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Vemuri S, Hynson J, Williams K, Gillam L. Conceptualising paediatric advance care planning: a qualitative phenomenological study of paediatricians caring for children with life-limiting conditions in Australia. BMJ Open 2022; 12:e060077. [PMID: 35577468 PMCID: PMC9115011 DOI: 10.1136/bmjopen-2021-060077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/04/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Advance care planning (ACP) helps families and paediatricians prepare and plan for end-of-life decision-making. However, there remains inconsistency in its practice with the limited literature describing what this preparation involves, and whether paediatricians recognise a difference between the process of ACP and its outcomes, such as resuscitation plans. This study aims to understand how paediatricians conceptualise ACP when caring for children with life-limiting conditions (LLC) who are unable to participate in decision-making for his/herself. DESIGN Individual, semistructured, vignette-based qualitative interviews. SETTING Acute inpatient and long-term outpatient paediatric care in three secondary and two tertiary centres in Victoria, Australia. PARTICIPANTS 25 purposively sampled paediatricians who treat children with LLC, outside the neonatal period. Paediatricians were excluded if they worked within specialist palliative care teams or assisted in this study's design. RESULTS Four key themes were identified when approaching end-of-life decision-making discussions: (1) there is a process over time, (2) there are three elements, (3) the role of exploring parental values and (4) the emotional impact. The three elements of this process are: (1) communicating the child's risk of death, (2) moving from theoretical concepts to practice and (3) documenting decisions about resuscitation or intensive technologies. However, not all paediatricians recognised all elements as ACP, nor are all elements consistently or intentionally used. Some paediatricians considered ACP to be only documentation of decisions in advance. CONCLUSION There is a preparatory process of discussions for end-of-life decision-making, with elements in this preparation practised within therapeutic relationships. Complexity in what constitutes ACP needs to be captured in guidance and training to include intentional exploration of parental values, and recognition and management of the emotional impact of ACP could increase its consistency and value.
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Affiliation(s)
- Sidharth Vemuri
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jenny Hynson
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Katrina Williams
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Lynn Gillam
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Children's Bioethics Centre, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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Reader TW, Dayal R, Brett SJ. At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit. J Intensive Care Soc 2021; 22:305-311. [PMID: 35154368 PMCID: PMC8829767 DOI: 10.1177/1751143720954723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care. METHODS Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians (n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care. RESULTS We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making. CONCLUSIONS To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making.
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Affiliation(s)
- Tom W Reader
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
| | - Ria Dayal
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
| | - Stephen J Brett
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK
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Carr K, Hasson F, McIlfatrick S, Downing J. Factors associated with health professionals decision to initiate paediatric advance care planning: A systematic integrative review. Palliat Med 2021; 35:503-528. [PMID: 33372582 PMCID: PMC7975890 DOI: 10.1177/0269216320983197] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Advance care planning for children with palliative care needs is an emotionally, legally and complex aspect of care, advocated as beneficial to children, families and health professionals. Evidence suggests healthcare professionals often avoid or delay initiation. An overview of evidence on the factors that influence and impact on the health care professional's initiation of paediatric advance care planning process is lacking. AIM To review and synthesise evidence on the factors associated with health care professional's decision to initiate paediatric advance care planning. DESIGN Systematic integrative review using constant comparison method. DATA SOURCES Electronic databases (CINAHL, PubMed, PsycINFO, Ovid MEDLINE, EMBASE, Web of Science and Cochrane) using MeSH terms and word searches in Oct 2019. No limit set on year of publication or country. Grey literature searches were also completed. RESULTS The search yielded 4153 citations from which 90 full text articles were reviewed. Twenty-one met inclusion criteria consisting of quantitative (n = 8), qualitative (n = 6) and theoretical (n = 7) studies.Findings revealed overarching and interrelated themes 'The timing of initiation', 'What makes an initiator, 'Professionals' perceptions' and 'Prerequisites to initiation'. CONCLUSIONS This review provides insights into the complexities and factors surrounding the initiation of advance care planning in paediatric practice. Uncertainty regarding prognosis, responsibility and unpredictable parental reactions result in inconsistent practice. Future research is required to inform intervention to assist health care professionals when initiating paediatric advance care planning conversations.
