Bereavement care interventions: a systematic review

BACKGROUND: Despite abundant bereavement care options, consensus is lacking regarding optimal care for bereaved persons. METHODS: We conducted a systematic review, searching MEDLINE, PsychINFO, CINAHL, EBMR, and other databases using the terms (bereaved or bereavement) and (grief) combined with (intervention or support or counselling or therapy) and (controlled or trial or design). We also searched citations in published reports for additional pertinent studies. Eligible studies had to evaluate whether the treatment of bereaved individuals reduced bereavement-related symptoms. Data from the studies was abstracted independently by two reviewers. RESULTS: 74 eligible studies evaluated diverse treatments designed to ameliorate a variety of outcomes associated with bereavement. Among studies utilizing a structured therapeutic relationship, eight featured pharmacotherapy (4 included an untreated control group), 39 featured support groups or counselling (23 included a control group), and 25 studies featured cognitive-behavioural, psychodynamic, psychoanalytical, or interpersonal therapies (17 included a control group). Seven studies employed systems-oriented interventions (all had control groups). Other than efficacy for pharmacological treatment of bereavement-related depression, we could identify no consistent pattern of treatment benefit among the other forms of interventions. CONCLUSIONS: Due to a paucity of reports on controlled clinical trails, no rigorous evidence-based recommendation regarding the treatment of bereaved persons is currently possible except for the pharmacologic treatment of depression. We postulate the following five factors as impeding scientific progress regarding bereavement care interventions: 1) excessive theoretical heterogeneity, 2) stultifying between-study variation, 3) inadequate reporting of intervention procedures, 4) few published replication studies, and 5) methodological flaws of study design

Differences associated with age, transfer status, and insurance coverage in end-of-life hospital care for children

BACKGROUND: More than 40% of childhood mortality occurs while children are hospitalized. End-of-life health care utilization patterns for children have not been well characterized at the national level. OBJECTIVE: To describe patterns of length of stay, total charges, and principal diagnoses for children who die while admitted to a hospital, versus those who survive to discharge. METHODS: We conducted a cross-sectional analysis of 3 years spanning a decade of the Nationwide Inpatient Sample (NIS), a nationally representative dataset of hospital discharges, to analyze sociodemographic characteristics and patterns of hospital resource use associated with in-hospital mortality. RESULTS: Inpatient mortality rate was significantly higher for non-newborn infants (<1 year old) than for all other age groups, and the overall number of deaths was greatest for newborns. Patients transferred between hospitals had significantly greater mortality rate, compared with patients admitted not on transfer. Insured children had lower mortality rates compared to uninsured, and decedents had significantly longer length of stay and higher charges compared with survivors. Uninsured decedents did not have longer lengths of stay than survivors, and hospital charges were significantly lower for uninsured children compared with insured children. CONCLUSION: As hospital staff strive to meet the needs of ill children and their families, they must be cognizant of the high burden of mortality among the youngest children and those transferred between hospitals, and the potential for less resource use and higher mortality risk for children without insurance, because these patients may require expanded services not readily available in most hospital settings. Journal of Hospital Medicine 2008;3:376–383. © 2008 Society of Hospital Medicine.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61213/1/360_ftp.pd

Hospital care for children and young adults in the last year of life: a population-based study

BACKGROUND: To help design population-based pediatric palliative care services, we sought to describe the hospital care received in the last year of life by children and young adults who died. We also determined the proportion with complex chronic conditions (CCCs) and tested whether the use of hospital services increased as the date of death drew nearer. METHODS: For all deaths occurring under 25 years of age from 1990 to 1996 in Washington State, USA, we linked death certificate information to hospital utilization records and analyzed the timing and duration of hospitalizations and the nature of hospital procedures during the year prior to death. RESULTS: Of the 8 893 deaths, 25 % had CCCs. Among infants with CCCs, 84 % were hospitalized at the time of death and 50 % had been mechanically ventilated during their terminal admission. Among the 458 CCC neonates dying under a week of age, 92% of all days of life were spent in the hospital; among the 172 CCC neonates dying during the second to fourth weeks of life, 85 % of all days of life were spent hospitalized; among the 286 CCC infants dying during the second to twelfth month of life, 41 % of all days of life were spent hospitalized. Among children and young adults with CCCs, 55 % were hospitalized at the time of death, and 19 % had been mechanically ventilated during their terminal admission. For these older patients, the median number of days spent in the hospital during the year preceding death was 18, yet less than a third of this group was hospitalized at any point in time until the last week of their lives. The rate of hospital use increased as death drew near. For subjects who had received hospital care, 44 % had governmental insurance as the source of primary payment. CONCLUSIONS: Infants who died spent a substantial proportion of their lives in hospitals, whereas children and adolescents who died from CCCs predominantly lived outside of the hospital during the last year of life. To serve these patients, pediatric palliative and end-of-life care will have to be provided in an integrated, coordinated manner both in hospitals and home communities

