Maternal-fetal surgery as part of pediatric palliative care
fetus surgery; palliative therapy; child; congenital diaphragm hernia; consultation; counseling; female; fetus; human; infant; Palliative Care; review; risk assessment; surgeon
Maternal-fetal surgical interventions have become a more common part of prenatal care. This third option, beside termination or post-natal interventions, complicates prenatal decision-making: while interventions may be lifesaving, survivors may face a life with disability. Pediatric palliative care (PPC) is more than end of life or hospice care, it aims at helping patients with complex medical conditions live well. In this paper, we briefly discuss maternal-fetal surgery, challenges regarding counseling and benefit-risk evaluation, argue that PPC should be a routine part of prenatal consultation, discuss the pivotal role of the maternal-fetal surgeon in the PCC-team, and finally discuss some of the ethical considerations of maternal-fetal surgery. We illustrate this with a case example of an infant diagnosed with congenital diaphragmatic hernia (CDH).Copyright © 2023
De Bie FR; Tate T; Antiel RM
Seminars in Fetal and Neonatal Medicine
2023
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.siny.2023.101440" target="_blank" rel="noreferrer noopener">10.1016/j.siny.2023.101440</a>
Impact of COVID-19 on Admissions and Outcomes for Children With Complex Chronic Conditions
COVID-19; Child; Chronic Disease; Cross-Sectional Studies; Hospitalization; Humans; Pandemics
BACKGROUND: Although pediatric health care use declined during the coronavirus disease 2019 (COVID-19) pandemic, the impact on children with complex chronic conditions (CCCs) has not been well reported. OBJECTIVE: To describe the impact of the pandemic on inpatient use and outcomes for children with CCCs. METHODS: This multicenter cross-sectional study used data from the Pediatric Health Information System. We examined trends in admissions between January 2020 through March 2021, comparing them to the same timeframe in the previous 3 years (pre-COVID-19). We used generalized linear mixed models to examine the association of the COVID-19 period and outcomes for children with CCCs presenting between March 16, 2020 to March 15, 2021 (COVID-19 period) to the same timeframe in the previous 3 years (pre-COVID-19). RESULTS: Children with CCCs experienced a 19.5% overall decline in admissions during the COVID-19 pandemic. Declines began in the second week of March of 2020, reaching a nadir in early April 2020. Changes in admissions varied over time and by admission indication. Children with CCCs hospitalized for pneumonia and bronchiolitis experienced overall declines in admissions of 49.7% to 57.7%, whereas children with CCCs hospitalized for diabetes experienced overall increases in admissions of 21.2%. Total and index length of stay, costs, and ICU use, although statistically higher during the COVID-19 period, were similar overall to the pre-COVID-19 period. CONCLUSIONS: Total admissions for children with CCCs declined nearly 20% during the pandemic. Among prevalent conditions, the greatest declines were observed for children with CCCs hospitalized with respiratory illnesses. Despite declines in admissions, overall hospital-level outcomes remained similar.
Markham JL; Richardson T; Teufel RJ; Hersh AL; DePorre A; Fleegler EW; Antiel RM; Williams DC; Hotz A; Wilder JL; Shah SS
Hospital Pediatrics
2022
<a href="http://doi.org/10.1542/hpeds.2021-006334" target="_blank" rel="noreferrer noopener">10.1542/hpeds.2021-006334</a>
Surgical Interventions During End-of-Life Hospitalizations in Children's Hospitals
Adolescent; Age Factors; Biopsy; Catheterization; Child; Chronic Disease; Ethnicity; Hospitalization; Infant; International Classification of Diseases; Newborn Infant; Pediatric Hospitals; Preschool Child; Prosthesis Implantation; Race Factors; Retrospective Studies; Salvage Therapy; Surgical Procedures, Operative; Terminal Care; United States; Young Adult
OBJECTIVES: To characterize patterns of surgery among pediatric patients during terminal hospitalizations in children's hospitals. METHODS: We reviewed patients ≤20 years of age who died among 4 424 886 hospitalizations from January 2013-December 2019 within 49 US children's hospitals in the Pediatric Health Information System database. Surgical procedures, identified by International Classification of Diseases procedure codes, were classified by type and purpose. Descriptive statistics characterized procedures, and hypothesis testing determined if undergoing surgery varied by patient age, race and ethnicity, or the presence of chronic complex conditions (CCCs). RESULTS: Among 33 693 terminal hospitalizations, the majority (n = 30 440, 90.3%) of children were admitted for nontraumatic causes. Of these children, 15 142 (49.7%) underwent surgery during the hospitalization, with the percentage declining over time (P < .001). When surgical procedures were classified according to likely purpose, the most common were to insert or address hardware or catheters (31%), explore or aid in diagnosis (14%), attempt to rescue patient from mortality (13%), or obtain a biopsy (13%). Specific CCC types were associated with undergoing surgery. Surgery during terminal hospitalization was less likely among Hispanic children (47.8%; P < .001), increasingly less likely as patient age increased, and more so for Black, Asian American, and Hispanic patients compared with white patients (P < .001). CONCLUSIONS: Nearly half of children undergo surgery during their terminal hospitalization, and accordingly, pediatric surgical care is an important aspect of end-of-life care in hospital settings. Differences observed across race and ethnicity categories of patients may reflect different preferences for and access to nonhospital-based palliative, hospice, and end-of-life care.
Traynor MD; Antiel RM; Camazine MN; Blinman TA; Nance ML; Eghtesady P; Lam SK; Hall M; Feudtner C
Pediatrics
2021
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1542/peds.2020-047464" target="_blank" rel="noreferrer noopener">10.1542/peds.2020-047464</a>
Pediatric Perioperative DNR Orders: A Case Series in a Children's Hospital
Palliative Care; Do-Not-Resuscitate Orders; End of Life; Palliative Surgery; Perioperative Guideline Adherence
Context Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period is limited. Objectives Evaluate perioperative management of DNR orders at a tertiary care children�s hospital. Methods We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from 2/1/2016 � 8/1/2017. Using standardized case report forms, we abstracted the following from physician notes: (A) patient/family wishes with respect to the DNR, (B) whether pre-operative DNRs were continued, modified, or suspended during the perioperative period, and (C) whether life threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision making in the perioperative period. Results Twenty-three patients aged six days to 17 years had a DNR in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures, and suspended for fifteen (51%). Three children (13%) suffered life threatening events. We identified four time points where systematic reconsideration should be documented in the medical record, recommended personnel, and important discussion points at each time point. Conclusion Opportunities exist to improve how DNR orders are managed during the perioperative period.
Brown SES; Antiel RM; Blinman TA; Shaw S; Neuman Mark D; Feudtner C
Journal of Pain and Symptom Management
2019
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.jpainsymman.2019.01.006" target="_blank" rel="noreferrer noopener">10.1016/j.jpainsymman.2019.01.006</a>