Decision-Making for Children with Medical Complexity: The Role of the Primary Care Pediatrician

Tracheostomy and long-term invasive ventilation decision-making in children: A scoping review

An increasing number of children are surviving critical illnesses requiring tracheostomy/long-term ventilation (LTV). This scoping review seeks to collate the available evidence on decision-making for tracheostomy/LTV in children. Systematic searches of electronic databases and websites were conducted for articles and reports. Inclusion criteria included: (1) children 0-18 years old; (2) described use of tracheostomy or tracheostomy/LTV; and (3) information on recommendations for tracheostomy decision-making or decision-making experiences of family-caregivers or health care providers. Articles not written in English were excluded. Of the 4463 records identified through database search and other methods, a total of 84 articles, 2 dissertations, 1 book chapter, 3 consensus statement/society guidelines, and 8 pieces of grey literature were included. Main thematic domains identified were: (1) legal and moral standards for decision-making; (2) decision-making models, roles of decision-makers, and decisional aids towards a shared decision-making model; (3) experiences and perspectives of decision-makers; (4) health system and society considerations; and (5) conflict resolution and legal considerations. A high degree of uncertainty and complexity is involved in tracheostomy/LTV decision-making. There is a need for a standardized decision-support process that is consistent with a child's best interests and shared decision-making. Strategies for optimizing communication and mechanism for managing disputes are needed.

Navigating Difficult Conversations in Caring for Children with Medical Complexity

Pediatricians are faced with a multitude of difficult tasks each day for a variety of age groups. Providing medical care and support to children with medical complexity and their families adds additional challenges, including management of polypharmacy, therapies, complications, and difficult conversations. The relationship a family has with their pediatrician is extremely special and valuable. As such, pediatricians may find themselves guiding parents through decision-making without the proper training or tools. They may struggle with navigating the conversations to assist families in reaching a helpful conclusion. This article reviews three difficult situations that families of children with medical complexity may face and three different readily available and valuable frameworks to assist with navigating those difficult conversations. [Pediatr Ann. 2024;53(3):e99-e103.].

Shared decision-making for children with medical complexity in community health services: a scoping review

BACKGROUND

Children with medical complexity is an increasing population whose parents and healthcare providers face multiple decisions. Shared decision-making is a process where patients, their families and healthcare providers collaborate to make decisions based on clinical evidence and informed preferences of the family. Shared decision-making has benefits for the child, family and healthcare providers, including improved parental understanding of the child's difficulties, increased participation, improved coping skills and more efficient healthcare use. It is, however, poorly implemented.

AIMS AND METHODS

A scoping review was conducted to explore shared decision-making for children with medical complexity in community health services, including how shared decision-making is defined in research, how it is implemented, including barriers and facilitators and recommendations for research. Six databases were systematically searched for papers published in English up to May 2022: Medline, CINAHL, EMBASE, PsycINFO, PubMed, Cochrane Database of Systematic Reviews and sources of grey literature. The review is reported according to the Preferred Reporting Items for Scoping Reviews.

RESULTS

Thirty sources met the inclusion criteria. Most factors can either be a facilitator or barrier to shared decision-making depending on the context. Two significant barriers to shared decision-making in this population include uncertainty about the child's diagnosis, prognosis, and treatment options and the presence of hierarchy and power imbalance during clinical encounters with healthcare providers. Further influencing factors include continuity of care, the availability of accurate, accessible, adequate, and balanced information and the interpersonal and communication skills of parents and healthcare providers.

CONCLUSION

Uncertainty about diagnosis, prognosis and treatment outcomes for children with medical complexity are additional challenges to the known barriers and facilitators to shared decision-making in community health services. Effective implementation of shared decision-making requires advancement of the evidence base for children with medical complexity, reducing power imbalance in clinical encounters, improving continuity of care, and improving the availability and accessibility of information resources.

