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Roberts HJ, Wang Y, Spruit JL, Taylor L, Franson AT. The impact of clinical trial enrollment on specialty palliative care utilization in pediatric patients with high-grade gliomas. Pediatr Blood Cancer 2023; 70:e30115. [PMID: 36458446 DOI: 10.1002/pbc.30115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/19/2022] [Accepted: 11/02/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Palliative care (PC) provides numerous benefits for children with cancer. Pediatric patients with high-grade glioma (HGG) are particularly well suited for early PC involvement given their high symptom burden and poor prognosis. However, studies continue to reveal that children with cancer, including HGG, have delayed PC involvement. We hypothesized that clinical trial enrollment may lead to a lack of or delay in PC involvement in this population. PROCEDURE For each patient in our cohort of 43 pediatric patients with HGG, demographic, diagnostic, therapeutic, clinical trial enrollment, and PC information were collected. Statistical analysis was performed comparing PC characteristics between patients who did and did not enroll in a clinical trial. RESULTS Seventy-two percent of patients had at least one visit with a PC provider. Fifty-six percent of patients enrolled in a clinical trial with HGG-directed therapy. Seventy-one percent of patients who enrolled in a clinical trial received specialty PC compared to 74% of non-trial participants (p = 1.000). Patients who enrolled in clinical trials received PC earlier in their disease course measured in days before death (mean = 177 days) compared to those who did not enroll (mean = 113 days, p = .180), though not statistically significant. CONCLUSIONS The prevalence of clinical trial enrollment is high in patients with HGG and will likely increase as the genomic/epigenomic landscape of these tumors is better understood. As such, our data reassuringly suggest that trial participation does not interfere with the receipt of specialty PC in this population.
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Affiliation(s)
- Holly J Roberts
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Yujie Wang
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jessica L Spruit
- Stepping Stones Pediatric Palliative Care, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Laura Taylor
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Stepping Stones Pediatric Palliative Care, C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Andrea T Franson
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Alotaibi Q, Dighe M. Assessing the Need for Pediatric Palliative Care in the Six Arab Gulf Cooperation Council Countries. Palliat Med Rep 2023; 4:36-40. [PMID: 36910455 PMCID: PMC9994439 DOI: 10.1089/pmr.2022.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 02/18/2023] Open
Abstract
Background Palliative care is an essential element of universal health coverage. However, palliative care services, particularly pediatric palliative care (PPC) services, are still inadequately developed in many countries, not least members of the Gulf Cooperation Council (GCC) (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). Advocating for palliative care services requires data-driven estimates of the number of patients needing these services. Objective To estimate the number of children living with life-threatening illnesses in the GCC countries requiring specialist and/or generalist palliative care service provision. Method Descriptive analysis of published cross-sectional epidemiological data. Subjects were from general and age-specific populations from individual GCC countries. The quantitative data on child population and mortality were collected from 2019 primary and secondary data sources. The need for PPC was estimated using mortality, incidence, and prevalence data from the Institute for Health Metrics and the Global Cancer Observatory. Results Our conservative analysis revealed that just under 22,000 children needed PPC in GCC countries in 2019, a minimum of 17.5 for every 10,000 children. Discussion There is a significant need for PPC services, suggesting that the medical needs of the pediatric population are currently not being fully met. Nationwide PPC services are essential to improve the quality of life of thousands of children in GCC countries by changing policies, professional education, and providing funding to palliative programs. To our best knowledge, this is the first study to highlight the clear and urgent need for the development of PPC services in the GCC countries.
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Affiliation(s)
- Qutaibah Alotaibi
- Pediatric Department, Aladan Hospital, Hadiya, Kuwait
- Address correspondence to: Qutaibah Alotaibi, MD, Pediatric Department, Aladan Hospital, King Faahad Bin Abdul Aziz Road, Hadiya, Al-Alhadi Governorate, Kuwait.
