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Pediatric Palliative Care

Next Reply: Re:Non Accidental Trauma (NAT)
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Post Non Accidental Trauma (NAT)
Author: Triley
Date: Feb 8, 2012 11:09 am
Does your Palliative Care Team provide PPC consultations with famlies with regard to End-of-Life Decision Making in NAT cases?
Is this an automatic referral criterion?
Who intitiates this referral, PICU, Trauma Team?
At what point in the care is this consult intitated?
I am curious how other PPC teams handle this very sad circumstance.
Replies: order by [Date] [Author] [Subject]
Re:Non Accidental Trauma (NAT) (by StacyRemke on 02/08/2012)
Hi. Yes, our Peds PC team has indeed become involved in a number of these. Our focus has been on illuminating the comfort and quality of life issues for the child and family when there is irreversible trauma. These are very delicate issues. Sometimes family opting to discontinue support means the perpetrator faces tougher criminal charges, for example. If the alleged perpetrator is a member of the family, consent issues can become very complex and emotionally charged. It is important to keep the focus on the child and family. Soemtimes we have been consultants to child protection services in essence.

The referrals have occured in a variety of ways, and with different timing too. I think it is most helpful when the family and primary care team are beginning to grapple with a "new normal," and the fallout from the injury. That said, the referring attendings will often influence when/ if the pPc referral gets made. Referral would be based on diagnostic criteria once the extent of injury has become clearer. For example, devstating traumatic brain injury or PVS.

One idea might be to build PPC referral into policies or guidelines for responding to these situations. I think sometimes the PPC team can offer a helpful perspective and even be a kind of helpful lightening rod, keeping focus on the best interests and comfort issues when there are also lots of other critical issues that need ot be addressed. I will be interested to hear about experinces of other programs too.
+ Re:Non Accidental Trauma (NAT) (by sfriebert on 02/12/2012)
Our team, as well, provides consultation relatively close to diagnosis of NAT, and it is pretty much considered to be a trigger diagnosis if the injuries are severe. Most of the time the referral comes from the PICU, and usually on admission, unless the injuries are minor. If the child's course progresses toward end-of-life decision making, it makes it easier if we've been on board from admission and/or diagnosis, to help with the complexities (ethical, legal and emotional) that Stacy alluded to in her post. We will often also manage the actual discontinuation of no-longer-beneficial life-sustaining therapy wherever it occurs.

The other role that our team plays is in staff care for these difficult cases - as you mentioned, they are sad circumstances and provoke strong feelings and distress among our staff from first responders to ED to PICU to floor, and so on. We have been involved in staff-based care for these unfortunate times as well.
Re:Non Accidental Trauma (NAT) (by AshleyMead on 03/15/2012)
Our program has had on average 1-2 NAT cases per year for the past 6-7 years. As the outpatient component of a program that provides both inpatient and outpatient care, the referrals I receive come when the family and the inpatient care team determine that the child is stable enough to discharge from the hospital - usually for terminal care. Our program is designed so that we have an inpatient and an outpatient component so we are usually called in by our inpatient team who in turn have been called by either the SW or case managers in the hospital to discuss discharge options. I do not think there is an automatic referral generated at the Children's Hospital we work with but, that being said, our inpatient team is usually brought in early on in the admission if it looks like there is a chance that the child will not survive. We are not called in on all NAT cases. I have received referrals from other hospitals directly from the NICU or PICU for NAT cases when the child's family has decided to take the child home rather than remain in the hospital and we are able to do a direct admit to our outpatient program.
A few differences between an NAT hospice level case and our other terminal cases on the outpatient/home side is that we take extra efforts to ensure that both the family and staff are aware of any legal issues that need to be worked with/around in the home setting as there is usually a criminal case or investigation pending. This usually means more detailed advanced planning around the actual death itself - if there are any visitation restrictions, etc. We also take extra care to prepare the family for what will actually happen after the child dies at home as wtih NAT cases the coroner and police will have to come which is not usual for home hospice deaths.
This probably isn't any new info but I thought I would reply as a representative of the outpatient side of things.
Re:Non Accidental Trauma (NAT) (by AshleyMead on 03/15/2012)
Our program has had on average 1-2 NAT cases per year for the past 6-7 years. As the outpatient component of a program that provides both inpatient and outpatient care, the referrals I receive come when the family and the inpatient care team determine that the child is stable enough to discharge from the hospital - usually for terminal care. Our program is designed so that we have an inpatient and an outpatient component so we are usually called in by our inpatient team who in turn have been called by either the SW or case managers in the hospital to discuss discharge options. I do not think there is an automatic referral generated at the Children's Hospital we work with but, that being said, our inpatient team is usually brought in early on in the admission if it looks like there is a chance that the child will not survive. We are not called in on all NAT cases. I have received referrals from other hospitals directly from the NICU or PICU for NAT cases when the child's family has decided to take the child home rather than remain in the hospital and we are able to do a direct admit to our outpatient program.
A few differences between an NAT hospice level case and our other terminal cases on the outpatient/home side is that we take extra efforts to ensure that both the family and staff are aware of any legal issues that need to be worked with/around in the home setting as there is usually a criminal case or investigation pending. This usually means more detailed advanced planning around the actual death itself - if there are any visitation restrictions, etc. We also take extra care to prepare the family for what will actually happen after the child dies at home as wtih NAT cases the coroner and police will have to come which is not usual for home hospice deaths.
This probably isn't any new info but I thought I would reply as a representative of the outpatient side of things.

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