A Focused Review of Long-Stay Patients and the Ethical Imperative to Provide Inpatient Continuity

Long-stay patients are an impactful, vulnerable, growing group of inpatients in today's (and tomorrow's) tertiary hospitals. They can outlast dozens of clinicians that necessarily rotate on and off clinical service. Yet, care from such rotating clinicians can result in fragmented care due to a lack of continuity that insufficiently meets the needs of these patients and their families. Using long-stay PICU patients as an example, this focused review discusses the impact of prolonged admissions and how our fragmented care can compound this impact. It also argues that it is an ethical imperative to provide a level of continuity of care beyond what is considered standard of care and offers a number of strategies that can provide such continuity.

Pediatric neuropalliative care

Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.

Updating the healthcare maintenance visit for children with medical complexity: applying lessons learned from the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

Coronavirus disease 2019 (COVID-19) has exposed the vulnerabilities of children with medical complexity (CMC). This article uniquely describes how pediatric providers in various clinical settings can adapt routine healthcare maintenance visits to meet the needs of CMC in the era of COVID-19. We also discuss unique visit components important to address when providing primary care to CMC, including caregiver support, disaster preparedness, long-term care planning, and telemedicine.

RECENT FINDINGS

Although some children may be less severely affected by COVID-19 than adults, current literature suggests that CMC may be at higher risk for severe disease. In addition, the COVID-19 pandemic has highlighted the value in consistent, primary care for CMC. Children, especially those with medical complexity, are at risk for interruptions in care, delayed vaccinations, increasing caregiver burden, and barriers to in-person care.

SUMMARY

This article summarizes the components of the healthcare maintenance visit for CMC, providing salient recommendations on how pediatric providers can adapt their approach to the primary care of CMC in the era of COVID-19.

The Child With Severe Chronic Illness in the ICU: A Concise Review

OBJECTIVES

Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs.

DATA SOURCES

English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed.

STUDY SELECTION

Original articles, review articles, and commentaries were considered.

DATA EXTRACTION

Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review.

DATA SYNTHESIS

Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured.

CONCLUSIONS

The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.

Parent and Adolescent Perspectives on the Impact of COVID on the Care of Seriously Ill Children

CONTEXT

Few studies have explored the impact of the Coronavirus Pandemic (COVID-19) on the care of seriously ill children which may be especially affected due to the child's vulnerability, complexity of care, and high reliance on hospital-based care.

OBJECTIVE

To explore parental and adolescent perspectives on the impact of COVID-19 on care of seriously children.

METHODS

We recruited a convenience sample of families of seriously ill children between September and December 2020. The study involved a semi-structured interview through Zoom followed by an online sociodemographic survey. Interviews were transcribed and coded using the constant comparison method. The sample intended to represent diversity in child age and diagnoses, and family sociodemographic characteristics.

RESULTS

Sixty-four families were approached; 29 enrolled (response rate 45%), including 30 parents and three AYAs. Most parents and AYAs identified as white (62%). Some families reported new financial hardships, with 17.2% having difficulty paying bills after March 2020 compared to 6.9% before. Emerging themes from interviews included additional roles parents managed due to cancelled services or shifting to telehealth, increased isolation, high emotional distress due increased in-home demands, uncertainty, and visitor restrictions in medical facilities, and benefits and challenges to telehealth. One positive outcome was the use of a hybrid care model whereby families choose telehealth appointments and in-person services, when necessary.

CONCLUSION

Families caring for seriously ill children during COVID-19 face increased challenges. Health systems should consider long-term telehealth/in-person hybrid care models that have potential to improve access to and satisfaction with care.

Partnering with Parents of Children with Medical Complexity: A Framework for Engaging Families for Practice Improvement

The role of patients and families has evolved over the years, from being viewed as entities who were told what to do, to consumers of health services, to being central to health system design and clinical decision-making. When designing health care practices and programs to be patient- and family-centered, we believe that parents of children with medical complexity (CMC) bring valuable viewpoints and experiences to the table. Good health and functional outcomes for CMC and their families are dependent on active family engagement with their health care partners. We apply the Patient Engagement in Redesigning Care Toolkit (PERCT) model to describe the experience of complex care programs with engaging families at various levels of program design and function, including strengths and pitfalls experienced with each PERCT category. Operationalizing the health care system to treat patients and families as equal stakeholders is necessary if we want to succeed in a patient-centered, value-based environment. [Pediatr Ann. 2020;49(11):e467-e472.].