Regional adaptation of the education in palliative and end-of-life Care Pediatrics (EPEC-Pediatrics) curriculum in Eurasia
Humans; Child; pediatric palliative care; Terminal Care; education; Palliative Care/methods; Curriculum; Covid-19; Terminal Care; pediatric oncology; Eurasia; Enteropathogenic Escherichia coli
BACKGROUND: Pediatric palliative care (PPC) is a priority to improve pediatric hematology oncology (PHO) care in Eurasia. However, there are limited regional opportunities for PPC education. We describe the adaptation and implementation of a bilingual end-user Education in Palliative and End-of-Life Care (EPEC)-Pediatrics course for PHO clinicians in Eurasia. METHODS: Due to COVID-19, this course was delivered virtually, consisting of prerecorded, asynchronous lectures, and a bilingual workshop with interactive lectures and small group sessions. A pre-postcourse design was used to evaluate the knowledge acquisition of the participants including their knowledge alignment with World Health Organization (WHO) guidance, ideal timing of palliative care, and comfort in providing palliative care to their patients. Questions were mostly quantitative with multiple choice or Likert scale options, supplemented by free-text responses. RESULTS: A total of 44 (76%) participants from 14 countries completed all components of the course including pre- and postcourse assessments. Participant alignment with WHO guidance improved from 75% in the pre- to 90% in the postcourse assessments (p < 0.001). After participation, 93% felt more confident controlling the suffering of children at the end of life, 91% felt more confident in prescribing opioids and managing pain, and 98% better understood how to hold difficult conversations with patients and families. Most participants (98%) stated that they will change their clinical practice based on the skills and knowledge gained in this course. CONCLUSIONS: We present a successful regional adaptation of the EPEC-Pediatrics curriculum, including novel delivery of course content via a virtual bilingual format. This course resulted in significant improvement in participant attitudes and knowledge of PPC along with an understanding of the ideal timing of palliative care consultation and comfort in providing PPC to children with cancer. We plan to incorporate participant feedback to improve the course and repeat it annually to improve access to high-quality palliative care education for PHO clinicians in Eurasia.
McNeil MJ; Ehrlich B; Yakimkova T; Wang H; Mishkova V; Bezler Z; Kumirova E; Madni A; Movsisyan N; Williams K; Baizakova B; Borisevich M; Chatman G; Erimbetova I; Quintero XG; Golban R; Kirby B; Nunez P; Ranadive R; Sakhar N; Sonnenfelt J; Volkova A; Moreira D; Friedrichsdorf SJ; Wolfe J; Remke S; Hauser J; Devidas M; Baker JN; Agulnik A
Cancer Medicine
2023
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<a href="http://doi.org/10.1002/cam4.5213" target="_blank" rel="noreferrer noopener">10.1002/cam4.5213</a>
Education in Palliative and End-of-Life Care-Pediatrics: Curriculum use and dissemination
palliative care; education; survey; Pediatric; training; curriculum
CONTEXT: The majority of seriously ill children do not have access to specialist pediatric palliative care (PPC) services nor to clinicians trained in primary PPC. The Education in Palliative and End-of-Life Care (EPEC)-Pediatrics curriculum and dissemination project was created in 2011 in response to this widespread education and training need. Since its implementation, EPEC-Pediatrics has evolved and has been disseminated worldwide. OBJECTIVES: Assessment of past EPEC-Pediatrics participants' ("Trainers") self-reported PPC knowledge, attitudes, and skills; use of the curriculum in teaching; and feedback about the program's utility and future direction. METHODS: 2011 - 2019 survey of EPEC-Pediatrics past conference participants, using descriptive and content analyses. RESULTS: 172/786 (22% response rate) EPEC-Pediatrics past participants from 59 countries across 6 continents completed the survey. Trainers, including Master Facilitators (MFs), used the curriculum mostly to teach interdisciplinary clinicians and reported improvement in teaching ability as well as in attitude, knowledge, and skills (AKS) in two core domains of PPC: communication and pain and symptom management. The most frequently taught modules were about multimodal management of distressing symptoms. Trainers suggested adding new content to the current curriculum and further expansion in low-medium income countries. Most (71%) reported improvements in the clinical care of children with serious illnesses at their own institutions. CONCLUSION: EPEC-Pediatrics is a successful curriculum and dissemination project that improves participants' self-reported teaching skills and AKS's in many PPC core domains. Participating clinicians not only taught and disseminated the curriculum content, they also reported improvement in the clinical care of children with serious illness.
