RPD324 - Between Cure and Comfort: How PICU, BMT, and Palliative Care Teams Align to Care for Critically Ill Children

Key Message : Children who undergo BMT requiring PICU admission face high mortality and long-term morbidity. Involvement of PPC remains inconsistent throughout these admissions. Qualitative interviews demonstrated the complex interplay between managing chronic and acute needs as well as differing perspectives in the timing and role of PPC involvement.

Abstract: Introduction

Children undergoing Bone Marrow Transplant (BMT) who require Pediatric Intensive Care Unit (PICU) admission face high mortality and long-term morbidity (1). Families often experience significant psychological stress further complicating informed decision-making. Early involvement of Pediatric Palliative Care (PPC) has been shown to facilitate communication and goal setting, decrease psychosocial distress, and improve quality of life (2,3). However, involvement remains inconsistent, especially in the PICU. This study explores factors influencing PPC utilization during PICU and BMT admissions, aiming to support more consistent collaborative care.

Methods

We conducted qualitative interviews within an exploratory mixed methods study. Participants included BMT, PICU, and PPC interdisciplinary clinicians at a single pediatric academic hospital. Semi-structured interview guides addressed domains specific to patients undergoing BMT, including knowledge and perceptions of PPC, level of comfort discussing prognosis and advanced care planning, needs of patients who have undergone BMT, and indications for optimal timing of PPC referral. Interviews were audio-recorded, transcribed, and thematically analyzed to identify barriers and facilitators to PPC utilization across the PICU and BMT setting.

Results/Implications

A total of 25 clinicians participated in the study. Themes identified include the complex interplay between ongoing and chronic care needs managed by PPC and BMT to the rapid shift in focus on acutely life-threatening care needs in the PICU. Additional themes include clinicians’ perspectives that medical teams and families differ in how they view PPC’s role and who is primarily managing and guiding ongoing care once patients undergoing BMT arrive in the PICU. Early PPC involvement can bridge these divides by increasing opportunities for goals‐of‐care conversations, aligning expectations, and ensuring families have the longitudinal and psychosocial support they need when considering the balance of continued curative efforts against comfort‐oriented care. Next steps include triangulating the data by conducting a retrospective chart review guided by the qualitative data.

References: 1. Zinter MS, Brazauskas R, Strom J, et al. Critical Illness Risk and Long-Term Outcomes Following Intensive Care in Pediatric Hematopoietic Cell Transplant Recipients. Preprint. medRxiv. 2023;2023.07.31.23293444. Published 2023 Aug 5. doi:10.1101/2023.07.31.23293444

2. Neuburg L. Early Initiation of Pediatric Palliative Care. J Pediatr Health Care. 2021;35(1):114-119. doi:10.1016/j.pedhc.2020.05.006

3. Stephen R. Connor, Julia Downing, Joan Marston, Estimating the Global Need for Palliative Care for Children: A Cross-sectional Analysis, Journal of Pain and Symptom Management, Volume 53, Issue 2, 2017, Pages 171-177, ISSN 0885-3924, https://doi.org/10.1016/j.jpainsymman.2016.08.020.