Longitudinal Impact of a Novel Condolence Expression Curriculum.

Background: Pediatric residents lack training in expressing condolences to bereaved families after a child's death. We previously developed a novel curriculum that improved residents' comfort with expressing condolences, and now we report assessment of the longitudinal impact of this curriculum on residents' practices of condolence expression. Methods: We applied Kern's 6-step approach to develop, implement, and evaluate a condolence expression curriculum. Residents completed surveys before, immediately after, and six months after participating in the educational intervention to assess curricular impact over time. Results: Twenty pediatric residents participated in the curriculum. Residents reported an increase in their practice of expressing condolences following participation in the curriculum, as well as appreciation for the value of the intervention. Conclusion: A condolence expression curriculum has potential to increase residents' practice of condolence expression to bereaved families over time. Future work will focus on the impact of curricular dissemination across pediatric residency programs.

Narrative Medicine in Hospice and Palliative Care: A Longitudinal Fellowship Curriculum Pilot.

INTRODUCTION: Growing evidence suggests that clinician exposure to narrative medicine (NM) may help bolster resilience and mitigate burnout. The value of formal longitudinal training in NM for hospice and palliative medicine (HPM) trainees remains understudied. METHODS: A 1-year longitudinal NM curriculum for HPM fellows was pilot-tested for feasibility, acceptability, and exploratory impact. Six monthly 45-minute sessions included reading literature, reflective writing, and sharing creative work. Quantitative and qualitative data were collected through a pre-intervention survey and post-intervention survey administered immediately upon completion of the curriculum. Longitudinal impact was assessed with a post-intervention survey administered three months after completion of the curriculum. RESULTS: All HPM fellows (n = 6) attended at least 5/6 sessions during the 1-year pilot, suggesting intervention feasibility. Participant engagement and self-reported comfort with NM exercises supported intervention acceptability. Post-intervention, participants described the positive influence of NM practice on their clinical practice and stated an intention to integrate NM skills in their future HPM careers. Three months following the intervention, participants had a sustained increase in their comfort level with NM. All participants felt that the NM sessions had been relevant to their life as HPM fellows and anticipated using NM moving forward in their practice of HPM. DISCUSSION: This novel NM curriculum was feasible and acceptable to implement in a 1-year HPM fellowship. Longitudinal impact showed sustained increase in trainee comfort and interest in using NM in their future clinical practice.

"Seed Planting" As an Approach for Longitudinal Prognostic Disclosure in Pediatric Cancer: A Case Series.

Most children with cancer and their parents desire honest communication about prognosis, even when prognosis is poor. Unfortunately, many parents perceive deficits in communication about prognosis, and strategies are needed to encourage timely person-centered prognostic discussions. To better understand patterns in prognostic communication, we audio-recorded serial disease re-evaluation conversations between pediatric oncologists, children with poor-prognosis cancer diagnoses, and their families across the illness trajectory. Prior analysis revealed broad prognostic communication patterns, including a "seed planting" approach where prognostic information was offered gradually across time. In this case series, we examine the seed planting approach more closely, identifying language strategies that clinicians used to help patients and families gain insight into prognostic gravity as their illness evolved. Although further research is needed to measure the full impact of a seed planting approach, this case series explores a longitudinal communication strategy with potential to improve prognostic communication across an advancing illness course.

Training in Expression of Authentic Condolences in Healthcare: A Pilot Study.

Background: Bereaved parents value receiving support from their children's health care teams. Pediatric residents are important members of the teams that care for children at end of life and can play a meaningful role in communication with bereaved families. Yet formal training in expressing condolences is currently lacking. Methods: We applied Kern's six step approach to develop, implement, and evaluate an innovative curriculum aimed at increasing pediatric residents' comfort levels with and practice of condolence expression. Results: Twelve residents participated in the pilot study. Quantitative and qualitative data demonstrate that residents' comfort levels with expressing condolences increased after implementation of the curriculum and that residents appreciated and benefitted from receiving this education. Conclusion: We successfully developed and piloted a condolence expression curriculum that was well received by pediatric residents and led to increased comfort level with expressing condolences. Research is ongoing to determine the full impact of this curriculum.

