Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins Hospital, Baltimore, MD.
Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
Pediatr Crit Care Med. 2023 Jan 1;24(1):e28-e43. doi: 10.1097/PCC.0000000000003062. Epub 2022 Sep 7.
Admission to the PICU may result in substantial short- and long-term morbidity for survivors and their families. Engaging caregivers in discussion of prognosis is challenging for PICU clinicians. We sought to summarize the literature on prognostic, goals-of-care conversations (PGOCCs) in the PICU in order to establish current evidence-based practice, highlight knowledge gaps, and identify future directions.
PubMed (MEDLINE and PubMed Central), EMBASE, CINAHL, PsycINFO, and Scopus.
We reviewed published articles (2001-2022) that examined six themes within PGOCC contextualized to the PICU: 1) caregiver perspectives, 2) clinician perspectives, 3) documentation patterns, 4) communication skills training for clinicians, 5) family conferences, and 6) prospective interventions to improve caregiver-clinician communication.
Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology.
Of 1,420 publications screened, 65 met criteria for inclusion with several key themes identified. Parent and clinician perspectives highlighted the need for clear, timely, and empathetic prognostic communication. Communication skills training programs are evaluated by a participant's self-perceived improvement. Caregiver and clinician views on quality of family meetings may be discordant. Documentation of PGOCCs is inconsistent and most likely to occur shortly before death. Only two prospective interventions to improve caregiver-clinician communication in the PICU have been reported. The currently available studies reflect an overrepresentation of bereaved White, English-speaking caregivers of children with known chronic conditions.
Future research should identify evidence-based communication practices that enhance caregiver-clinician PGOCC in the PICU and address: 1) caregiver and clinician perspectives of underserved and limited English proficiency populations, 2) inclusion of caregivers who are not physically present at the bedside, 3) standardized communication training programs with broader multidisciplinary staff inclusion, 4) improved design of patient and caregiver educational materials, 5) the development of pediatric decision aids, and 6) inclusion of long-term post-PICU outcomes as a measure for PGOCC interventions.
儿童重症监护病房（PICU）的收治可能导致幸存者及其家属在短期和长期内出现严重的发病率。对于 PICU 临床医生来说，让照顾者参与预后讨论具有挑战性。我们旨在总结 PICU 中预后、关怀目标谈话（PGOCC）的文献，以确定当前基于证据的实践，突出知识空白，并确定未来方向。
PubMed（MEDLINE 和 PubMed Central）、EMBASE、CINAHL、PsycINFO 和 Scopus。
我们回顾了 2001 年至 2022 年期间发表的文章，这些文章考察了 PGOCC 中六个与 PICU 相关的主题：1）照顾者观点，2）临床医生观点，3）记录模式，4）临床医生沟通技巧培训，5）家庭会议，6）改善照顾者-临床医生沟通的前瞻性干预。
两位审稿人独立使用系统评价和荟萃分析方法评估了合格性。
在筛选出的 1420 篇论文中，有 65 篇符合纳入标准，确定了几个关键主题。父母和临床医生的观点强调了需要进行清晰、及时和富有同情心的预后沟通。沟通技巧培训计划通过参与者的自我感知改善来评估。照顾者和临床医生对家庭会议质量的看法可能存在分歧。PGOCC 的记录不一致，最有可能在死亡前不久进行。只有两项改善 PICU 中照顾者-临床医生沟通的前瞻性干预措施被报道。目前可用的研究反映了过度代表有悲伤经历的、讲英语的、患有已知慢性疾病的儿童的白人照顾者。
未来的研究应确定增强 PICU 中照顾者-临床医生 PGOCC 的基于证据的沟通实践，并解决以下问题：1）服务不足和英语水平有限的人群中照顾者和临床医生的观点，2）包括不在床边的照顾者，3）纳入更广泛的多学科工作人员的标准化沟通培训计划，4）改进患者和照顾者教育材料的设计，5）开发儿科决策辅助工具，6）将 PICU 后长期结果作为 PGOCC 干预措施的衡量标准。
