Tensions At The End Of Life In Pediatrics: Actors, Causes, Coping Strategies And Remedies

Tensions At The End Of Life In Pediatrics: Actors, Causes, Coping Strategies And Remedies

Payot A; Archambault-Grenier MA; Roy-Gagnon MH; Humbert N; Stojanovic S; Janvier A; Duval M

Journal Of Pain And Symptom Management

2016

Background: The majority of children die in pediatric hospitals after a decision to withhold or withdraw life sustaining interventions. Tensions and conflicts at the end of life (EOL) are not rare in pediatric hospitals. Objective: To investigate how frequent these conflicts are and how health-care professionals (HCPs) experience, cope and suggest improvements regarding endof- life communications in pediatrics. Design/Methods: Questionnaire sent to all 2300 HCPs who care for patients in a large mother-child university hospital. Results: 946 HCPs answered the questionnaire (nurses, physicians and other disciplines). A majority (70%, 663) had witnessed or cared for at least one dying child over the preceding five years. Of those, 73% experienced at least a conflict at the end of life. Conflict occurred more frequently among HCPs (58%) than between HCPs and parents (33%), p LT 0.05. More than 40% reported the following factors as being frequently associated with end-of-life conflicts: * HCP Related: lack of continuity (physicians and/ or nurses), differences in values and beliefs between HCP. * Patient-Disease Related: precipitated or critical situations, uncertain prognosis. * Parent Related: unprepared parents, emotional load, unrealistic parental expectations, differences in values and beliefs, parents' fear of hastening death. * Institution Related: lack of practical guidelines to deal with difficult end-of-life cases. HCP report using these strategies to solve confrontations: negotiating with parents and patients, educating parents and discussing with peers. Nurses and physicians reported significantly different types of coping strategies. For 66% of respondents, conflicts were resolved by the time of the child's death. Only 25% felt they received adequate training to cope with EOL conflicts. Suggestions for improvement: primary health-care providers or case-managers, interdisciplinary meetings involving the parents, post-death ethics meetings, bereavement follow-up protocols andearlier consultation in pediatric palliative care and/or clinical ethics service. Conclusions: End-of-life conflicts are frequent in pediatrics. The main source of tension is between providers who may have different views and values. Coping mechanisms may be different from one provider to another, but many identify useful strategies to solve conflicts. Future research should investigate whether these perspectives parallel those of parents and patients.

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