Palliative Care in Pediatric Oncology

Advantages of Early Integration of Palliative Care

Before the patient is clearly in the last phase of life, physicians may find it difficult to initiate conversations about a poor prognosis. But the majority of parents of children with cancer say they want prognostic information, even when the news is upsetting. Patients and families who are poorly prepared for death tend to choose more intensive disease-directed care at the end of life. Without realistic information, they may not have the opportunity to make choices for care that are consistent with their values.

Just as physicians sometimes prefer not to discuss prognosis, pediatricians sometimes consider palliative care to be equivalent to hospice care. As a result they may integrate palliative care concepts such as advanced care planning and anticipatory guidance only once curative options have been exhausted. Yet families may find earlier integration of palliative care to be helpful. A study of bereaved family members of adult cancer patients, for example, found that half believed that palliative care was provided too late in the disease course, whereas less than 5% believed palliative care referrals occurred too early. Physician communication was found to be an important contributing factor; families who believed that the physician had communicated effectively about the patient's prognosis and end-of-life care were less likely to believe that palliative care was introduced too late.

Early initiation of palliative care facilitates attention to symptoms and quality of life. Involvement of palliative care services improves symptom detection and identification of communication needs among children with advanced cancer. Similarly adults with advanced cancer tend to experience improvement in symptoms, including pain, anorexia, nausea, vomiting, sleeplessness, and constipation, after referral to palliative care services. In addition patients who receive palliative care frequently experience improvements in overall quality of life and well-being.

It is also possible that early discussions about palliative care can help parents to cope with the death. Mothers who experience the sudden death of a child tend to have more intense grief than mothers whose children die after a chronic condition. These findings raise the possibility that emotional and psychological adjustment before a child's death can help parents to cope with the loss of the child over time.

Perhaps most importantly parents value preparation for the end-of-life period. In a study of bereaved parents of children with cancer, physician communication about what to expect in the end-of-life care period was a component of high-quality care. Parents who felt prepared for the circumstances surrounding the child's death were also more likely to consider care to be of high quality overall. Communication with parents in advance of the child's death may allow them to process and be prepared for the death before it happens and to make choices about end-of-life care that are right for them and their child.

Box 70-1 gives some general guidance for discussion about end-of-life preferences. Even if the patient's outcome is uncertain, death can be discussed as a possibility so that the patient has opportunities to express goals for care.

Enhancing Integration of Palliative Care When Cure is No Longer Possible

Although integration of palliative care from the time of diagnosis is often ideal, sometimes a clinical event such as relapse or a severe complication makes it necessary to discuss a poor prognosis for the first time. A transition from care intended to cure the child can be experienced as a terrible loss for families. However as with discussions about care at the time of diagnosis, honest communication about the child's prognosis can help the family make reasonable decisions about care, based on their values.

Delays in parental understanding of a poor prognosis can affect the care they choose for their children. In a study of parents of children who died of cancer, parents recalled understanding that the child was likely to die about 3 and one half months after the physician realized this. Earlier parental realization of the low likelihood of cure was associated with increased hospice use and decreased cancer-directed therapy in the end-of-life care period. Although parents sometimes have difficulty accepting a poor prognosis, the difficulty physicians have in communicating a poor prognosis also contributes to parents' overly optimistic expectations about cure.

Discussing a Change in Prognosis

A statement that physicians can use when introducing this discussion with parents is, “Although I had hoped that your child's disease would be cured and your child could live a long life, I am now worried that this is no longer possible.” Acknowledging the sadness of the situation, responding to the parent's emotions, and allowing for silence can also be helpful. Parents may ask about treatment options, but such discussion should not obscure the fact that the child's disease is unlikely to be cured. The physician might respond to such requests by saying, for instance, “It is possible that treatment might help your child to feel better and possibly live longer; the hope would be for the treatment to control the cancer for as long as possible.” Although these conversations are difficult for families and for medical providers, such honesty can help parents to make the best possible decisions for their child. In addition although honest provision of information is important, physicians may be able to clarify the goals of care without needing to have parents necessarily openly acknowledge that cure is not likely; this approach may be preferable to some parents.

Discussing Goals of Care

An important aspect of providing care for children with cancer is an understanding of the goals of care. Often these goals are identified by the parents, but adolescents and even younger children are often able to define priorities for their care as well. Understanding goals of care allows the medical team to make recommendations for care that fit with patient and family values. In addition goals of care, and conversations about these goals, provide another window into parents' perceptions of what is ahead.

