“He is normal”: phenomenological considerations of child/adolescent’s perception of the disabled sibling
Adolescent; Child; Disabled Persons; Female; Humans; Learning; Male; Perception; Qualitative Research; Siblings
Freitag VL; Motta MdGC; Milbrath VM; Bazzan JS; Debatin G; Gabatz RIB
Revista Gaúcha de Enfermagem
2022
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/10.1590/1983-1447.2022.20220129.en" target="_blank" rel="noreferrer noopener">10.1590/1983-1447.2022.20220129.en</a>
“It’s brilliant! It’s working! It’s needed!” A Hospice Short Break Innovation for Young Adults
Hospice; Adult; Child; clinical article; conference abstract; drug withdrawal; Female; health care delivery; Hospice; Human; human experiment; interview; learning; Male; outcome assessment; Palliative Therapy; positive feedback; questionnaire; sibling; trust; young adult
Background More young adults with life-limiting conditions are surviving into adulthood needing adult palliative care (Gibson- Smith, Jarvis, Norman et al., 2021). The evidence on appropriate service models is sparse (Clark & Fasciano, 2015. Am J Hosp Palliat Med. 31: 101). Adult hospices report lack of competence and confidence in young adult complex care needs (Knighting, Bray, Downing, et al., 2018. J Adv Nurs. May 6). Loss of children's hospice short break provision after transition has been described by families as like 'falling off a cliff edge' (Knighting, Pilkington, Noyes, et al., 2021. Health Serv Deliv Res. 9, 6). There is a lack of equivalent provision in adult services (Together for Short Lives, 2015). To address unmet need, a pilot residential short break service in an adult hospice was co-produced and evaluated with families to determine future provision. Aims With the aim of facilitating future service optimisation the service evaluation had the following objectives: a) to identify the outcomes and benefits; b) to enable learning; c) to explore staff experiences, training and support needs; d) to scope the financial and service delivery implications. Methods A service evaluation of the pilot (delivered May 2019-March 2020,) including process data and feedback gathered using semi-structured questions via questionnaires, interviews and focus groups with young adults, siblings, parent/ guardians and staff. Results Sixty short breaks delivered, accessed by 15 young adults >18 years and their families. Evaluation participants: 3 young adults, 6 siblings, 10 parent/guardians, 11 staff. Highly positive feedback with no withdrawals from the pilot. Triangulated themes: a) social and developmental benefits for young adults; b) respite benefits for families; c) achieving parents' trust, d) ability of adult hospice to meet complex care needs; e) positive staff experiences; f) identified areas for service improvement. Conclusion Persuasive evidence from the evaluation resulted in the service being commissioned. The report offers recommendations for adult hospices aspiring to develop young adult palliative care services. How innovative or of interest is the abstract? To our knowledge this is the first young adult short break service in a UK adult hospice.
Finlinson H; Spathis A
BMJ Supportive and Palliative Care
2022
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/10.1136/spcare-2022-HUNC.5" target="_blank" rel="noreferrer noopener">10.1136/spcare-2022-HUNC.5</a>
A One Day Paediatric Palliative Care Study Day Improves Skills
Palliative Care; child; controlled study; female; human; male; advance care planning; ethics; palliative therapy; clinical article; consultation; human experiment; questionnaire; conference abstract; skill; learning; appetite
Objectives To see if a network Palliative Care Study day increases knowledge of participants. Method This was the first paediatric palliative care network study day run in the region. 20 doctors (both consultants and those in training) participated. The day was a mixture of presentations and in depth work shops covering advance care planning discussions (with actors); symptom management and discussion of ethical and legal principles underpinning palliative care. The course was run face to face. A pre-course questionnaire was sent out online to applicants to gain an understanding of their prior knowledge and their learning objectives. Post course feedback was obtained via paper questionnaire at the end of the study day. Results Participants ranked their pre-course knowledge of Advance Care Planning; End of life processes; Symptom Management; Ethics in palliative care as 3/5 (mode and median, n=19) and post course as 4 (mode and median, n=16). 100% of respondents would recommend this course to a colleague and 100% felt the course met the objectives. Feedback on how to improve identified an appetite for clinicians to have more practice in discussing advance care planning with families. Conclusion Feedback identified clinicians (both those in training and consultants) do not feel equipped to start advance care planning discussions, manage symptoms or know what to do when a child dies. Our study day demonstrated a gain in these skills.
Aidoo E
Archives of Disease in Childhood
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/10.1136/archdischild-2023-rcpch.55" target="_blank" rel="noreferrer noopener">10.1136/archdischild-2023-rcpch.55</a>
An innovative hybrid palliative care fellowship program: empowering pediatricians and enhancing care for children in resource-limited settings
child; Canada; Palliative Care; pediatrics; Bangladesh; controlled study; female; human; major clinical study; male; child health; palliative therapy; total quality management; India; pediatrician; skill; clinical examination; conference abstract; Philippines; learning; rotation; leadership; teaching; rigor; career; mentor; running; resource limited setting; Southeast Asia
Objective To describe the development and implementation of a 1-year 'Hybrid' Pediatric Palliative Care (PPC) Fellowship, which includes both clinical and online learning to train paediatricians as specialists and leaders in paediatric palliative care in South and Southeast Asia. Methods Globally, 97% of children needing palliative care (PC) live in low- or middle-income countries, where access is often very limited. In India, less than 1% of the 1.6 million children needing PC can access these services. Building capacity and training opportunities for paediatricians are essential to improve access to PC in these settings. The Hybrid fellowship was developed through the existing partnership between Two Worlds Cancer Collaboration, Canada and the Hyderabad Centre for Palliative Care to train paediatricians as specialists and leaders in paediatric palliative care in South and Southeast Asia. A team of PPC experts developed the fellowship after a rigorous review of relevant literature and educational materials, incorporating their experiences running PPC traditional (in-person) fellowship programs in both high and lowerresourced settings. Results The fellowship includes formal teaching, clinical rotations, mentorship, regular assessments of trainees, and a scholarly project. Teaching includes 100 hours of weekly online classes, with a focus on case-based learning and leadership skills. Mandatory 4 months of clinical rotations in PC includes 2 months in the regional centre of PPC excellence in Hyderabad, India. Trainees' progression towards program competencies is assessed through written and observed standardised clinical examinations. A mentorship program provides additional support, which continues beyond the fellowship through an early career mentorship group. As a part of research and quality improvement (QI) training, fellows complete a scholarly project with support and supervision from experienced research mentors. More than 30 regional and international PPC experts contribute to the program as faculty. Since 2021, 6 paediatricians have completed the 'Hybrid' fellowship, from India (2), Bangladesh (1), and the Philippines (3), with 3 fellows currently in training. Graduated fellows have become regional and national leaders in PPC, developing new PPC programs, and implementing new PPC training in their home country. The program successfully sought endorsement from the Royal College of Paediatrics and Child Health (UK), which has strengthened the program's rigor and quality. Conclusion A 1-year Hybrid PPC Fellowship, which trains pediatricians to become specialists and champions of PPC, is an innovative model that can successfully build PPC capacity in resource-limited settings and increase access to PPC for children with life-limiting illnesses.