Leveraging Grief: Involving Bereaved Parents in Pediatric Palliative Oncology Program Planning and Development.

As pediatric palliative care (PPC) became a recognized medical specialty, our developing clinical PPC team longitudinally partnered with bereaved parents to understand the care that their children received as they transitioned towards end of life. Families developed Eight Priorities, shared within, to improve care for children with a poor chance of survival based on their experience of losing a child to cancer. In this paper, we delineate the top eight PPC needs from a parent perspective to offer multi-layered, individually tailored resources for patients and families. One of these Eight Priorities noted that bereavement care for the remaining family members is vital for healing after the death of a child to promote meaning making and resilience in bereaved families. Here, we outline the creation of a bereaved parent-designed bereavement support program as one example of how we have partnered with parents to fulfill their Eight Priorities for quality care.

Development and evaluation of a computable phenotype to identify pediatric patients with leukemia and lymphoma treated with chemotherapy using electronic health record data.

BACKGROUND: Widespread implementation of electronic health records (EHR) has created new opportunities for pediatric oncology observational research. Little attention has been given to using EHR data to identify patients with pediatric hematologic malignancies. METHODS: This study used EHR-derived data in a pediatric clinical data research network, PEDSnet, to develop and evaluate a computable phenotype algorithm to identify pediatric patients with leukemia and lymphoma who received treatment with chemotherapy. To guide early development, multiple computable phenotype-defined cohorts were compared to one institution's tumor registry. The most promising algorithm was chosen for formal evaluation and consisted of at least two leukemia/lymphoma diagnoses (Systematized Nomenclature of Medicine codes) within a 90-day period, two chemotherapy exposures, and three hematology-oncology provider encounters. During evaluation, the computable phenotype was executed against EHR data from 2011 to 2016 at three large institutions. Classification accuracy was assessed by masked medical record review with phenotype-identified patients compared to a control group with at least three hematology-oncology encounters. RESULTS: The computable phenotype had sensitivity of 100% (confidence interval [CI] 99%, 100%), specificity of 99% (CI 99%, 100%), positive predictive value (PPV) and negative predictive value (NPV) of 100%, and C-statistic of 1 at the development institution. The computable phenotype performance was similar at the two test institutions with sensitivity of 100% (CI 99%, 100%), specificity of 99% (CI 99%, 100%), PPV of 96%, NPV of 100%, and C-statistic of 0.99. CONCLUSION: The EHR-based computable phenotype is an accurate cohort identification tool for pediatric patients with leukemia and lymphoma who have been treated with chemotherapy and is ready for use in clinical studies.

Factors associated with the development of severe asthma exacerbations in children.

BACKGROUND: Asthma exacerbations are one of the most common causes of hospitalization in children and account for approximately 10,000 intensive care unit (ICU) admissions per year in the United States. Despite the prevalence of this disease in children, the factors associated with the development of these severe exacerbations are largely unknown. METHODS: A retrospective case-control study was conducted involving all eligible children admitted to the hospital with asthma for a 1-year period. Potential associated factors and outcomes of children admitted to the ICU with a severe exacerbation (cases) were compared to those of children with acute asthma admitted to the ward (controls). RESULTS: A total of 188 children were hospitalized with asthma during the study period, 57 (30%) of whom required admission to the ICU. There were no differences in age, gender, or race between cases and controls. Children admitted to the ICU were significantly more likely to have an allergy or irritant-triggered exacerbation than children admitted to the ward (OR 3.9; 95% CI 1.9-8.2; p = .0003). Additionally, children in the ICU had a significantly shorter duration of illness before being admitted to the hospital compared to those admitted to the ward (1.7 ± 2.3 vs. 3.4 ± 4.8 days; p = .002). CONCLUSIONS: In this retrospective review, severe asthma exacerbations in children are associated with a more rapid onset of symptoms and are more likely to be associated with allergens or irritants, supporting the importance of atopy in this population.