A discussion about goals of care can be started by asking parents what is most important to them as they think about what is ahead for the child. Specific questions about hopes for the future and worries about what is ahead can also be useful. Often parents will verbalize general goals, such as maintaining a good quality of life for as long as possible, minimizing suffering, prolonging life, or curing the child's cancer. Parents often hold more than one goal and may have separate goals for cancer-directed and symptom-directed therapy; for example, goals of cancer-directed therapy may be to cure or to prolong life, whereas goals of symptom-directed therapy may be to lessen suffering and maximize quality of life. Although such goals may appear to be conflicting, holding more than one goal of care is normal, and physicians can make plans for care with both sets of goals in mind.

Acceptance of the parents' goals is an important aspect of acknowledging the parents' values, even when the goals are not in concert with the physicians' goals. At times, however, parents will continue to articulate a goal of cure, when the medical team believes that such an outcome is not possible. Understanding what the parent would want if the child cannot be cured can help the medical team to make plans for care. Back and colleagues have recommended that the physician ask what the family would want if cure is not possible, a strategy described as hoping for the best but preparing for the worst. This strategy allows the medical team to have a conversation about what the family would want in such a situation.

Even when parents hold goals of cure, physicians need to have clear discussions about the goals of treatment, especially cancer-directed treatment. Depending on the circumstances, the oncologist may want to express goals of controlling the disease for as long as possible, for example. When the purpose of treatment is to help cancer research, with little hope of direct benefit to the child, that goal also should be stated.

In addition to the specific nature of goals of care, parents also consider a number of other values while they make these difficult decisions. For example parents sometimes think about what it means to be a good parent to their child as one compass for decision making. Parents may believe, for instance, that a good parent would focus on preserving the child's life, would make unselfish decisions in the child's best interest, or show the child that he or she is loved. In addition to helping parents clarify their own wishes, having conversations about the meaning of the good parent role can help clinicians to reinforce that role as the child's illness progresses.

Similarly parents may use phrases to sum up the things that are most important to them: “I want the best for my child;” “I have to fight;” “I want my child to have quality of life.” By listening for and probing these phrases, clinicians partner with parents in clarifying their goals and making decisions. Ultimately these conversations about parents' values allow clinicians and the parents themselves to recognize their values, enact them in the child's care, and work together during these very difficult times.

Eliciting Children's Goals

Children and adolescents may express goals in general terms, like their parents, or they may have very specific wishes, such as staying at home, spending time with siblings, or minimizing invasive procedures. Knowing about these goals, which can be elicited by asking children for their hopes and worries, and what is most important to them when they think about what is ahead, can allow the medical team to work toward meeting any specific hopes or needs.

Creating a Plan for Care Based on Goals

Once goals of care have been elicited, then a plan of care can be made. It is important to acknowledge that this plan is flexible and may change frequently. Importantly each family is unique, and even with similar goals there may be very different plans of care. As previously mentioned, pediatric palliative care should be integrated while a family is seeking a life-prolonging or potentially curative therapy. Therefore a plan of care may include preventative therapies, looking for life-prolonging or curative therapies, rehabilitation, and intensive quality of life and symptom management. Having parents consider these questions may help them with decision making.

• How will this treatment affect my child's quality of life?

• What is likely to happen without this treatment?

• How will the treatment change my child's prognosis?

• What will it be like for my child (and family) to go through this treatment?

• Are there other options we should consider that might have the same outcome but with a different approach?

Particularly as cure becomes less likely, helping parents to think deeply about what brings a child joy or which experiences provide quality of life may help their decision making. Ideally the child will be included in these decisions and plan of care. In one study, children aged 8 to 17 years wanted to be told if they were dying and adolescents in particular wanted to participate in palliative care decisions.

Appointing a Health Care Proxy

For patients older than 18 years, the decision of whom to appoint as a health care proxy may provide an opportunity for discussion of care preferences. This document, often completed on admission to the hospital, allows the patient to designate someone to make medical decisions if the patient is unable to do so. The proxy ideally makes decisions based on knowledge of what the patient would want in various situations and not on what the proxy would want or believe to be appropriate. Most hospitals have standard forms that are completed by the patient and an admissions staff person. This could be an opportunity to explore the true wishes of the young adult patient and lead to rich discussion and meaningful decision making.

Resuscitation Status and Other Aspects of Advance Care Planning

Advance care planning may include (1) designation of a decision maker or, for those older than 18 years old, choosing a health care proxy; (2) discussion of the illness and prognosis; (3) establishment of goals of care; (4) discussion of preferences for resuscitation, artificial nutrition and hydration, and palliative sedation; (5) primary location of care and death; and (6) discussion about organ or tissue donation, including autopsy, and preferences for funeral arrangements. Advanced care planning is a process that requires time and often occurs through multiple conversations and at different phases of the child's illness.

Of note many clinicians believe that these conversations happen later than they should. Clinicians cite multiple barriers to discussions about advance care planning, especially unrealistic parent expectations about the child's illness, differences between clinicians' and parents' understanding of prognosis, and a lack of parent readiness to have these conversations. Clinician perceptions about parent understanding or readiness, however, should not preclude having these conversations. Physicians also report that they often do not know what to say.