Palat G; Doherty M; Brown S; Shah A
Archives of Disease in Childhood
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/10.1136/archdischild-2023-rcpch.53" target="_blank" rel="noreferrer noopener">10.1136/archdischild-2023-rcpch.53</a>
Attention and communication in Rett Syndrome
Communication; Learning; Attention; Rett Syndrome; trajectory; characteristics; alertness
The study of selective attention and its influence on communication in patients with Rett Syndrome (RS), in which communication abilities are impaired is particularly relevant. The aim of this study was to analyse attention and communication abilities in RS. A sample of 20 children (10 girls with RS and 10 control girls, matched on mental age) were tested on both attention and non-verbal communication abilities. Results showed that girls with RS have specific deficits in the ability to attend selectively to the relevant sources of information, and that they pay attention to irrelevant stimuli. Results related to non-verbal communication partially show specific impairment in girls with RS. Educational implications are discussed.
Fabio R A; Antonietti A; Castelli I; Marchetti A
Research in Autism Spectrum Disorders
2009
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.rasd.2008.07.005" target="_blank" rel="noreferrer noopener">10.1016/j.rasd.2008.07.005</a>
Being there: A scoping review of grief support training in medical education
learning; medical education; patients; pediatrics; physicians; psychological stress; trainees; workshops
INTRODUCTION: Medical education experts argue that grief support training for physicians would improve physician and patient and family wellness, and should therefore be mandatory. However, there is little evidence about the range of curricula interventions or the impact of grief training. The aim of this scoping review was to describe the current landscape of grief training worldwide in medical school, postgraduate residency and continuing professional development in the disciplines of pediatrics, family medicine and psychiatry. METHODS: Using Arksey and O'Malley's scoping review principles, MEDLINE, EMBASE, ERIC, PsychInfo and Web of Science were searched by a librarian. Two levels of screening took place: a title and abstract review for articles that fit a predefined criteria and a full-text review of articles that met those criteria. Three investigators reviewed the articles and extracted data for analysis. To supplement the search, we also scanned the reference lists of included studies for possible inclusion. RESULTS: Thirty-seven articles published between 1979 and 2019 were analyzed. Most articles described short voluntary grief training workshops. At all training levels, the majority of these workshops focused on transmitting knowledge about the ethical and legal dimensions of death, dying and bereavement in medicine. The grief trainings described were characterized by the use of diverse pedagogical tools, including lectures, debriefing sessions, reflective writing exercises and simulation/role-play. DISCUSSION: Grief training was associated with increased self-assessed knowledge and expertise; however, few of the studies analyzed the impact of grief training on physician and patient and family wellness. Our synthesis of the literature indicates key gaps exist, specifically regarding the limited emphasis on improving physicians' communication skills around death and dying and the limited use of interactive and self-reflexive learning tools. Most trainings also had an overly narrow focus on bereavement grief, rather than a more broadly defined definition of loss.
Sikstrom L; Saikaly R; Ferguson G; Mosher P J; Bonato S; Soklaridis S
PLoS One
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/10.1371/journal.pone.0224325" target="_blank" rel="noreferrer noopener">10.1371/journal.pone.0224325</a>
Bereavement follow-up: Listening and learning
bereavement;follow up;learning;Child;clinical article;conference abstract;consultation;diagnosis;Female;genetic transcription;Human;intensivist;Male;memory;nurse;staff;terminal care
Aims & Objectives: Providing family focussed care through lessons learned from bereavement follow-up. Methods RMCH is a tertiary PICU in UK with 750 admissions annually. Families of all patients who die in PICU are offered bereavement follow-up at 6-8 weeks. The meeting is attended by the parents, consultant intensivist and a family liaison nurse (recently appointed). As a service improvement project, these meetings have been routinely observed by a senior staff member using shadowing techniques (April 2017 onwards). Transcripts are recorded in a pre-designed field journal. Team debrief is held following meetings to identify recurrent themes to guide service improvement. Results 25 patients died between January-November 2017. 6 families attended bereavement follow-up. Families who attended had unanswered questions around care (pre-hospital/hospital) or were waiting to get the final postmortem /genetic test results. Two families declined as they were "happy with the care", three are awaiting follow-up dates and the remaining did not reply. To improve quality of discussions, team realised that prior interaction with parents to identify their objectives from the meeting is essential. Recurrent themes that emerged from shadowing technique included feedback around care (pre-hospital / in the hospital), communication gaps (during transfer of care, what to expect upon PICU admission, what happens after a child dies), making memories and wanting to know pending test results. Conclusions Families who have unanswered questions around care or diagnosis, tend to attend bereavement follow up. Shadowing technique has revealed what families want from end of life care and has helped to shape improvement in our service.