Postier AC; Wolfe J; Hauser J; Remke SS; Baker JN; Kolste A; Dussel V; Bernadá M; Widger K; Rapoport A; Drake R; Chong PH; Friedrichsdorf SJ
Journal of Pain and Symptom Management
2021
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<a href="http://doi.org/10.1016/j.jpainsymman.2021.11.017" target="_blank" rel="noreferrer noopener">10.1016/j.jpainsymman.2021.11.017</a>
Exposure to home-based pediatric palliative and hospice care and its impact on hospital and emergency care charges at a single institution
adolescent; Child; Female; Hospitalization; Humans; infant; Male; retrospective studies; Young Adult; Palliative Care; hospice care; Length of Stay; Hospitals; Hospital Charges; Emergency Service; quality of life; Pediatric; Preschool; Hospital
BACKGROUND: Pediatric palliative care (PPC) aims to promote quality of life for children and their families through prevention and relief of physical and psychosocial symptoms. Little is known about how PPC/hospice services impact health care resource utilization in an uncertain financial landscape. OBJECTIVE: The study objective was to compare pediatric hospital health care resource utilization before and after enrollment in a home PPC/hospice program. DESIGN: The study was a retrospective administrative data analysis. SETTING/SUBJECTS: The study took place in a pediatric multispecialty hospital. Data were analyzed for 425 children ages 1-21 years who received home-based PPC/hospice services between 2000 and 2010. MEASUREMENTS: Hospitalization and emergency room (ER) administrative data were examined to determine whether or not there were changes in total number of hospital admissions, length of stay (LOS), and hospital billed charges before compared to after PPC/hospice exposure. RESULTS: There was no change in average total number of admissions pre-/post-PPC/hospice exposure; however, we found a significant increase in hospital/ER admissions for children with cancer diagnoses with longer exposure to PPC/hospice services. There were statistically significant reductions in LOS and total charges for hospital-based care; reductions were more pronounced in the noncancer group. Noncancer patients with at least six months of PPC exposure showed a significant decrease in total LOS from pre- to post-program admission by an average of 38 days, and an average decrease in total hospital charges of nearly $275,000. CONCLUSION: Enrollment in home-based PPC/hospice was associated with lower hospital and ER LOS and total hospital charges as compared with the period prior to enrollment for children with noncancer diagnoses.
2014-02
Postier A; Chrastek J; Nugent S; Osenga K; Friedrichsdorf SJ
Journal Of Palliative Medicine
2014
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Journal Article
<a href="http://doi.org/10.1089/jpm.2013.0287" target="_blank" rel="noreferrer">10.1089/jpm.2013.0287</a>
Improved Quality of Life at End of Life Related to Home-Based Palliative Care in Children with Cancer
Background: Nearly 2000 children die due to a malignancy in the United States annually. Emerging data suggest that home is the desired location of care for children with cancer at end of life. However, one obstacle to enrollment in a pediatric palliative care (PPC) home care program may be fear that distressing symptoms at end of life cannot be adequately managed outside the hospital. Objective: To compare the symptom distress and quality-of-life experience for children who received concurrent end-of-life care from a PPC home care program (PPC/Oncology) with that of those who died without exposure to the PPC program (Oncology). Methods: We conducted a retrospective survey study of a cohort of bereaved parents of children who died of cancer between 2002 and 2008 at a U.S. tertiary pediatric institution. Results: Sixty bereaved parents were surveyed (50% PPC/Oncology). Prevalence of constipation and high distress from fatigue were more common in the PPC/Oncology group; other distressing symptoms were similar between groups, showing room for improvement. Children who received PPC/Oncology were significantly more likely to have fun (70% versus 45%), to experience events that added meaning to life (89% versus 63%), and to die at home (93% versus 20%). Conclusions: This is the first North American study to assess outcomes among children with cancer who received concurrent oncology and palliative home care compared with those who received oncology care alone. Symptom distress experiences were similar in groups. However, children enrolled in a PPC home care program appear to have improved quality of life and are more likely to die at home.
