Effect of timing of palliative care consultation on end-of-life care for children with advanced cardiac disease

Effect of timing of palliative care consultation on end-of-life care for children with advanced cardiac disease

Songer K; Wawrzynski SE; Olson L; Harousseau M; Moresco B; Fitzgerald L; Meeks H; Delgado-Corcoran C

Cardiology in the Young

2024

child; terminal care; cohort analysis; controlled study; female; human; major clinical study; male; resuscitation; retrospective study; palliative therapy; patient comfort; consultation; artificial ventilation; time of death; therapy; conference abstract; extracorporeal oxygenation; drug therapy; pediatric patient; coronary care unit; brain death; heart disease; chi square distribution; escalation of care; mode of death

Background: Pediatric patients with advanced cardiac disease often receive high intensity medical care at the end of life (EOL). Specialized pediatric palliative care (PPC) has been shown to improve symptom management and EOL goal-concordant care, resulting in fewer invasive medical interventions prior to death. PPC has been recommended for advanced cardiac disease by the American Heart Association. However, optimal timing of PPC consultation has not been described. <br/>Method(s): In this retrospective cohort study, we compared EOL care indicators of pediatric patients (0-21 years) with heart disease treated in the cardiac intensive care unit January 2014-December 2022, who died during the same period. Patients were grouped according to whether they had received PPC and then by timing of PPC consultation: >30 days from (early) or within 30 days of death (late). Demographics, medical interventions, and mode of death (i.e., during CPR, comfort care, withdrawal of care, no escalation of care, and brain death) were compared using Kruskal- Wallis rank sum test for continuous variables and Pearson's Chisquare test and Fisher's exact test for categorical variables. <br/>Result(s): Of 218 patients included, 78 received no PPC, 76 received early PPC and 64 received late PPC. Patients who received PPC were less likely to die during cardiopulmonary resuscitation (CPR) (12.1% vs. 32.1%; p<0.001), and more likely to receive comfort care (22.9% vs 2.6%; p<0.001). They also had fewer invasive interventions within 14 days of death (74.3% vs. 92.3%; p = 0.006) and lower intensity of care at the end of life (77.1 vs. 96.2%; p<0.001). Care was considered highly intense if it included ECMO, mechanical ventilation, or vasoactive medications at time of death, or CPR in the last 7 days prior to death. Mode of death was not significantly different between early and late PPC groups. Patients who received early PPC were less likely to have invasive interventions within 14 days of death (65.8% vs. 84.4%; p = 0.006), but the intensity of care was not different (75% vs. 79.7%; p = 0.511). <br/>Conclusion(s): Early PPC consultation, at least 30 days before death, was significantly associated with enhanced EOL indicators. Further exploration is warranted to determine optimal timing to improve mode of death and to assess for additional potential benefits of PPC involvement.

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