Subramanian G;Consterdine K;Ryan C
Pediatric Critical Care Medicine
2018
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/10.1097/01.pcc.0000537861.99545.54" target="_blank" rel="noreferrer noopener">10.1097/01.pcc.0000537861.99545.54</a>
Challenges experienced by paediatricians providing palliative care to children; A thematic analysis
death; child; female; human; major clinical study; male; palliative therapy; controlled study; thematic analysis; human experiment; learning; pediatrics; conference abstract; questionnaire; e-mail; pediatrician; health care system; needs assessment; Australia; expectation; holistic care; social welfare; specialist registrar
Background: and aim Palliative Care for Children is defined as 'an active and total approach to care, from the point of diagnosis or recognition throughout the child's life, death and beyond'. It is recognised that the prevalence of children with life-limiting conditions (LLC) is increasing. In Ireland the majority of children with LLC are cared for by paediatricians working in hospitals with no direct access to specialist paediatric palliative care(PPC) services. This study was part of a learning needs assessment of paediatrician's training and experience in PPC. Method(s): Consultants and Specialist Registrars in Paediatrics were approached by email and asked to complete a questionnaire regarding their learning needs in PPC. The Quality of Care Collaborative for Australia in PPC Project Research Study Group Learning Needs Assessment template was used with permission. The questionnaire included both multiple choice and free-text questions. Quantitative data from the study has been reported elsewhere. Thematic analysis based on the approach of Braun and Clarke (2006) was used to analyse data provided in the free-text answers. Result(s): 114 paediatricians responded to the survey, 72 respondents (63%) provided free-text answers to the question 'Reflecting on your most recent clinical interactions with children requiring palliative care support. What were the challenges?' On analysis, three overarching themes emerged, 'Best interests of the child', 'Inadequate training and confidence' and 'Co-ordinating care'. 'Best interests of the child' referred to the challenges experienced in ensuring that best interests of the child remain at the core of all decisions made when providing palliative care. This overarching theme included two sub-themes 'Complex communication' which referred to the challenges in managing parental expectations in increasingly technologically advanced healthcare systems and 'First do no harm' referring to the frequent ethical dilemmas that arise in PPC. 'Inadequate adequate training and confidence' referred to lack of specific education in complex symptom management and also to lack of familiarity with community based healthcare services. The theme of 'coordinating care' encompassed the need to liaise with community services but also the need to provide holistic care to the whole family which may be unfamiliar paediatricians working in an acute hospital setting. Conclusion(s): This study explores the challenges experienced by paediatricians providing palliative care to children with LLCs. The themes provide insight into those experiences and provides valuable direction to support the development of future educational programmes in this important and rapidly evolving paediatric sub-speciality.
Balfe J; Whitla L; Devins M; Molloy E; Twomey M; O'Reilly M
Archives of Disease in Childhood
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).
Child Death And Deterioration Review Group
Child Death; Deterioration; Adoption; Adverse Drug Reaction; Case Study; Cause Of Death; Child; Clinical Article; Controlled Study; Female; Health Care Quality; Human; Learning; Male; Nursing Staff; Palliative Therapy; Perception; Side Effect; Student; Trust
Background In order to improve outcomes for acutely unwell children and young people it is essential to learn from those cases in which children deteriorate and die. In our trust there was no universal record of child deaths or deteriorations and no over view of cases to identify learning, either positive or developmental. Aims The child death and deterioration (CDAD) review group was formed to enable a rapid multi-disciplinary timely review of every child death and unplanned PICU admissions. It allows concerns related to the care or cause of death to be identified, identifies need for more detailed reviews, investigation of adverse events and noting of good practice. Methods Group includes senior doctors and nursing staff, palliative care and risk team. Weekly meetings review cases from the preceding week. Cases are allocated 15 min and the patient's team (ideally medical and nursing) presents. Trainees are encouraged to attend. Cases are discussed, actions generated and graded 1-6 according to standard of care given. We also gather parent/patient feedback regarding unplanned PICU admissions to help provide insight into the perception they have of care provided. Results/measures Over the first year of CDAD, 38 child deaths and 138 unplanned PICU admissions have been reviewed. Various data including demographics, clinical area admitted from, involvement of outreach and palliative care teams, cause of death/deterioration and clinical grading are available (see figures 1-4). Multiple lessons of positive and negative practices as well as action plans are collated and fed back via care groups QuEST (M and M type) meeting. Favourable event reporting forms are completed for individuals and teams who have delivered excellent care. Lessons for practice Good discussion between professional groups and different specialities occurs including consideration of number areas of non technical elements. This has identified system, human interaction, equipment, environment and personal factors (including knowledge) that can be improved as well as a number of areas of good practice for spread and adoption.
Alderton M; Pryde K
Archives Of Disease In Childhood
2017
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).
10.1136/archdischild-2017-313087.20
Children's palliative care education and training: developing an education standard framework and audit
Child; Children; Clinical Competence; Curriculum; Education; End of life care; Learning; nursing education; Paediatric; Palliative care; Teaching; Training
BACKGROUND: The need to align the range of guidance and competencies concerning children's palliative care and develop an education framework have been recommended by a UK All-Party Parliament Group and others. In response to these recommendations the need for a revised children's palliative care competency framework was recognized. A Children's Palliative Care Education and Training Action Group, comprising champions in the field, was formed across UK and Ireland in 2019 to take this work forward. Their aim was to agree core principles of practice in order to standardize children's palliative care education and training. METHODS: Over four meetings the Action Group reviewed sources of evidence and guidance including palliative care competency documents and UK and Ireland quality and qualification frameworks. Expected levels of developing knowledge and skills were then agreed and identified competencies mapped to each level. The mapping process led to the development of learning outcomes, local indicative programme content and assessment exemplars. RESULTS: Four sections depicting developing levels of knowledge and skills were identified: Public Health, Universal, Core, Specialist. Each level has four learning outcomes: Communicating effectively, Working with others in and across various settings, Identifying and managing symptoms, Sustaining self-care and supporting the well-being of others. An audit tool template was developed to facilitate quality assurance of programme delivery. The framework and audit tool repository is on the International Children's Palliative Care Network website for ease of international access. CONCLUSIONS: The framework has received interest at UK, Ireland and International launches. While there are education programmes in children's palliative care this is the first international attempt to coordinate education, to address lay carer education and to include public health.