2014-11
Friedrichsdorf SJ; Postier A; Dreyfus J; Osenga K; Sencer S; Wolfe J
Journal Of Palliative Medicine
2014
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Journal Article
<a href="http://doi.org/10.1089/jpm.2014.0285" target="_blank" rel="noreferrer">10.1089/jpm.2014.0285</a>
The management of pain in children with life-limiting illnesses
Child; Humans; Pain Measurement; Analgesics; Severity of Illness Index; Chronic disease; Methadone/therapeutic use; Hydromorphone/therapeutic use; Opioid/therapeutic use; Fentanyl/therapeutic use; Morphine/therapeutic use; Nociceptors/physiology; Codeine/therapeutic use; Ketamine/therapeutic use; Oxycodone/therapeutic use; Pain/diagnosis/drug therapy/physiopathology
The management of pain in children with life-limiting illnesses is complex and unfortunately not often done effectively. Pain is a multidimensional symptom that can overshadow all other experiences of both the child and family. This article focuses on topics common to practitioners caring for children with lifelimiting illnesses, including a review of myths and obstacles to achieving adequate pain control, a review of the pathophysiology of pain, an overview of the use of opioids in children, an approach to the management of neuropathic pain, and a brief discussion of nonpharmacologic pain management strategies.
2007
Friedrichsdorf SJ; Kang T
Pediatric Clinics Of North America
2007
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Journal Article
<a href="http://doi.org/10.1016/j.pcl.2007.07.007" target="_blank" rel="noreferrer">10.1016/j.pcl.2007.07.007</a>
Status quo of palliative care in pediatric oncology-a nationwide survey in Germany
Child; Female; Humans; infant; Male; Data Collection; Treatment Outcome; adolescent; Preschool; Non-U.S. Gov't; Research Support; infant; Physician's Practice Patterns/statistics & numerical data; Pediatrics/methods/trends; Newborn; location of death; Germany/epidemiology; Home Care Services/statistics & numerical data/trends; Medical Oncology/methods/trends; Neoplasms/mortality/therapy; Palliative Care/methods/statistics & numerical data/trends
Cancer is the leading cause of death among the pediatric population with life-limiting conditions. The provision of palliative care at home and on the children's cancer unit has not been surveyed previously on a national scale. A survey of 71 (of 73) German pediatric oncology units (response rate 97%) provided information on the timing of breaking bad news, place of death, orchestrating palliative care at home and on the ward, integration of services and staff, funding of palliative care, bereavement services for siblings and parents, educational needs, level of self-satisfaction, and designated integrated palliative care services for children with cancer. More than 60% of children with malignancies died as inpatients in 2000, fewer than 40% at home. Twenty-nine pediatric cancer departments were able to provide comprehensive medical palliative home care, and nine units incorporate a designated palliative care team or person. Only half of the departments provide bereavement services for siblings. Many health professionals working on pediatric cancer units in Germany provide palliative home care in their free time without any payment. They predominantly use their private vehicles and often are unclear about the legal background and insurance arrangements covering their provision of care. The data suggest an important need for education about palliative and end-of-life care. The majority of children dying from cancer in Germany do not have access to comprehensive palliative care services at home. Our study highlights the necessity of incorporating the palliative paradigm into the care of children with cancer. Barriers to its implementation must be identified and overcome.