Fortunately several resources are available to assist in these discussions. Five Wishes (for those >18 years) (available at www.agingwithdignity.org ) is a legal document in 37 states. This document presents information and questions in a way that enhances communication about these difficult subjects, and it addresses what kinds of nonmedical interventions would be wanted, such as music, prayer, presence of family, and so on. My Wishes (for those <18 years) (also available at www.agingwithdignity.org ) is not a legal document, but through simple questions and the opportunity to write and draw it affords the child or adolescent the opportunity to communicate his or her wishes. In addition Voicing My Choices has been recently developed for adolescents and young adults aged 16 to 28, using materials from Five Wishes and modified after interviews with adolescent and young adult patients with cancer or who are infected with human immunodeficiency virus. This work involves four priority areas, which can serve as a model for younger patients as well: the ability to express and document preferences for (1) the medical treatment they want and the treatment they do not want; (2) how they would like to be cared for; (3) information they want family and friends to know; and (4) how they want to be remembered.

Other techniques may be helpful, such as asking an adolescent to name his or her wishes, realistic or not. The provider may also ask a question such as, “What is your understanding of your illness now?” Another technique is to suggest that the adolescent write, with a trusted person, such as a child life specialist, psychosocial clinician, or parent, what questions he or she would like to ask of the health care team. Ideally advance care planning among adolescents is family centered, with the family and adolescent both taking part in shaping wishes for care, in an effort to develop a plan for care that all can support. Doing so can allow families to understand their adolescent's wishes and ultimately carry out these wishes.

Making Recommendations

Even when curative therapies are no longer sought, families report wanting recommendations regarding available interventions. Most do not want the burden of making decisions completely on their own. Providers may believe that, especially when there are treatments with uncertain or marginal benefit, plans for care should be the parents' choice. However parents can often be best supported by providers who clearly discuss the positives and negatives of each treatment or therapy and then recommend a treatment in the context of the family's goals and values. This can apply to a wide spectrum of situations such as participating in a phase I or II clinical treatment trial, putting in a chest tube for pleural effusions, using intravenous antibiotics to treat an infection, or instituting a do not resuscitate (DNR) order. Clinicians who make recommendations can alleviate this burden from the parents and help to minimize the parents' sense of regret and responsibility for choices that ultimately allow death to occur.

Talking with Children about Advanced Illness

To tell or not to tell? This is the question that typically arises when parents and health care providers of children with life-threatening illnesses face the issue of discussing prognosis with children. Health care providers have reported a wide range (10% to 80%, with a median 45% prevalence) of open discussions among parents and children regarding the child's impending death. Of a sample of 429 parents in Sweden, 34% discussed death with their child, and none of those parents regretted having this discussion. When children were given the information that their illness was terminal, most (63%) received it from the parent and physician together. In addition, several studies have shown that children as young as 6 to 10 years old are willing to participate in end-of-life decision making. Parents' and health care providers' distress in navigating these communication processes (especially regarding death) may prevent children and families from accessing appropriate and timely pediatric palliative care.

Parents may be reluctant to discuss death with their child because of the understandable worry that such a conversation may be very upsetting to the child. However children may have some understanding that death is likely but, because they sense the parents' distress, may feel unable to discuss this topic with a parent. This choice often stems from concern for the parent's well-being. Providing the child with an opportunity to talk, however, can be therapeutic for the child. We therefore often encourage parents to allow for such an opportunity. For parents to initiate discussion, they need to be supported for their efforts in broaching and carrying out these difficult conversations with their child. When parents were asked how they best could be supported during end-of-life care of their child, they responded by saying that respect for the family's role, comfort, spiritual care, access to care and resources, communication, support for parental decision making, and caring/humanism were central.

By describing to parents a nonthreatening mode of communication when carrying out discussions with their child, centered on exploring what the child knows and what the child may be worrying about and hoping for in the time ahead, we can often reassure parents that this conversation will be sensitive and guided by the needs of the child.