Neilson S; Randall D; McNamara K; Downing J
BMC Medical Education
2021
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<a href="http://doi.org/10.1186/s12909-021-02982-4" target="_blank" rel="noreferrer noopener">10.1186/s12909-021-02982-4</a>
Children's perspectives on the benefits and burdens of research participation
BACKGROUND: Participation in research is associated with benefits and burdens for individual research participants. Children living with a chronic illness are considered particularly vulnerable as they are already burdened with symptoms of their illness. In particular contexts, such as learning health care systems (LHS), where research and clinical care are integrated, children with chronic illnesses may be asked to participate in research related to their illness. A growing body of literature has focused on children's perspectives as research subjects; however, a relatively understudied aspect concerns children's experiences of research in clinics where they are also patients. METHODS: We interviewed 25 Canadian children and adolescents living with inflammatory bowel disease (IBD) about their experiences of research participation. RESULTS: Our participants described aspects of the research process and particular experiences as benefits and others as burdens. Benefits included helping others, receiving incentives, receiving the results of previous studies, and participating in fun activities. Burdens included the time required for particular types of research, physical and psychological discomfort, and feelings of obligation. CONCLUSIONS: Our study describes the experiences of children participating in research at a site that integrates research and clinical care. Our participants described experiences that often go unreported (such as feelings of obligation); we mention these as important considerations to be mindful of when interacting with children as (potential) research participants in an LHS and when thinking about research ethics protocols or the assent/consent process.
Barned C; Dobson J; Stintzi A; Mack D; O'Doherty KC
AJOB Empirical Bioethics
2018
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<a href="http://doi.org/10.1080/23294515.2018.1430709" target="_blank" rel="noreferrer noopener">10.1080/23294515.2018.1430709</a>
Conflicting realities experienced by children with life-limiting and life-threatening conditions when transitioning to adult health services
social support; qualitative analysis; palliative therapy; major clinical study; sibling; non profit organization; skill; joint; human; article; child; female; male; controlled study; adult; interview; total quality management; transition to adult care; learning; social media; adult child; secondary analysis; dilution; facilitation; social isolation
AIMS: The aim of this study was to report a secondary qualitative analysis exploring the cultural and practical differences that young people and parents experience when transitioning from children's to adult services. BACKGROUND: Despite two decades of research and quality improvement initiatives, young people with life-limiting and life-threatening conditions still find transition unsatisfactory. DESIGN: Secondary analysis: 77 qualitative interviews with children and young people (20), parents (35), siblings (1), professionals (21).
Noyes J; Pritchard S; Pritchard A; Bennett V; Rees S
Journal of advanced nursing
2018
<a href="http://doi.org/10.1111/jan.13811" target="_blank" rel="noreferrer noopener">10.1111/jan.13811</a>
Cultivating Gratitude in Bereaved Families: Description of the Impact of the Bereavement Workshop on Families of Deceased Patients in the Pediatric Palliative Care Program
active listening; bereavement; butterfly; child; conference abstract; coping behavior; genetic transcription; grief; group therapy; human; learning; music therapy; nonhuman; palliative therapy; perception; qualitative research; quantitative analysis; ritual; writing
Background and Aims: Grief in parents has been described as a very intense long-lasting experience, characterized by deep sadness, and social isolation, therefore, the recommendation of scientific societies in pediatrics is to provide bereavement care to parents and relatives of deceased children who have previously been cared for by health professionals. In this study, a bereavement workshop for parents is proposed as an intervention strategy, providing accompaniment to the families of deceased patients who received pediatric palliative care (PPC). Method(s): We conducted a quantitative and qualitative study in a focus group of parents of deceased children who participated in a bereavement workshop. The intervention consisted of a bereavement workshop, guided by the multidisciplinary PPC team, in which 4 activities were developed: group psychotherapy, music therapy, gratitude activity, symbolic ritual of delivery of butterfly. The gratitude activity consisted of motivating the families to express their gratitude by writing on cards with phrases that encourage reflection: during this process I am grateful for., I thank my child or family member for. . . , I thank the pediatric palliative care program for. . .; the cards were transcribed into a database constructed for this study and analyzed by 4 evaluators, thematic categories were assigned to each reflective sentence. Result(s): 60 families received the personalized letter of condolences with invitation to the workshop, 23 families attended the workshop. From the gratitude activity, families made 49 thank you cards, the following categories were highlighted: Communication, Hope, compassion, acceptance, humanization, learning, gratitude, active listening, coping strategies, regards, faith and humanization Conclusion(s): Strategies that favor adequate emotional management of the grieving process should be promoted. This study reflects the perceptions of parents attending a bereavement workshop. It highlights the gratitude, feelings and reflections of the family members during the health process and the death of the child while receiving accompaniment by a pediatric palliative care team.