| | - Manjiri Dighe
- Pediatric Department, Aladan Hospital, Hadiya, Kuwait
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Ananth P, Lindsay M, Nye R, Mun S, Feudtner C, Wolfe J. End-of-life care quality for children with cancer who receive palliative care. Pediatr Blood Cancer 2022; 69:e29841. [PMID: 35686746 PMCID: PMC10498672 DOI: 10.1002/pbc.29841] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND We previously developed stakeholder-informed quality measures to assess end-of-life care quality for children with cancer. We sought to implement a subset of these quality measures in the multi-center pediatric palliative care (PPC) database. PROCEDURES We utilized the Shared Data and Research database to evaluate the proportion of childhood cancer decedents from 2017-2021 who, in the last 30 days of life, avoided chemotherapy, mechanical ventilation, intensive care unit admissions, and > 1 hospital admission; were enrolled in hospice services, and reported ≤ 2 highly distressing symptoms. We then explored patient factors associated with the attainment of quality benchmarks. RESULTS Across 79 decedents, 82% met ≥ 4 quality benchmarks. Most (76%) reported > 2 highly distressing symptoms; 17% were enrolled in hospice. In univariable analyses, patients with an annual household income ≤$50,000 had lower odds of hospice enrollment and avoidance of mechanical ventilation or intensive care unit admissions near end of life (odds ratio [OR] 0.10 [95% confidence interval (C.I.) 0.01, 0.86], p = 0.04; OR 0.13 [0.02, 0.64], p = 0.01; OR 0.36 [0.13, 0.98], p = 0.04, respectively). In multivariable analyses, patients with an income ≤$50,000 remained less likely to enroll in hospice, after adjusting for cancer type (OR 0.10 [0.01, 0.87]; p = 0.04). CONCLUSIONS Childhood cancer decedents who received PPC met a large proportion of quality measures near the end of their life. Yet, many reported highly distressing symptoms. Moreover, patients with lower household incomes appeared less likely to enroll in hospice and more likely to receive intensive hospital services near the end of life. This study identifies opportunities for palliative oncology quality improvement.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, Connecticut, USA
| | - Meghan Lindsay
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Russell Nye
- Justin Michael Ingerman Center for Palliative Care, Children’s Hospital of Philadelphia; Departments of Pediatrics, Medical Ethics, and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sophia Mun
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Chris Feudtner
- Justin Michael Ingerman Center for Palliative Care, Children’s Hospital of Philadelphia; Departments of Pediatrics, Medical Ethics, and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ananth P, Mun S, Reffat N, Kang SJ, Pitafi S, Ma X, Gross CP, Wolfe J. Refining Patient-Centered Measures of End-of-Life Care Quality for Children With Cancer. JCO Oncol Pract 2022; 18:e372-e382. [PMID: 34613797 PMCID: PMC8932486 DOI: 10.1200/op.21.00447] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There are no existing quality measures (QMs) to optimize end-of-life care for children with cancer. Previously, we developed a set of 26 candidate QMs. Our primary objective in this study was to achieve stakeholder consensus on priority measures. METHODS We conducted an iterative, cross-sectional electronic survey, using a modified Delphi method to build consensus among clinician and family stakeholders. In each of the two rounds of surveys, stakeholders were asked to rate QMs on a 9-point Likert scale, on the basis of perceived importance. Health care professionals were additionally asked to rate measures on perceived feasibility. After each round, we computed median scores on importance and feasibility of measurement, retaining QMs with median importance scores ≥ 8. RESULTS Twenty-five participants completed both rounds of the survey. In round 1, participants were asked to rate 26 QMs; nine QMs, including QMs pertaining to health care use, were removed because of median importance scores < 8. Two new measures were proposed for consideration in round 2, on the basis of participant feedback. Following round 2, 17 QMs were ultimately retained. QMs related to symptom screening and palliative care consultation were rated highly in importance and feasibility. QMs related to communication were rated highly important, yet less feasible. Measuring whether a patient's needs were heard by their health care team was rated among the least feasible. CONCLUSION Childhood cancer stakeholders prioritized QMs pertaining to patient-reported outcomes, deeming measures of health care resource use less important. Future research should seek to develop novel tools for quality assessment to enhance feasibility of implementing priority measures.