Friedrichsdorf SJ; Menke A; Brun S; Wamsler C; Zernikow B
Journal Of Pain And Symptom Management
2005
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Journal Article
<a href="http://doi.org/10.1016/j.jpainsymman.2004.05.004" target="_blank" rel="noreferrer">10.1016/j.jpainsymman.2004.05.004</a>
Palliative care in Poland -- the Warsaw hospice for children
Child; Patient Discharge; Patient Admission; Poland; Editorial Board Reviewed; Expert Peer Reviewed; Hospice palliative care; Nursing Journals; Online/Print; Palliative Care/ei [Ethical Issues]; Palliative Care/td [Trends]; Pediatric Care; Pediatric Care/td [Trends]; Peer Reviewed Journals; UK & Ireland Journals.
Stefan Friedrichsdorf, Sandra Brun, Boris Zernikow and Tomasz Dangel report on epidemiological data and describe Warsaw's paediatric hospice home care programme.
2006
Friedrichsdorf SJ; Brun S; Zernikow B; Dangel T
European Journal Of Palliative Care
2006
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Journal Article
Pediatric palliative care patients: a prospective multicenter cohort study
adolescent; Child; Female; Hospitalization; Humans; infant; Male; United States; Young Adult; Palliative Care; Prevalence; Chronic disease; Eligibility Determination; Follow-Up Studies; Medical Audit; Prospective Studies; adolescent; Preschool; Palliative Care/organization & administration; infant; Newborn; PEDI Study; United States/epidemiology; Chronic Disease/epidemiology/therapy; Eligibility Determination/methods; Hospitalization/trends; Medical Audit/organization & administration
OBJECTIVE: To describe demographic and clinical characteristics and outcomes of patients who received hospital-based pediatric palliative care (PPC) consultations. DESIGN, SETTING, AND PATIENTS: Prospective observational cohort study of all patients served by 6 hospital-based PPC teams in the United States and Canada from January to March 2008. RESULTS: There were 515 new (35.7%) or established (64.3%) patients who received care from the 6 programs during the 3-month enrollment interval. Of these, 54.0% were male, and 69.5% were identified as white and 8.1% as Hispanic. Patient age ranged from less than one month (4.7%) to 19 years or older (15.5%). Of the patients, 60.4% lived with both parents, and 72.6% had siblings. The predominant primary clinical conditions were genetic/congenital (40.8%), neuromuscular (39.2%), cancer (19.8%), respiratory (12.8%), and gastrointestinal (10.7%). Most patients had chronic use of some form of medical technology, with gastrostomy tubes (48.5%) being the most common. At the time of consultation, 47.2% of the patients had cognitive impairment; 30.9% of the cohort experienced pain. Patients were receiving many medications (mean: 9.1). During the 12-month follow-up, 30.3% of the cohort died; the median time from consult to death was 107 days. Patients who died within 30 days of cohort entry were more likely to be infants and have cancer or cardiovascular conditions. CONCLUSIONS: PPC teams currently serve a diverse cohort of children and young adults with life-threatening conditions. In contrast to the reported experience of adult-oriented palliative care teams, most PPC patients are alive for more than a year after initiating PPC.
Feudtner C; Kang T; Hexem KR; Friedrichsdorf SJ; Osenga K; Siden H; Friebert SE; Hays Ross M; Dussel V; Wolfe J
Pediatrics
2011
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Journal Article
<a href="http://doi.org/10.1542/peds.2010-3225" target="_blank" rel="noreferrer">10.1542/peds.2010-3225</a>
Integration of hypnosis into pediatric palliative care
Child; Hypnosis; Hypnotherapy; Integrative Medicine; Pediatric Palliative Care (ppc)
At least 8 million children would need specialized pediatric palliative care (PPC) services annually worldwide, and of the more than 42,000 children and teenagers dying annually in the United States, at least 15,000 children would require PPC. Unfortunately, even in resource-rich countries the majority of children dying from serious advanced illnesses are suffering from unrelieved, distressing symptoms such as pain, dyspnea, nausea, vomiting, and anxiety. State of the art treatment and prevention of those symptoms requires employing multi-modal therapies, commonly including pharmacology, rehabilitation, procedural intervention, psychology, and integrative modalities. This article describes the current practice of integrating hypnosis into advanced pain and symptom management of children with serious illness. Three case reports of children living with a life-limiting condition exemplify the effective use of this clinical modality to decrease distressing symptoms and suffering. Hypnosis for pediatric patients experiencing a life-limiting disease not only provides an integral part of advanced symptom management, but also supports children dealing with loss and anticipatory loss, sustains and enhances hope and helps children and adolescents live fully, making every moment count, until death.