Cuervo M; Devia A; Pereira L; Alvarez T; Molina K; Bolanos J; Correa I; Garcia X
Pediatric Blood and Cancer
2022
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<a href="http://doi.org/10.1002/pbc.299522" target="_blank" rel="noreferrer noopener">10.1002/pbc.299522</a>
Early Integration of Pediatric Palliative Care in Pediatric Hematopoietic Stem Cell Transplant Patients
distress syndrome; hematopoietic stem cell; palliative therapy; transplantation; child; conference abstract; consultation; controlled study; evidence based practice center; female; Hematopoietic Stem Cells; human; human cell; learning; major clinical study; male; medical record review; morbidity; mortality; Palliative Care; retrospective study; risk assessment; satisfaction; staff training; Stem Cell Transplantation
Topic significance and study purpose/background/rationale: Patients undergoing hematopoietic stem cell transplant (HSCT) are at risk for significant morbidity and mortality and experience distressing psychological and physical symptoms. Access to palliative care services early in the treatment course can mitigate psychological suffering, address physical symptoms, and establish rapport with the palliative care team. There is no standardized practice for palliative care consultations for these patients. The aim of this evidence-based practice project was to determine if the early implementation of a palliative care trigger tool increases the number of palliative care consults in this population. Methods, intervention, and analysis: A pre-intervention survey was administered to assess staff understanding and satisfaction with palliative care services. A retrospective chart review was conducted to determine patients at highest risk for morbidity and mortality from HSCT. A paper trigger tool was developed to identify patients considered highest risk in order to place a palliative care consultation prior to or on admission for HSCT. Implementation included staff education via various medias. The trigger tool was implemented over a 6-month period on a 24 bed HSCT Unit. Findings and interpretation: The staff pre-survey demonstrated support for the project with 79% being very or extremely interested in learning more about palliative care. Additionally, 60% disagreed or strongly disagreed that palliative care services were introduced early enough. Based on a two and a half year retrospective chart review, 51 patients met criteria for early integration of palliative care services and 15 received consultations. To date, the trigger tool has been used on 14 patients and has resulted in early consultation in 11 patients. Discussion and implications: Based on the trigger tool, most patients admitted for HSCT qualify for early integration of palliative care services. The tool effectively identified patients for early integration of palliative care services. Providing early palliative care is an important priority of care for patients undergoing HSCT.Copyright © 2023 American Society for Transplantation and Cellular Therapy
Kent L; Williams M; Pinner LA; Callard E; Fisher J; Pyke-Grimm K
Transplantation and Cellular Therapy
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/S2666-6367%2823%2900179-3" target="_blank" rel="noreferrer noopener">10.1016/S2666-6367%2823%2900179-3</a>
Educational needs and preferred learning approaches of the paediatric palliative care workforce: A qualitative exploratory study
education; exploratory research; learning; pediatric palliative care; pediatric palliative care workforce; qualitative study
Malcolm C; McGirr D
Nurse education today
2020
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.nedt.2020.104417" target="_blank" rel="noreferrer noopener">10.1016/j.nedt.2020.104417</a>
Evaluating a Pediatric Palliative Care Elective Rotation Through Prompted Reflective Writing and Aligning with Competencies
fatigue; Palliative Care; child; article; human; United States; population health; palliative therapy; hospice; resident; clinical evaluation; physical examination; intestine obstruction; medical education; Rotation; learning; writing; accreditation; professionalism; rotation; inductive reasoning
Background: Hospice and palliative medicine is important in the education of pediatric residents. Little is known about if and how residents' learnings during a pediatric palliative care elective fulfill core competencies and Pediatrics subcompetencies as set forth by the Accreditation Council for Graduate Medical Education (ACGME) and published subspecialty competencies for residents in pediatric hospice and palliative medicine (pHPM). Objective(s): To evaluate what residents are learning on a four-week pediatric palliative care elective rotation at a single institution and how these learnings fulfill ACGME and pHPM competencies. Setting/Subjects: Prompted, written reflections were collected from residents completing a pediatric palliative care rotation at a large, urban academic center in the United States between academic years 2016-2017 and 2020-2021. Measurements: A qualitative, inductive reasoning approach was used to analyze reflections for emergent themes and codes. A deductive approach was used to map resulting codes to ACGME core competencies, Pediatric subcompetencies, and pHPM competencies. Result(s): Twenty-five resident reflections were collected. Inductive analysis revealed three primary themes and 102 codes. These codes were mapped to all six ACGME core competencies and mapped to most Pediatric subcompetencies with the exception of performing a physical examination, organizing and prioritizing patients, diagnostic evaluation, and community and population health. Codes mapped to most pHPM competencies with the exception of two symptom-based competencies, malignant bowel obstruction and severe fatigue. Conclusion(s): Residents' written reflections following a pediatric palliative care elective rotation demonstrated robust learnings that fulfill many core, specialty, and subspecialty competencies, particularly those that relate to patient- and family-centered care, communication, professionalism, and systems-based practice.
Crawford C; Arevalo Soriano T; Lu S; Rubenstein J; Jarrell JA
Journal of palliative 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/10.1089/jpm.2023.0072" target="_blank" rel="noreferrer noopener">10.1089/jpm.2023.0072</a>
Increasing access to children's palliative care education through e-learning: a review of the ICPCN experience
article; child; female; human; major clinical study; male; palliative therapy; Children; E-learning; Education; human experiment; language; learning; mandarin; nonhuman; nurse; Paediatrics; Palliative; pediatrics; skill; writing
Education is integral to the development of children's palliative care (CPC) globally; thus, the International Children's Palliative Care Network (ICPCN) developed a training programme including face-to-face and e-learning programmes to increase access to CPC. A review of ICPCN's e-learning programmes was undertaken in April/May 2018. At the time of writing, there are seven courses available, with more scheduled to be released in the near future. All courses are available in English, with some available in other languages, including Mandarin, Czech and Dutch. Between May 2016 and April 2018, 1501 individuals accessed the courses from 96 countries (39% nurses, 28% doctors). English was the prevalent language used (74%), followed by Spanish (8.5%). To date, over 3106 participants have accessed the e-learning programme from 124 countries. An evaluation in 2015/16 found that \textgreater80% of respondents said the courses were clear, understandable, rated them highly and found them useful. Some 75% of respondents reported improved knowledge, skills and change in attitude, while 61% reported a change in practice. The ICPCN e-learning platform is an innovative way of improving knowledge and understanding of CPC, thereby increasing the accessibility and availability of CPC.