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Affiliation(s)
- Karen Carr
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Felicity Hasson
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Julia Downing
- International Children's Palliative Care Network, UK & Makerere University, Kampala, Uganda
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Mooney-Doyle K, Ulrich CM. Parent moral distress in serious pediatric illness: A dimensional analysis. Nurs Ethics 2020; 27:821-837. [PMID: 32138577 DOI: 10.1177/0969733019878838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Moral distress is an important and well-studied phenomenon among nurses and other healthcare providers, yet the conceptualization of parental moral distress remains unclear. OBJECTIVE The objective of this dimensional analysis was to describe the nature of family moral distress in serious pediatric illness. DESIGN AND METHODS A dimensional analysis of articles retrieved from a librarian-assisted systematic review of Scopus, CINAHL, and PsychInfo was conducted, focusing on how children, parents, other family members, and healthcare providers describe parental moral distress, both explicitly through writings on parental moral experience and implicitly through writings on parental involvement in distressing aspects of the child's serious illness. ETHICAL CONSIDERATIONS To promote child and family best interest and minimize harm, a nuanced understanding of the moral, existential, emotional, and spiritual impact of serious pediatric illness is needed. The cases used in this dimensional analysis come from the first author's IRB approved study at the Children's Hospital of Philadelphia and subsequent published studies; or have been adapted from the literature and the authors' clinical experiences. FINDINGS Three dimensions emerged from the literature surrounding parent moral distress: an intrapersonal dimension, an interpersonal dimension, and a spiritual/existential dimension. The overarching theme is that parents experience relational solace and distress because of the impact of their child's illness on relationships with themselves, their children, family, healthcare providers, their surrounding communities, and society. DISCUSSION Elucidating this concept can help nurses and other professionals understand, mitigate, or eliminate antecedents to parental moral distress. We discuss how this model can facilitate future empirical and conceptual bioethics research, as well as inform the manner in which healthcare providers engage, collaborate with, and care for families during serious pediatric illness. CONCLUSION Parent moral distress is an important and complex phenomenon that requires further theoretical and empirical investigation. We provide an integrated definition and dimensional schematic model that may serve as a starting point for future research and dialogue.
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Forbat L, Barclay S. Reducing healthcare conflict: outcomes from using the conflict management framework. Arch Dis Child 2019; 104:328-332. [PMID: 30154178 DOI: 10.1136/archdischild-2018-315647] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To test a new conflict management framework (CMF) to help staff identify and de-escalate conflict between staff and patients/families. DESIGN Before/after study that reports staff quality of life, frequency/severity of conflicts and qualitative interviews on using the framework. Data were collected from May 2017 to September 2017. SETTING A paediatric oncology department day-patient and 23-bed inpatient ward. INTERVENTION A two-stage CMF used by staff during daily handovers to identify and then manage conflict cases with families. RESULTS Staff found the CMFto be helpful in identifying and de-escalating conflicts. The number of conflicts reported decreased by 64% from baseline to follow-up. Communication regarding conflict identification improved. Reports of staff burn-out decreased between the two time-points (n=55 at baseline, n=31 at follow-up; p=0.001). Scores on compassion and secondary traumatic stress did not change. CONCLUSIONS The CMF substantially reduces the incidence of conflicts and is an acceptable approach for staff. Continued use of the framework would require it to be fully integrated into the working of the ward, which would need to include senior medical buy-in. Further refinements to the framework have been made and will be tested in four UK sites in 2018/2019.