Friedrichsdorf SJ; Kohen DP
Annals Of Palliative Medicine
2017
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10.21037/apm.2017.05.02
Four Steps To Eliminate Or Reduce Pain In Children Caused By Needles (part 1)
Analgesia; Clinical Study; Needle; Needle/am [adverse Device Effect]; Pain/co [complication]; Pain/pc [prevention]; Pain/th [therapy]; Acupuncture; Aromatherapy; Child; Chronic Pain/co [complication]; Chronic Pain/th [therapy]; Controlled Study; Human; Hypnosis; Injection Pain/co [complication]; Injection Pain/th [therapy]; Integrative Medicine; Minnesota; Note; Pain Clinic; Palliative Therapy; Priority Journal; Self Care; Treatment Planning; Vaccination
Friedrichsdorf SJ
Pain Management
2017
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10.2217/pmt-2016-0050
Multimodal Pediatric Pain Management (part 2)
analgesia; integrative strategies; multimodal; pediatric pain management
Dr Stefan Friedrichsdorf speaks to Commissioning Editor Jade Parker: Stefan Friedrichsdorf, MD, is medical director of the Department of Pain Medicine, Palliative Care and Integrative Medicine at Children's Hospitals and Clinics of Minnesota in Minneapolis/St Paul, MN, USA, home to one of the largest and most comprehensive programs of its kind in the country. The pain and palliative care program is devoted to control acute, chronic/complex and procedural pain for inpatients and outpatients in close collaboration with all pediatric subspecialties at Children's Minnesota. The team also provides holistic, interdisciplinary care for children and teens with life limiting or terminal diseases and their families. Integrative medicine provides and teaches integrative, nonpharmacological therapies (such as massage, acupuncture/acupressure, biofeedback, aromatherapy and self-hypnosis) to provide care that promotes optimal health and supports the highest level of functioning in all individual children's activities. In this second part of the interview they discuss multimodal (opioid-sparing) analgesia for hospitalized children in pain and how analgesics and adjuvant medications, interventions, rehabilitation, psychological and integrative therapies act synergistically for more effective pediatric pain control with fewer side effects than a single analgesic or modality.
Friedrichsdorf SJ
Pain Management
2017
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DOI: 10.2217/pmt-2016-0051
Pain Reporting And Analgesia Management In 270 Children With A Progressive Neurologic, Metabolic Or Chromosomally Based Condition With Impairment Of The Central Nervous System: Cross-sectional, Baseline Results From An Observational, Longitudinal Study
Hospice; Life-limiting; Neuropathic Pain; Palliative; Pediatric Palliative Care
Little is known about the prevalence, characterization and treatment of pain in children with progressive neurologic, metabolic or chromosomal conditions with impairment of the central nervous system. The primary aims of this study were to explore the differences between parental and clinical pain reporting in children with life-limiting conditions at the time of enrollment into an observational, longitudinal study and to determine if differences in pain experiences were associated with patient- or treatment-related factors. Pain was common, under-recognized and undertreated among the 270 children who enrolled into the "Charting the Territory" study. Children identified by their parents as experiencing pain (n=149, 55%) were older, had more comorbidities such as dyspnea/feeding difficulties, were less mobile with lower functional skills and used analgesic medications more often, compared to pain-free children. Forty-one percent of children with parent-reported pain (21.8% of all patients) experienced pain most of the time. The majority of clinicians (60%) did not document pain assessment or analgesic treatment in the medical records of patients who were experiencing pain. Documentation of pain in the medical record was positively correlated with children receiving palliative care services and being prescribed analgesics, such as acetaminophen, nonsteroidal anti-inflammatory drugs and opioids, as well as the adjuvant analgesics gabapentin and amitriptyline.