Daniels A; Downing J
International journal of palliative nursing
2018
<a href="http://doi.org/10.12968/ijpn.2018.24.7.351" target="_blank" rel="noreferrer noopener">10.12968/ijpn.2018.24.7.351</a>
Learning Disability Nurses in Palliative Care - A Narrative on Diversifying the Workforce and the Caseload
learning disorder; narrative; nurse; Palliative Therapy; workforce; Adult; Adulthood; Attention; Autism; Child; cognitive defect; cohort analysis; conference abstract; distress syndrome; employment; epilepsy; Female; geriatric disorder; Hospice; Human; learning; Learning Disorders; malignant cardiac tumor; neurodisability; Palliative Care; skill; Terminal Care; treatment failure
There have been multiple recent reports regarding the inequalities in palliative and end of life care for people with learning disabilities; but little if any attention paid to the role of learning disability nurses working in palliative care. Children's hospices often have a well-established cohort of learning disability nurses in their employment. This has not currently translated into adult palliative care; increasingly though, children with complex neuro-disabilities and life-limiting conditions are living into adulthood with good care, and need specialist symptom management and end of life care through transition into adult services. Adults with learning disabilities and other complex health conditions are also now living into later life and are more likely to develop age related illnesses such as cancers, heart failure etc., rather than dying from an acute episode related to epilepsy, for example. Learning disability nurses bring a specialist skill set in supporting people with a known LD diagnosis, but also those with acquired cognitive impairment, those in mental distress, people with communication difficulties and autistic people. A Learning Disability Nurse may recognise undiagnosed learning or support needs in patients, and be able to provide strategies to ameliorate those needs. The author would like to present a narrative on her experiences of moving into palliative care and how Learning Disability Nurses can provide a new perspective and skill set within the specialist palliative care team.
Marsden S
BMJ Supportive and Palliative Care
2022
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/10.1136/spcare-2022-HUNC.102" target="_blank" rel="noreferrer noopener">10.1136/spcare-2022-HUNC.102</a>
Peer-designed parents' bereavement panel: Exposing first-year medical students to pediatric end-of-life care
Bereavement; care behavior; child; clinical article; comfort; conference abstract; controlled study; curriculum; female; human; human experiment; learning; Likert scale; male; medical school; medical student; pediatric oncologist; pediatrics; preclinical study; terminal care
Program Goals: Despite the Liaison Committee for Medical Education (LCME) mandatory requirement for the incorporation of end-of-life care education into medical school curriculum, very few studies have reported successful approaches, and standardization across medical schools is lacking. Furthermore, very little effort has focused on the incorporation of pediatric-specific end-of-life care education into the preclinical years. The purpose of this study is to determine whether a bereavement panel consisting of parents who had a child pass away from a life threatening condition: (1) improved first-year medical students' self-reported ability to interact with children suffering from life-threatening conditions and their families, and (2) changed students' opinions about pediatric end-of-life care curriculum. Evaluation: A total of 23 first-year medical students attended a two-hour panel consisting of four parents who had a child pass away from a life threatening condition. The panel was part of a weeklong, peer-designed elective focused on exposing students to various aspects of pediatrics. It consisted of a question-and-answer discussion facilitated by a pediatric oncologist, with a focus on the parents' positive and negative experiences with different aspects of health care throughout their child's illness. Pre-panel and post-panel surveys were administered, asking students to report agreement with various statements using a 10- point Likert scale.
Rolfes M; Sunde K; Jones A; Starr S
Pediatrics
2018
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).
Preparing for Good Grief: Grief and Loss in the Hospice and Palliative Context (P07)
bereavement support; child; complicated grief; conference abstract; exercise; hospice; human; learning; palliative therapy; professional practice; program development; risk factor; survivor; videorecording
Objectives: * Describe state of current science and theory related to grief and bereavement. * Discuss variations of grief and strategies to support bereaved individuals. * Identify best practices to support healthy grief in hospice and palliative care contexts. * Identify special needs of unique populations across the lifespan (e.g., children, teens), persons with intellectual disabilities, those experiencing unexpected death of a family member or close friend, or those having complicated grief. * Identify program services and opportunities that utilize current best practices and knowledge within their own agency. Grief and bereavement are universal human experiences, and inevitable outcomes for those who lose a family member or close friend. For hospice and palliative care providers, understanding the complexities of this universal yet individualized experience, and providing support to the bereaved is a critical part of our field. This practical, interactive workshop will provide an overview of current theories, best practices, and approaches to support healthy grief and manage loss in a modern society. Through a variety of learning exercises, including discussion of field experience and current research, case studies, video exercises, and reflections, this presentation will discuss the complexities within the grief experience in hospice and palliative care. Phases of bereavement care needs, including the initial diagnosis, grieving through the disease process, becoming eligible for hospice services, support through the ongoing trajectory of grief, and facilitating access to community supports, will be discussed. Implications for hospice and palliative care inter-professional practice, program planning, and community advocacy will be provided. Special circumstances that challenge bereavement will be identified, including children, teens, survivors of traumatic loss, and risk factors for Prolonged Grief Disorder (PGD). Concerns that can particularly be addressed in the palliative context to support healthy grieving, and gaps in knowledge and services will also be highlighted.
Remke S S; Shukraft A E; Supiano K P; Wladkowski S P
Journal of Pain and Symptom Management
2020
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.2019.12.018" target="_blank" rel="noreferrer noopener">10.1016/j.jpainsymman.2019.12.018</a>
Punishment learning and self mutilation in Lesch Nyhan disease
automutilation; aversion; child; etiology; learning; Lesch Nyhan syndrome; punishment; reinforcement therapy; behavioral problems; psychological intervention; aversive stimulation electric shock; positive reinforcement; time-out; self-injury; self-mutilation
The self injurious behavior of five male children with Lesch Nyhan disease was studied during three learning paradigms: punishment, positive reinforcement and time out from reinforcement following an attempt at self injury. Punishment of self injury by contingent electric finger shock failed to suppress this behavior but positive reinforcement of non self injury and time out procedures were effective. The results stress the importance of environmental factors in the development and control of self injurious behavior, and suggest the presence of an unusual harmful defect which may be related to the specific enzyme deficiency in Lesch Nyhan disease.
