both from a healthcare professional and parent/caregiver perspective. DESIGN A modified three-round e-Delphi survey, followed by a survey of parents of the top 20 healthcare professional priorities. SETTING U.K. PICUs. PATIENTS U.K. PICU healthcare professionals who are members of the professional society and parents and family members of children, with experience of a U.K. PICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-nine healthcare professional submitted topics in round 1, 98 participated in round 2, and 102 in round 3. These topics were categorized into eight broad domain areas, and within these, there were 73 specific topics in round 2. At round 3, 18 topics had a mean score less than 5.5 and were removed, leaving 55 topics for ranking in round 3. Ninety-five parents and family members completed the surveys from at least 17 U.K. PICUs. Both parents and healthcare professional prioritized research topics associated with the PICU workforce. Healthcare professional research priorities reflected issues that impacted on day-to-day management and practice. Parents' prioritized research addressing acute situations such as infection identification of and sepsis management or research addressing long-term outcomes for children and parents after critical illness. Parents prioritized research into longer term outcomes more than healthcare professional. Parental responses showed clear support for the concept of research in PICU, but few novel research questions were proposed. CONCLUSIONS This is the first research prioritization exercise within U.K. PICU setting to include parents' and families' perspectives and compare these with healthcare professional. Results will guide both funders and future researchers.
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Affiliation(s)
- Lyvonne N Tume
- School of Health & Society, University of Salford, Salford, United Kingdom
| | - Julie C Menzies
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Samiran Ray
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
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16
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O'Keefe S, Czaja AS. Validation of Administrative Codes for Palliative Care Consultation Among Critically Ill Children. Hosp Pediatr 2021; 11:179-182. [PMID: 33509843 DOI: 10.1542/hpeds.2020-001263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To determine the validity of palliative care (PC) administrative codes (V66.7 and Z51.5) among critically ill pediatric patients. METHODS In this single-center retrospective cohort study, we included all hospitalizations with a PICU admission between March 2016 and March 2018. Sensitivity, specificity, and positive and negative predictive values of the relevant codes were estimated by using a gold standard of a local PC registry. RESULTS During the study period, 4670 hospitalizations were included. The median admission age was 5 years (interquartile range 1.5-12.9) with 55% having at least 1 complex chronic condition. The median length of PICU stay was 1.8 days (interquartile range 1-3.4) and mortality was low (1.3%). A total 182 (3.9%) hospitalizations had evidence of a PC consultation. Administrative codes for PC had a sensitivity of 11% (95% confidence interval [CI] 6.8%-16.5%) and a specificity of 99.8% (95% CI 99.6%-99.9%). The positive and negative predictive values were 66.7% (95% CI 47.2%-82.7%) and 96.5% (95% CI 95.9%-97.0%), respectively. CONCLUSIONS Among critically ill children, PC administrative codes had high specificity but poor sensitivity. The potential for underascertainment of this resource should be considered in future research using administrative data.
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Affiliation(s)
- Siobhán O'Keefe
- Department of Paediatric Critical Care, Children's Health Ireland, Dublin, Ireland; and
| | - Angela S Czaja
- Section of Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Colorado and Children's Hospital Colorado, Aurora, Colorado
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17
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Bogetz JF, Revette A, Rosenberg AR, DeCourcey D. "I Could Never Prepare for Something Like the Death of My Own Child": Parental Perspectives on Preparedness at End of Life for Children With Complex Chronic Conditions. J Pain Symptom Manage 2020; 60:1154-1162.e1. [PMID: 32629083 DOI: 10.1016/j.jpainsymman.2020.06.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/17/2022]
Abstract
CONTEXT Children with complex chronic conditions (CCCs) have high morbidity and mortality. While these children often receive palliative care services, little is known about parental preparedness for their child's end of life (EOL). OBJECTIVES This study aimed to elucidate aspects important to preparedness at EOL among bereaved parents of children with CCCs. METHODS In this cross-sectional study, parents of children who received care at Boston Children's Hospital and died between 2006 and 2015 completed 21 open-response items querying communication, decision-making, and EOL experiences as part of the Survey of Caring for Children with CCCs. Additional demographic data were extracted from the child's medical record. An iterative multistage thematic analysis of responses was utilized to identify key contexts, conditions, and themes pertaining to preparedness. RESULTS One hundred ten of 114 parents responded to open-ended items; 63% (n = 69) had children with congenital or central nervous system progressive primary conditions for a median of 7.5 years (IQR 0.8-18.1) before death. Seventy-one percent (n = 78/110) had palliative care involvement and 65% (n = 69/106) completed advance care planning. Parents described preparedness as a complex concept that extended beyond "readiness" for their child's death. Three domains emerged that contributed to parents' lack of preparedness: 1) chronic illness experiences; 2) pretense of preparedness; and 3) circumstances and emotions surrounding their child's death. CONCLUSIONS Most bereaved parents of children with CCCs described feeling unprepared for their child's EOL, despite palliative care and advance care planning, suggesting preparedness is a nuanced concept beyond "readiness." More research is needed to identify supportive elements among parents facing their child's EOL.
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Affiliation(s)
- Jori F Bogetz
- Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA.
| | - Anna Revette
- Qualitative Research Scientist, Survey and Data Management Core, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Abby R Rosenberg
- Division of Hematology and Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA; Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
| | - Danielle DeCourcey
- Division of Critical Care, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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18
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PICU Frequent Flyers: An Opportunity for Reconciling Humanism and Science! Pediatr Crit Care Med 2020; 21:846-847. [PMID: 32890089 DOI: 10.1097/pcc.0000000000002370] [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: 11/25/2022]
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Abstract
Pediatric palliative care and pediatric hospice care (PPC-PHC) are often essential aspects of medical care for patients who have life-threatening conditions or need end-of-life care. PPC-PHC aims to relieve suffering, improve quality of life, facilitate informed decision-making, and assist in care coordination between clinicians and across sites of care. Core commitments of PPC-PHC include being patient centered and family engaged; respecting and partnering with patients and families; pursuing care that is high quality, readily accessible, and equitable; providing care across the age spectrum and life span, integrated into the continuum of care; ensuring that all clinicians can provide basic palliative care and consult PPC-PHC specialists in a timely manner; and improving care through research and quality improvement efforts. PPC-PHC guidelines and recommendations include ensuring that all large health care organizations serving children with life-threatening conditions have dedicated interdisciplinary PPC-PHC teams, which should develop collaborative relationships between hospital- and community-based teams; that PPC-PHC be provided as integrated multimodal care and practiced as a cornerstone of patient safety and quality for patients with life-threatening conditions; that PPC-PHC teams should facilitate clear, compassionate, and forthright discussions about medical issues and the goals of care and support families, siblings, and health care staff; that PPC-PHC be part of all pediatric education and training curricula, be an active area of research and quality improvement, and exemplify the highest ethical standards; and that PPC-PHC services be supported by financial and regulatory arrangements to ensure access to high-quality PPC-PHC by all patients with life-threatening and life-shortening diseases.
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