Friedrichsdorf SJ; Postier A; Andrews GS; Hamre K E; Steele R; Siden H
Journal Of Pain Research
2017
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<a href="https://doi.org/10.2147/JPR.S138153" target="_blank" rel="noreferrer">10.2147/jpr.s138153</a>
A Comparison Of Circumstances At The End Of Life In A Hospital Setting For Children With Palliative Care Involvement Versus Those Without
Context: Specialized pediatric palliative care (PPC) services have become more common in urban pediatric hospital settings, although little is known about palliative care specialist involvement.Objectives: The objective of this study was to compare circumstances before death in children who spent their last days of life in an inpatient pediatric hospital setting, with or without PPC provider involvement during their inpatient stay.Methods: Retrospective chart review of medical records of children for the last inpatient stay that resulted in death at a children's hospital setting between January 2012 through June 2013. The setting was a free-standing, 385-bed tertiary care children's hospital.Results: Charts were reviewed for 114 children between 0 and 18 years of age, who were hospitalized for at least 24 hours before their death. Half of the children who died as inpatients were infants (median age five weeks). Children who received an inpatient PPC consult (25% of the sample) experienced 1) a higher rate of pain assessments, 2) better documentation around specific actions to manage pain, 3) greater odds of receiving integrative medicine services, 4) fewer diagnostic/monitoring procedures (e.g., blood gases, blood draws, placements of intravenous lines) in the last 48 hours of life, and 5) nearly eight times greater odds of having a do-not-resuscitate order in place at the time of death.Conclusion: The integration of a PPC team was associated with fewer diagnostic/monitoring procedures and improved pain management documentation in this study of 114 children who died as inpatients.
Osenga K; Postier A; Dreyfus J; Foster L; Teeple W; Friedrichsdorf SJ
Journal Of Pain And Symptom Management
2016
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<a href="https://doi.org/10.1016/j.jpainsymman.2016.05.024">10.1016/j.jpainsymman.2016.05.024</a>
Protocol: Evaluating The Impact Of A Nation-wide Train-the-trainer Educational Initiative To Enhance The Quality Of Palliative Care For Children With Cancer
Adolescent; Canada; Child; Child Preschool; Curriculum/standards; Health Personnel/education; Humans; Neoplasms/therapy; Palliative Care/methods; Palliative Care/standards; Pediatrics/methods; Program Evaluation; Quality Of Life/psychology; Teaching/standards
Pediatrics; Palliative Care; Cancer Quality Care; Education Knowledge Translation
Background
There are identified gaps in the care provided to children with cancer based on the self-identified lack of education for health care professionals in pediatric palliative care and in the perceptions of bereaved parents who describe suboptimal care. In order to address these gaps, we will implement and evaluate a national roll-out of Education in Palliative and End-of-Life Care for Pediatrics (EPEC®-Pediatrics), using a ‘Train-the-Trainer’ model.
Methods/design
In this study we are using a pre- post-test design and an integrated knowledge translation approach to assess the impact of the educational roll-out in four areas: 1) self-assessed knowledge of health professionals; 2) knowledge dissemination outcomes; 3) practice change outcomes; and 4) quality of palliative care. The quality of palliative care will be assessed using data from three sources: a) parent and child surveys about symptoms, quality of life and care provided; b) health record reviews of deceased patients; and c) bereaved parent surveys about end-of-life and bereavement care. After being trained in EPEC®-Pediatrics, ‘Master Facilitators’ will train ‘Regional Teams’ affiliated with 16 pediatric oncology programs in Canada. Each team will consist of three to five health professionals representing oncology, palliative care, and the community. Each team member will complete online modules and attend one of two face-to-face conferences, where they will receive training and materials to teach the EPEC®-Pediatrics curriculum to ‘End-Users’ in their region. Regional Teams will also choose a Tailored Implementation of Practice Standards (TIPS) Kit to guide implementation of a quality improvement project in their region; support will be provided via quarterly meetings with Co-Leads and via a listserv and webinars with other teams.