Anderson L; Dancis J; Alpert M; Herrmann L
Nature
1977
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/10.1038/265461a0" target="_blank" rel="noreferrer noopener">10.1038/265461a0</a>
Sharing care at the End of life for adolescent patients with neuro-disability: A case series
child; Adolescent; adult; female; hospital admission; human; male; palliative therapy; patient care; terminal care; young adult; clinical article; hospital discharge; groups by age; adolescent; deterioration; conference abstract; learning; adulthood; case study; neurodisability; bereavement support; community health nursing; family support; health hazard
Background Adolescents with long term conditions are recognised to have unique needs and to experience particular health risks as they transfer to adult services. Some young people with complex neuro-disability may live years following transfer to adult services; for others however, reaching adulthood coincides with a significant deterioration in their health. Identifying the best team to support the patient in this situation can be controversial. Community and hospital adult palliative care teams may have an important role to play in supporting these patients, yet clinicians may lack experience working with this age group or managing the symptoms associated with paediatric neurodisability. We present reflections from a series of 6 young adults who received shared-care from adult and paediatric palliative teams and raise discussion about the strengths and learning needs of the different teams involved. Intervention Over a period of 2 years, patients who were between the age of 15 and 19 years and experiencing a significant deterioration in their health were referred to the children's palliative care team for the North East North Cumbria region. Where appropriate, the children's team identified a local adult palliative care team and established a model of shared-care with this team. Findings Across the region 3 adult hospital palliative liaison teams and 4 adult community palliative care teams were involved in shared end of life care. Cross-team debriefs identified benefits including * Improved continuity of care * Access to out of hours support * Avoiding hospital admission/Safe discharge planning * Confidence with medication for symptom management * Access to local family support and bereavement services * Building relationships for future joint working * Support for adult and children's community nursing teams Conclusion Sharing end of life care between adult and paediatric palliative care services can improve the experience of young adults and their families.
Elverson J; Aspey H; Bond E; Mackerness C; Hoskins R; Shiell A
BMJ Supportive and Palliative Care
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/10.1136/spcare-2023-PCC.196" target="_blank" rel="noreferrer noopener">10.1136/spcare-2023-PCC.196</a>
Simulated learning for staff at a children's hospice: a quality improvement project
Child; child; terminal care; article; human; palliative therapy; Hospices; anxiety; hospice; Only Child; education; skill; questionnaire; care behavior; simulation; conversation; nurse; learning; total quality management; paramedical personnel
Simulated learning has well known positive effects but its use in palliative care education is limited. A quality improvement project was undertaken at a children's hospice to develop and evaluate simulation workshops. The aim was to increase the knowledge, skills and confidence of nurses and healthcare assistants in managing challenging situations commonly experienced when caring for children with life-limiting conditions and their families. The Plan, Do, Study, Act (PDSA) model for improvement was used to test simulation workshops on a small scale using a post-workshop questionnaire and reflective diaries. Despite some initial anxiety, participants felt that the workshop had enhanced their confidence, knowledge and skills, particularly in relation to conducting challenging conversations. The project has provided insight and evidence to develop simulated learning at the children's hospice and further afield.Copyright © 2023 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.
Richardson S; Price J; Sheedy G; Chadwick A
Nursing Children and Young People
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/10.7748/ncyp.2023.e1489" target="_blank" rel="noreferrer noopener">10.7748/ncyp.2023.e1489</a>
The use of a theatre workshop in developing effective communication in paediatric end of life care
child; human; terminal care; statistics; article; perception; quantitative analysis; bereavement support; communication skill; convenience sample; human experiment; questionnaire; clinical practice; registration; nursing student; learning; teaching
Being able to communicate effectively is an essential skill for all nurses. Communication in paediatric end of life care can be challenging for both the student and lecturer as it is a rare experience and challenging to teach. Innovative approaches to teaching communication skills such as role play, simulation and drama have been used; however there is a dearth of literature examining the use of drama in this specialist context. The aim of this study was to explore the effectiveness of a novel workshop in teaching transferable knowledge and skills in palliative, end of life and bereavement care communication to a convenience sample of first year pre-registration nursing students undertaking clinical skills training at a UK university. Qualitative and quantitative data were obtained from pre and post intervention questionnaires exploring student's perception of communication skills. Qualitative data were analysed thematically and quantitative data presented as standard descriptive statistics. The novel communication workshop facilitated students' exploration of how good and poor communication looks and feels and introduced aids to inform communication in clinical practice. Exposure to different learning approaches provided opportunities to both gain confidence in engaging in new learning activities and develop knowledge and skills through purposeful engagement.