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Affiliation(s)
- Prasanna Ananth
- Department of Pediatrics, Yale School of Medicine, New Haven, CT,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT,Prasanna Ananth, MD, MPH, Department of Pediatrics, Section of Pediatric Hematology/Oncology, Yale School of Medicine, 330 Cedar St, LMP 2082C, New Haven, CT 06510; e-mail:
| | - Sophia Mun
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Noora Reffat
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Soo Jung Kang
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Sarah Pitafi
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
| | - Xiaomei Ma
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT,Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA,Department of Pediatrics, Boston Children's Hospital, Boston, MA,Harvard Medical School, Boston, MA
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5
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Abstract
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.
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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 576104 India
| | - Sean Hughes
- Division of Health Research, Health Innovation One, Lancaster University, Sir John Fisher Drive, Lancaster, LA1 4AT UK
| | - Nancy Preston
- Division of Health Research, Health Innovation One, Lancaster University, Sir John Fisher Drive, Lancaster, LA1 4AT UK
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Cuviello A, Yip C, Battles H, Wiener L, Boss R. Triggers for Palliative Care Referral in Pediatric Oncology. Cancers (Basel) 2021; 13:1419. [PMID: 33808881 DOI: 10.3390/cancers13061419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Palliative care (PC) can improve the quality of life for pediatric cancer patients, yet these services remain underutilized, with referrals occurring late in the disease course or not at all. We previously described the patient and family characteristics that diverse pediatric oncology providers agree should be high yield triggers for PC referral in pediatric cancer patients. The current study examined how often those triggers were associated with a completed PC consult for a cohort of 931 patients. We discovered that PC referrals occur very infrequently and patients with stated triggers often do not get referred. These findings help support the need for a screening tool to standardize PC integration and improve care. Abstract Palliative care (PC) integration into the care of pediatric oncology patients is growing in acceptance and has been shown to improve the quality of life of children with cancer. Yet timing for referrals and referral practices remain inconsistent, and PC remains underutilized. We conducted a retrospective chart review of pediatric oncology patients treated at an academic institution between January 2015 to November 2018. Data collected included demographics, disease and therapy characteristics, and consultation notes, specifically documenting existence of predetermined “high yield triggers” for PC consultation. Among 931 eligible patients the prevalence of PC consultation was 5.6% while approximately 94% of patients had at least 1 trigger for PC consultation. The triggers that more often resulted in PC consultation included: symptom management needs (98%; n = 51) high-risk disease (86%; n = 45), poor prognosis (83%; n = 43), multiple lines of therapy (79%; n = 41) and a documented ICU admission (67%; n = 35). Our findings suggest that the high yield triggers for palliative care consultation that pediatric oncologists identify as important are not translating into practice; incorporating these triggers into a screening tool may be the next step to improve early PC integration.
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Cuviello A, Raisanen JC, Donohue PK, Wiener L, Boss RD. Initiating Palliative Care Referrals in Pediatric Oncology. J Pain Symptom Manage 2021; 61:81-89.e1. [PMID: 32711123 PMCID: PMC9116129 DOI: 10.1016/j.jpainsymman.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Early palliative care (PC) has been shown to improve the quality of life of children with cancer, yet referral practices by pediatric oncology providers remains inconsistent and few patients receive a formal PC consult. OBJECTIVES We sought to describe patient characteristics used by oncologists for PC referral and identify ways to improve PC integration into the care for children with cancer. METHODS This mixed-methods study used semistructured audiotaped interviews to explore the patient or disease characteristics used by pediatric oncology providers to trigger PC referral. Conventional content analysis was applied to interview transcripts. RESULTS About 77 participants with diverse experience were interviewed. More than 75% of participants reported that PC was consulted too late and cited communication and systems issues as the top barriers. Most participants (85%) stated that a screening tool would be helpful to standardize referral practices to PC. Characteristics such as poor prognosis (88%), symptom management (86%), comorbidities (65%), and psychosocial needs (65%) were commonly reported triggers that should initiate PC consultation. However, when presented with case scenarios that included these characteristics, participants did not consistently identify the PC triggers. Nearly 50% of participants stated they had received some formalized PC training; however, only one-third of these participants noted completing a PC rotation. CONCLUSION Our findings suggest that pediatric oncologists are committed to improving the integration of PC for their patients and that standardization of referral practices, through the use of a screening tool, would be of benefit. Additional PC education might reinforce pediatric oncologists' recognition of PC triggers.