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Affiliation(s)
- Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, UK
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Zuniga-Villanueva G, Ramirez-GarciaLuna JL, Weingarten K. Factors Associated With Knowledge and Comfort Providing Palliative Care: A Survey of Pediatricians in Mexico. J Palliat Care 2019; 34:132-138. [PMID: 30714468 DOI: 10.1177/0825859719827021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Lack of education and training in palliative care has been described to be one of the most important barriers to pediatric palliative care implementation. OBJECTIVE: To examine what factors determine the degree of knowledge and level of comfort Mexican pediatricians have providing pediatric palliative care. METHODS: A questionnaire that assessed palliative care concepts was developed and applied online to Mexican pediatricians, both generalists and specialists. RESULTS: A total of 242 pediatricians responded. The majority had not received palliative care education (92.6%) and felt uncomfortable discussing palliative needs with patients and families (92.1%). The mean score of the questionnaire was 6.8 (±1.4) of 10 correct answers. Knowledge in palliative care was associated with exposure to oncologic patients ( P = .01) and previous palliative care education ( P = .02) but inversely related to the pediatrician's age ( P = .01). Comfort addressing patient's palliative care needs was associated with knowledge in palliative care ( P < .01), exposure to oncologic patients ( P = .03), and previous education in palliative care ( P = .02). CONCLUSIONS: Although Mexican pediatricians have basic knowledge of palliative care concepts, they do not feel comfortable addressing palliative care needs, suggesting that the main barrier for implementing palliative care is not the lack of knowledge but rather feeling uncomfortable when addressing these issues with patients and families. Educational programs should incorporate strategies that could help physicians develop comfort in approaching palliative care patients.
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Affiliation(s)
| | | | - Kevin Weingarten
- 3 Pediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
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Moore JA, Samuel SS. Is It Practical to Apply Moral Hazard in the Pediatric Setting? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:52-54. [PMID: 27292853 DOI: 10.1080/15265161.2016.1180457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Fischer MO, Dechanet F, du Cheyron D, Gérard JL, Hanouz JL, Fellahi JL. Evaluation of the knowledge base of French intensivists and anaesthesiologists as concerns the interpretation of respiratory arterial pulse pressure variation. Anaesth Crit Care Pain Med 2015; 34:29-34. [PMID: 25829312 DOI: 10.1016/j.accpm.2014.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 06/26/2014] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aims of the study were to assess the knowledge of intensivists and/or anaesthesiologists concerning respiratory arterial pulse pressure variation (PPV) and to define the criteria used to indicate a fluid challenge. STUDY DESIGN A prospective observational study. PATIENTS AND METHODS Intensivists and anaesthesiologists from one region of France were evaluated for their knowledge about the prerequisites (continuous arterial pressure monitoring, regular sinus rhythm, mechanical ventilation without spontaneous breathing) and confounding factors shifting the threshold value of PPV (low tidal volume, decreased pulmonary compliance, low heart rate/respiratory rate ratio, right ventricular dysfunction, and/or intra-abdominal hypertension) using clinical vignettes. Criteria used by physicians to indicate a fluid challenge were also collected. RESULTS One hundred and forty-five physicians were included in the study. Among them, 87 (60%) knew prerequisites but none of them had full knowledge of all confounding factors. Criteria used to perform a fluid challenge were mainly PPV and the passive leg-raising test for the residents and PPV, blood pressure, oliguria and hydric balance for the qualified physicians. CONCLUSIONS PPV was widely employed to indicate a fluid challenge and 60% of the physicians knew the prerequisites. However, the physicians did not correctly interpret all confounding factors.
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Affiliation(s)
- Marc-Olivier Fischer
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France; EA 4650, Université de Caen Basse-Normandie, esplanade de la Paix, CS 14 032, 14000 Caen, France.
| | - Fabien Dechanet
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Damien du Cheyron
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Jean-Louis Gérard
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France
| | - Jean-Luc Hanouz
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France; EA 4650, Université de Caen Basse-Normandie, esplanade de la Paix, CS 14 032, 14000 Caen, France
| | - Jean-Luc Fellahi
- Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, avenue de la Côte-de-Nacre, CS 30001, 14000 Caen, France; EA 4650, Université de Caen Basse-Normandie, esplanade de la Paix, CS 14 032, 14000 Caen, France
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McDougall RJ, Gillam L. Doctors' "judgements" and parents' "wishes": ethical implications in conflict situations. Med J Aust 2014; 200:372. [PMID: 24794656 DOI: 10.5694/mja13.11326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 03/17/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Rosalind J McDougall
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.
| | - Lynn Gillam
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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