Neilson S J; Reeves A
Nurse Education in Practice
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.nepr.2019.02.014" target="_blank" rel="noreferrer noopener">10.1016/j.nepr.2019.02.014</a>
Training perinatal nurses in palliative communication by using scenario-based simulation: A quasi-experimental study
interpersonal communication; nurse; palliative therapy; quasi experimental study; simulation; Taiwan; training; article; communication skill; continuing education; controlled study; delivery room; experimental design; female; health care personnel; human; intensive care unit; learning; newborn; purposive sample; registered nurse; structured questionnaire; teaching; terminal disease; therapy
Aim: This study aimed to assess the impact of two educational modules on enhancing the communication confidence, competence and performance of perinatal nurses in the context of palliative care. Background: Concerns have arisen regarding the preparedness of perinatal nurses in delivering palliative care, especially in terms of deficiencies in communication skills and negative attitudes toward making life-support decisions for parents facing neonates with terminal conditions. Bridging this gap necessitates improved perinatal palliative care education for healthcare providers. Research has shown that simulation-based teaching effectively enhances procedural competence, communication skills and confidence among healthcare professionals. However, comprehensive curricula focusing on perinatal palliative communication remain limited. Design: This study used a quasi-experimental design employing a two-group repeated measure approach. It involved a purposive sample of 79 perinatal nurses from a hospital in northern Taiwan. Methods: A palliative communication course specifically designed for registered nurses in perinatal units was developed. Participants were allocated to either the experimental group (Scenario-Based Simulation, SBS) or the control group (traditional didactic lecture). Communication confidence and competence were assessed before and immediately after the course through structured questionnaires. Learning satisfaction was collected post-intervention and participants underwent performance evaluation by standardized parents one week later. Results: A significant training gap in palliative care exists among nurses in OB/GYN wards, delivery rooms and neonatal critical care units, highlighting the need for continuing education. All 79 participants completed the training course. Following the intervention, nurses in the SBS group (n=39) exhibited significant improvements in self-reported confidence (p <0.05), competence (p <0.01) and performance (p <0.001) in neonatal palliative communication compared with the traditional didactic lecture group (n=40). The SBS group also received higher satisfaction ratings from nurse learners (p <0.001). Conclusions: The research findings support scenario-based simulation as a more effective educational approach compared with traditional didactic lectures for enhancing communication confidence and competence. These results were further reinforced by evaluation from standardized patients, highlighting the value of direct feedback in enhancing nurses' performance. Tailoring SBS designs to diverse nursing contexts and incorporating a flipped approach can further enrich the overall learning experience. Given its high effectiveness and positive reception, we recommend integrating this educational module into palliative care training programs for perinatal nurses.
Chen HW; Cheng SF; Hsiung Y; Chuang YH; Liu TY; Kuo CL
Nurse Education in Practice
2024
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.nepr.2024.103885" target="_blank" rel="noreferrer noopener">10.1016/j.nepr.2024.103885</a>
Transforming Care for Young Adults with Complex and Life-Limiting Conditions
Adult; Child; conference abstract; Human; immersion; learning; logic; peer group; quantitative analysis; young adult
Background More young people with complex life-limiting conditions are living into adulthood, generating greater demand for appropriate care (Fraser, Gibson-Smith, Jarvis, et al., 2021. Palliat Med. 35:1641). We implemented Project ECHO (Extension of Community Healthcare Outcomes) to improve young people's palliative care, Sept 2019 - Dec 2022. Aim(s) Evaluate Project ECHO and associated National Transition Community of Practice (CoP) as a mechanism to transform palliative care for young people. Methods Following expressions of interest, three ECHO Hubs were trained and a CoP established (year 1). Our appointed Evaluation Partner is analysing qualitative and quantitative evidence (obtained throughout) applying a logic model. Results Work in progress; findings demonstrate enhanced knowledge, confidence and peer support. Key metrics: * ECHO Immersion Training x3 Hubs (Dec 2019). * 10 ECHO sessions per year x3. * Quarterly Transition (Professional) meetings: 'Really helpful, a wealth of experience and enthusiasm.' * 141 CoP subscribers (March 2022). Conclusions Children and young people's needs are diverse, complex and require a higher profile (NHS. The NHS long term plan. 2019). Initial findings reveal a positive contribution to learning and improved outcomes reflecting NICE Guidance (National Institute for Health and Care Excellence. [NG43], 2017; National Institute for Health and Care Excellence [NG213], 2022; National Institute for Health and Care Excellence. [NG61], 2019). Our Transition project addresses gaps in knowledge across the UK.
James C; Horsley A; Shouls S
BMJ Supportive and Palliative Care
2022
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/10.1136/spcare-2022-HUNC.65" target="_blank" rel="noreferrer noopener">10.1136/spcare-2022-HUNC.65</a>
Use of Mobile Cold Sheets in Paediatric Hospice Care
cold stress; Hospice Care; Australia; Child; child parent relation; Cold Temperature; conference abstract; cooling; emergency care; funeral home; Hospice Care; Hospice; Human; learning; Memory; nut; posthumous care; practice guideline; privacy; twins; unlicensed drug use
After death care is an essential service offered by paediatric hospices in the time between the death of a child and their funeral or care being transferred to a funeral home. This service allows families time together, privacy and memory making opportunities (Oldham, 2021. ehospice. [Int. Child. ed.], Sept.29) when this may have been limited in the acute care setting or families may have been focused on acute care and interventional management. Resources that are required include family support and clinical teams with experience in after death management, and resources to promote cooling. The length of admission provided to families varies across paediatric hospices and depends on a balance of family preferences, policies of the facility based on experience and condition of the body. As such, any resources that can promote optimal cooling facilitate more time and a better experience for families. Hummingbird House Hospice (Brisbane, Australia) and Acorns (West Midlands, UK) are experienced in after death care. Hummingbird House uses innovative mobile cold sheets to best support after death care, now being adopted as practice in Acorns Hospices with collaboration between services. Mobile cooling sheets are inexpensive, simple to use and do not require coolant to be pumped through like 'cuddle cots' or other cooling mat devices. Advantages include decreased reliance on coolant-based technology (more vulnerable to malfunction), ability to facilitate twins (or other multiple births) being laid together, and increased portability to experience 'normal' parenting such as having time outside in a pram. A case study highlights advantages from a family perspective. The organisational barriers to implementing this new practice have included: justifying additional resources to those already available; need for educational resources and organisational guidelines; lack of local experience; concern about unlicensed use of products and correct storage. We hope to share our experiences and learnings with this new technology to increase the options in care available to bereaved families across the UK.
Mott C; Oldham K
BMJ Supportive and Palliative Care
2022
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/10.1136/spcare-2022-HUNC.207" target="_blank" rel="noreferrer noopener">10.1136/spcare-2022-HUNC.207</a>