The needs and wishes of the individual child should guide how communication takes place and its content. A child's age and level of cognitive development as well as the changing comprehension of death by age can help shape the appropriate conversations regarding the prognosis, treatment choices, and end-of-life decisions; however, all this information cannot necessarily predict what a child understands about death. Furthermore depending on the disease (e.g., brain tumor), the act of communication may be functionally difficult on the part of the child. Thus careful assessment of a child's physical abilities, maturity, level of comprehension, and coping abilities rests on the family and health care team. Himelstein explains appropriate communication interventions (i.e., language, details, expression, participation) based on age ( Table 70-1 ). Chesler and colleagues found that the age at which the child was diagnosed with cancer was strongly and significantly related to the amount of information the parents provided about the illness: the older the child, the more information was given. However, in another study that retrospectively collected information regarding psychosocial variables on 45 pediatric oncology patients who died, it was found that children between the ages of 3 to 6 years had more information about their own death from their parents than older children between the ages of 7 to 11 years. The investigators concluded that perhaps children in the younger age group had a “magical concept” of death, thus making it easier for caregivers to discuss end of life with these younger children. Hurwitz and colleagues provide questions and statements children raise about dying at various ages, thoughts that guide the behavior, their underlying developmental understanding of death, and strategies and responses that can help children in these situations ( Table 70-2 ).

Assessing the child's level of autonomy, perception of threat and safety, and individual coping style can help the clinician determine how to communicate with the child regarding palliative care. Independence and individuation will vary. For example, some adolescents, especially those who have close relationships with their parents, may not make a lot of the day-to-day decisions on their own and depend on their parents' authority and life experience for critical decision making. Other adolescents may be accustomed to “heading” the household and making many of the daily decisions for a family.

Understanding the child's family history with regard to illness and experience with death are important components to consider when broaching sensitive issues within palliative care. A child who has previously witnessed a relative die or suffer from a serious illness and observed his or her family's grief may have unique needs related to this experience. Children who are accustomed to making decisions along with their siblings may request to have siblings present during important decision-making events.

Understanding whether the child has a current and/or premorbid history of anxiety and/or depression is also critical in how information is delivered during advanced care planning discussions.

Within the framework of the American culture is the diversity of the various ethnic and religious cultural subgroups that utilize a range of guiding principles with regard to illness and truth-telling. It is critical to assess the family's identification with their particular culture and inquire what their beliefs are with regard to communication with children about issues pertaining to advanced care, because this may vary from the protective approach (shielding young patients and siblings from full knowledge of the disease) to a more open approach. Although every family's style of disclosing sensitive information may be different for a variety of reasons, health care providers should consider how parents may feel if they do not prepare their child for impending death, because this has been shown to have long-term implications for parental grief.

Techniques for Communication

In many instances communicating with children regarding palliative care issues is best received when health-care professionals are aware of the child's level of desired information and concurrently reinforce the primary role of parents. Children between the ages of 8 and 17 years who were interviewed about disclosure regarding their diagnosis and prognosis reported a range of views about the form of disclosure they preferred: a few believed it was better to hear the news at the same time as their parents, some thought it was more appropriate for their parents to be told first, and others reported no strong feelings either way. Patients reported the roles their parents performed in facilitating communication with their health care team: asking questions for them, being the source of information, and reframing the information from the health care team so they could understand it better. Some children reported feeling “protected” by the parent's executive role in screening the communication with doctors and “marginalized” by the nonparticipant status. Parents of cancer survivors indicated that the shielding of information that took place (i.e., preference regarding whether to provide information to their child about prognosis and treatment options) depended on their child's age and emotionality.

The range of views reported by pediatric patients exemplifies the necessity for tailoring one's approach of communication to the individual child. The most beneficial method for determining the most appropriate way to communicate with a particular child is by spending time with him or her. A provider who knows the child well may be best suited for this conversation whenever possible. Prior to the delivery of information, it is helpful to uncover what the child already knows. This can be done through direct conversation or through nonverbal communication (e.g., drawing and symbolic play). Storytelling, such as using the experience of another family with a child or a loved one facing death, may be another modality that can be used by parents and health care providers to broach sensitive topics related to death. Ensuring privacy, confidentiality, and support can facilitate the trust that is needed for the child to disclose what it is that he or she already knows. The next step is finding out what the child wants to know. Then the clinician can give information in small amounts, responding to the child's reactions and feelings; and can remind the child that there will be additional opportunities to discuss the issues of concern.

Listening

Listening to a child cannot be underrated nor under­utilized. Because a child confronting a life-threatening illness is at his or her most vulnerable, listening to the child can be a very powerful tool in placing some of the control back in the hands of the child. Allowing moments for silence in the discussion only reinforces this acknowledgement that the clinician is listening. Providing a child with a tape recorder can be another method for empowering the child. This allows the child to record his or her questions for the upcoming appointment with the clinician, and also allows them to record the clinician's answers so they can be reviewed if necessary. Asking about and listening to the child's priorities and providing choices, when possible, may allow the child to participate in “life-enhancing experiences even at the close of life.” ^{(p 746)} Listening to the voice of the parent(s) goes hand-in-hand with listening to the child to provide comprehensive family-centered care; it can provide helpful information about the child and make the health care provider a better listener for the child. Listening to the parent without the presence of the child can also be a valuable tool in certain instances when the child's presence may restrict communication.