Preparing Pediatric Healthcare Professionals for End-of-Life Care Discussions: An Exploratory Study

BACKGROUND

Preparedness to initiate end-of-life (EoL) discussions is a confronting and daunting task for all healthcare professionals. We conducted a group interview to explore healthcare professionals' experiences of preparing for EoL discussions with the patient and their family in a pediatric context.

AIM

To identify what pediatric healthcare professionals consider important when preparing for an EoL discussion.

METHODS

A qualitative design using a group interview. Two open-ended questions were asked: (1) How could preparedness to initiate EoL care discussions between healthcare professionals and the patient and family be enhanced? (2) What education resources/strategies could be developed to support preparation for EoL care discussions?

SETTING/SUBJECTS

Healthcare professionals, including medical, nursing, and allied health professionals working in pediatric palliative care settings across Queensland, Australia. These settings included major tertiary hospitals, general practice, community, and nongovernment organizations. A convenience sample of 36 healthcare professionals consented to participate in the study.

RESULTS

An analysis of the data identified seven themes that had relevance for preparing for an EoL discussion: communication, healthcare professional perspectives, interdisciplinary team role, patient and family perspectives, practical issues, addressing mistakes, and healthcare professional education.

CONCLUSIONS

Pediatric healthcare professionals confirmed that gaps exist in preparing for an EoL discussion. The findings support a need for further research in two areas. First, a systematic review of interdisciplinary resources that are available to support healthcare professionals in preparing for EoL discussions is recommended. Second, evidence-based interdisciplinary interventions to support pediatric EoL discussions need to be developed and evaluated.

A pilot study of the effectiveness of home teleconsultations in paediatric palliative care

We conducted a pilot study to investigate the effectiveness of a home telehealth service for paediatric palliative care consultations. Over a 10 week period, 14 of the 17 caregivers approached to be part of the study agreed to participate. Families were allocated, non-randomly, to a control group (usual care) or an intervention group (usual care with the addition of home telehealth consultations). The primary outcome measure was quality-of-life score. Caregivers were surveyed for up to 99 days following recruitment. A descriptive analysis of the quality-of-life data showed no differences between caregivers in the two groups. However, important lessons were learnt regarding factors which influence the success of studies in this population group, and the domains of caregiver quality-of-life that warrant intervention. Palliative care is complex, and multiple interventions and supports are required if care is to be managed at home. Home telehealth consultations are a feasible and acceptable means of facilitating a palliative care consultation which can reduce the burden on families at a distressing time.

Palliative Care Afterhours

Families caring for a child with incurable cancer require access to support and advice round the clock. In Brisbane, Australia, an after-hours phone service was established to support these families. This service is operated by oncology clinical nurse consultants (CNCs) experienced in pediatric palliative care. This is the first review of 8 years of activity, totaling 106 patients and 1954 calls. The majority of calls were between parents and CNCs (51%). Updating of the patient’s condition (18%) was the primary reason for calls, with support and reassurance (16%), and symptom management of pain (10%) being the other frequent reasons. The majority of calls occurred over the weekends in the morning, with only 11% (n = 209) of calls occurring between 10:00 pm and 7:00 am. Of all the calls made, 43% (n = 814) were calls managed by the CNC without requiring further intervention. Calls were received from throughout Queensland, indicating the value of the service in supporting families throughout the state. The after-hours phone service has proven to be a simple, effective, and valuable service, which is consistently accessed by families, regardless of distance from the hospital.

Hospitalisation for venous thromboembolism in cancer patients and the general population: a population-based cohort study in Denmark, 1997-2006

Background:

Venous thromboembolism (VTE) frequently complicates cancer. Data on tumour-specific VTE predictors are limited, but may inform strategies to prevent thrombosis.

Methods:

We computed incidence rates (IRs) with 95% confidence intervals (CIs) for VTE hospitalisation in a cohort of cancer patients (n=57 591) and in a comparison general-population cohort (n=287 476) in Denmark. The subjects entered the study in 1997–2005, and the follow-up continued through 2006. Using Cox proportional-hazards regression, we estimated relative risks (RRs) for VTE predictors, while adjusting for comorbidity.

Results:

Throughout the follow-up, VTE IR was higher among the cancer patients (IR=8.0, 95% CI=7.6–8.5) than the general population (IR=4.7, 95% CI=4.3–5.1), particularly in the first year after cancer diagnosis (IR=15.0, 95% CI=13.8–16.2, vs IR=8.6, 95% CI=7.6–9.9). Incidence rates of VTE were highest in patients with pancreas (IR=40.9, 95% CI=29.5–56.7), brain (IR=17.7, 95% CI=11.3–27.8) or liver (IR=20.4, 95% CI=9.2–45.3) tumours, multiple myeloma (IR=22.6, 95% CI=15.4–33.2) and among patients with advanced-stage cancers (IR=27.7, 95% CI=24.0–32.0) or those who received chemotherapy or no/symptomatic treatment. The adjusted RR (aRR) for VTE was highest among patients with pancreas (aRR=16.3, 95% CI=8.1–32.6) or brain cancer (aRR=19.8 95% CI=7.1–55.2), multiple myeloma (aRR=46.1, 95% CI=13.1–162.0) and among patients receiving chemotherapy, either alone (aRR=18.5, 95% CI=11.9–28.7) or in combination treatments (aRR=16.2, 95% CI=12.0–21.7).

Conclusions:

Risk of VTE is higher among cancer patients than in the general population. Predictors of VTE include recency of cancer diagnosis, cancer site, stage and the type of cancer-directed treatment.

Home telemedicine for paediatric palliative care

Children with life limiting conditions require intensive, complex management of the physical, psychosocial and spiritual issues that evolve for the child and their family as the focus of care moves from curative treatment to palliation. Optimal palliative care for children can be limited by the lack of health professionals with the necessary skills and experience to confidently and competently manage the care of both the child and the family. The University of Queensland's Centre for Online Health has been working closely with the Paediatric Palliative Care Service (PPCS) at the Royal Children's Hospital (RCH) in Brisbane, Australia, to investigate the potential of telemedicine for the delivery of specialist support in the home or local community. Research conducted in Queensland has shown how telemedicine can be effectively used to link the specialist paediatric palliative care team into the home of families caring for a child receiving palliative care, regardless of their physical distance from the RCH. This qualitative report describes two case studies, each illustrating the value of home telemedicine for families at this vulnerable and distressing time. This work should provide a useful insight for other specialty disciplines contemplating home telemedicine applications.