Response to Suffering of the Seriously Ill Child: A History of Palliative Care for Children

Most pediatric clinicians aspire to promote the physical, emotional, and developmental well-being of children, hoping to bestow a long and healthy life. Yet, some infants, children, and adolescents confront life-threatening illnesses and life-shortening conditions. Over the past 70 years, the clinician's response to the suffering of these children has evolved from veritable neglect to the development of pediatric palliative care as a subspecialty devoted to their care. In this article, we review the history of how clinicians have understood and responded to the suffering of children with serious illnesses, highlighting how an initially narrow focus on anxiety eventually transformed into a holistic, multidimensional awareness of suffering. Through this transition, and influenced by the adult hospice movement, pediatric palliative care emerged as a new discipline. Becoming a discipline, however, has not been a panacea. We conclude by highlighting challenges remaining for the next generation of pediatric palliative care professionals to address

Symptom Monitoring in Pediatric Oncology Using Patient-Reported Outcomes: Why, How, and Where Next

Symptom monitoring using patient-reported outcomes (PROs) is not common in pediatric oncology, despite interest from stakeholders—including patients, families, clinicians, and regulatory organizations—and proven clinical benefit in adult oncology. This article examines the foundational data for patient-reported symptom reporting in this population and posits the next investigative steps toward the implementation of patient-reported symptom monitoring in the care and research of pediatric oncology patients. The reasoning behind, and feasibility of, monitoring symptoms in pediatric oncology patients using PRO measures are discussed, as well as specific tools that have been developed to track symptoms in this population, including innovative electronic self-reporting platforms built to engage children in the symptom reporting process. Aspects of engaging both patients and clinicians in the symptom self-report process are reviewed, as are the experiences of “early adopters” of this process in pediatric oncology and across pediatrics. It is clear that there are key issues that remain regarding the use of PROs for symptom monitoring, including selection of specific outcomes to monitor, how to resolve discrepant reports, and determination of benefit. The next steps for investigation of these issues are discussed. Unanswered questions notwithstanding, work should continue to make patient-reported symptom monitoring an established, evidence-based part of routine and research practice in pediatric oncology

What\u27s missing in missing data? Omissions in survey responses among parents of children with advanced cancer

Background: Missing data is a common phenomenon with survey-based research; patterns of missing data may elucidate why participants decline to answer certain questions. Objective: To describe patterns of missing data in the Pediatric Quality of Life and Evaluation of Symptoms Technology (PediQUEST) study, and highlight challenges in asking sensitive research questions. Design: Cross-sectional, survey-based study embedded within a randomized controlled trial. Setting: Three large children\u27s hospitals: Dana-Farber/Boston Children\u27s Cancer and Blood Disorders Center (DF/BCCDC); Children\u27s Hospital of Philadelphia (CHOP); and Seattle Children\u27s Hospital (SCH). Measurements: At the time of their child\u27s enrollment, parents completed the Survey about Caring for Children with Cancer (SCCC), including demographics, perceptions of prognosis, treatment goals, quality of life, and psychological distress. Results: Eighty-six of 104 parents completed surveys (83% response). The proportion of missing data varied by question type. While 14 parents (16%) left demographic fields blank, over half (n=48; 56%) declined to answer at least one question about their child\u27s prognosis, especially life expectancy. The presence of missing data was unrelated to the child\u27s diagnosis, time from progression, time to death, or parent distress (p&gt;0.3 for each). Written explanations in survey margins suggested that addressing a child\u27s life expectancy is particularly challenging for parents. Conclusions and Relevance: Parents of children with cancer commonly refrain from answering questions about their child\u27s prognosis, however, they may be more likely to address general cure likelihood than explicit life expectancy. Understanding acceptability of sensitive questions in survey-based research will foster higher quality palliative care research. &copy; Copyright 2014, Mary Ann Liebert, Inc. 2014

Physical health outcomes of childhood exposure to intimate partner violence: A systematic review.

A Systematic Review Physical Health Outcomes of Childhood Exposure to Intimate Partner Violence: http://www.pediatrics.org/cgi/content/full/117/2/e278 located on the World Wide Web at: The online version of this article, along with updated information and services, is The authors have indicated they have no financial relationships relevant to this article to disclose. ABSTRACT BACKGROUND. Children exposed to intimate partner violence (IPV) are at increased risk for adverse mental and behavioral health sequelae, as has been documented by both systematic reviews and meta-analyses. Studies addressing the physical health impact of childhood IPV exposure, however, have not been summarized in a manner that might facilitate additional hypothesis-driven research and accelerate the development of targeted interventions

Pediatric weekend admission and increased unplanned readmission rates

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/115940/1/jhm2426.pd

Pediatric hospital discharge interventions to reduce subsequent utilization: A systematic review

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/106901/1/jhm2134.pd