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Affiliation(s)
- Andrea Cuviello
- St Jude Children's Research Hospital, Memphis, Tennessee, USA.
| | | | | | - Lori Wiener
- National Institutes of Health, Bethesda, Maryland, USA
| | - Renee D Boss
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA; Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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8
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Abstract
BACKGROUND Specialist paediatric palliative care services are promoted as an important component of palliative care provision, but there is uncertainty about their role for children with cancer. AIM To examine the impact of specialist paediatric palliative care for children and young people with cancer and explore factors affecting access. DESIGN A mixed-methods systematic review and narrative synthesis (PROSPERO Registration No. CRD42017064874). DATA SOURCES Database (CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO) searches (2000-2019) identified primary studies of any design exploring the impact of and/or factors affecting access to specialist paediatric palliative care. Study quality was assessed using The Mixed Methods Appraisal Tool. RESULTS An evidence base of mainly low- and moderate-quality studies (n = 42) shows that accessing specialist paediatric palliative care is associated with less intensive care at the end of life, more advance care planning and fewer in-hospital deaths. Current evidence cannot tell us whether these services improve children's symptom burden or quality of life. Nine studies reporting provider or family views identified uncertainties about what specialist paediatric palliative care offers, concerns about involving a new team, association of palliative care with end of life and indecision about when to introduce palliative care as important barriers to access. There was evidence that children with haematological malignancies are less likely to access these services. CONCLUSION Current evidence suggests that children and young people with cancer receiving specialist palliative care are cared for differently. However, little is understood about children's views, and research is needed to determine whether specialist input improves quality of life.
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Affiliation(s)
- Johanna Taylor
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
| | - Alison Booth
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
| | - Bryony Beresford
- Martin House Research Centre, University of York, York, UK
- Social Policy Research Unit, University of York, York, UK
| | - Bob Phillips
- Martin House Research Centre, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Kath Wright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Lorna Fraser
- Department of Health Sciences, University of York, York, UK
- Martin House Research Centre, University of York, York, UK
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Cheng BT, Rost M, De Clercq E, Arnold L, Elger BS, Wangmo T. Palliative care initiation in pediatric oncology patients: A systematic review. Cancer Med 2018; 8:3-12. [PMID: 30525302 PMCID: PMC6346252 DOI: 10.1002/cam4.1907] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/06/2018] [Accepted: 11/08/2018] [Indexed: 02/06/2023] Open
Abstract
Palliative care (PC) aims to improve quality of life for patients and their families. The World Health Organization and American Academy of Pediatrics recommend that PC starts at diagnosis for children with cancer. This systematic review describes studies that reported PC timing in the pediatric oncology population. The following databases were searched: PubMed, Web of Science, CINAHL, and PsycInfo databases. Studies that reported time of PC initiation were independently screened and reviewed by 2 researchers. Studies describing pilot initiatives, published prior to 1998, not written in English, or providing no empirical time information on PC were excluded. Extracted data included sample characteristics and timing of PC discussion and initiation. Of 1120 identified citations, 16 articles met the inclusion criteria and comprised the study cohort. Overall, 54.5% of pediatric oncology patients received any palliative service prior to death. Data revealed PC discussion does not occur until late in the illness trajectory, and PC does not begin until close to time of death. Despite efforts to spur earlier initiation, many pediatric oncology patients do not receive any palliative care service, and those who do, predominantly receive it near the time of death. Delays occur both at first PC discussion and at PC initiation. Efforts for early PC integration must recognize the complex determinants of PC utilization across the illness timeline. This systematic review examines the timing of palliative care initiation in pediatric oncology patients to assess the state of palliative care integration. Many pediatric oncology patients do not receive any palliative service, and those who do, typically receive it late in the illness trajectory.
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Affiliation(s)
- Brian T Cheng
- Department of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael Rost
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Eva De Clercq
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Louisa Arnold
- Institute of Psychology, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Bernice S Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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10
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Cunningham MJ. The phases of end of life care. Pediatr Blood Cancer 2018; 65. [PMID: 28960831 DOI: 10.1002/pbc.26830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/06/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Melody J Cunningham
- Division of Palliative Care, Le Bonheur Children's Hospital, Memphis, Tennessee
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