Discussion
Through this study we aim to raise the level of pediatric palliative care education amongst health care professionals in Canada. Our study will be a significant step forward in evaluation of the impact of EPEC®-Pediatrics both on dissemination outcomes and on care quality at a national level. Based on the anticipated success of our project we hope to expand the EPEC®-Pediatrics roll-out to health professionals who care for children with non-oncological life-threatening conditions.
Widger K; Friedrichsdorf SJ; Wolfe J; Liben S; Pole JD; Bouffet E; Greenberg M; Husain A; Siden H; Whitlock JA; Rapoport A
Bmc Palliative Care
2016
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DOI: 10.1186/s12904-016-0085-8
Contemporary Pediatric Palliative Care: Myths And Barriers To Integration Into Clinical Care.
At least 20 million children would benefit from Pediatric Palliative Care (PPC) annually, and 8 million children would need specialized PPC services. In the USA alone, more than 42,000 children 0-19 years died in 2013, fifty-five percent of them infants younger than 1 year. This article aims to critically review eight common assumptions, myths and barriers, which may hinder the implementation of PPC into the care of a child with advanced serious illnesses. Interdisciplinary PPC is about matching treatment to patient goals and is considered specialized medical care for children with serious illness. It is focused on relieving pain, distressing symptoms, and stress of a serious illness and appropriate at any age and at any stage, together with curative treatment. The primary goal is to improve quality of life for child and his or her family. Emerging evidence shows, that palliative care involvement results in improved quality of life as well as prolongation of life.
Friedrichsdorf SJ
Current Pediatric Reviews
2016
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Methadone Conversion In Infants
And Children: Retrospective Cohort Study Of 199 Pediatric Inpatients.
Administration Oral; Adolescent; Age Factors; Analgesics Opioid/administration & Dosage; Analgesics Opioid/adverse Effects; Child; Child Preschool; Consciousness/drug Effects; Drug Administration Schedule; Drug Dosage Calculations; Drug Monitoring; Drug Overdose/etiology; Drug Substitution; Hospitals Pediatric; Humans; Infant; Infant Newborn; Inpatients; Intubation Intratracheal; Methadone/administration & Dosage; Methadone/adverse Effects; Minnesota; Pain/diagnosis; Pain/drug Therapy; Pharmacy Service Hospital; Respiration Artificial; Retrospective Studies; Risk Factors; Substance Withdrawal Syndrome/etiology; Tertiary Care Centers; Time Factors; Treatment Outcome; Substances; Analgesics Opioid; Methadone
OBJECTIVE:
Methadone administration has increased in pediatric clinical settings. This review is an attempt to ascertain an equianalgesic dose ratio for methadone in the pediatric population using standard adult dose conversion guidelines.
SETTING:
US tertiary children's hospital.
PATIENTS:
Hospitalized pediatric patients, 0-18 years of age.
MAIN OUTCOME MEASURES:
A retrospective chart review was conducted for patients who were converted from their initial opioid therapy regimen (morphine, hydromorphone, and/or fentanyl) to methadone. The primary endpoint was whether or not a dose correction was needed for methadone in the 6 days following conversion using standard dose conversion charts for adults. Documented clinical signs of withdrawal, unrelieved pain, or oversedation were examined.
RESULTS:
The majority (53.7 percent) of the 199 children were converted to methadone on intensive care units prior extubation or postextubation. The mean conversion ratio was 23.7 mg of oral morphine to 1 mg of oral methadone (median, 18.8 mg:1 mg, SD=25.7). Most patients experienced an adequate conversion (n=115, 57.8 percent), while 83 (41.7 percent) appeared undermedicated, and one child was oversedated. There were no associations found with conversion ratios for initial morphine dose, days to conversion, or effect of withdrawal of concomitant agents with potential for withdrawal.
CONCLUSIONS:
Opioid conversion to methadone is commonly practiced at our institution; however, dosing was significantly lower compared to adult conversion ratios, and more than 40 percent of children were undermedicated. The majority of children in this study received opioids for sedation while intubated and ventilated; therefore, safe and efficacious pediatric methadone conversion rates remain unclear. Prospective studies are needed.
Fife A; Postier A; Flood A; Friedrichsdorf SJ
Journal Of Opioid Management
2016
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