Opioid Tapering in Children: A Critical Review of the Literature
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I. Background. The end-of-life (EOL) experience of children undergoing SCT, intensive therapy delivered with curative intent has not been described. II. Research Objectives. To evaluate patterns of par- ent and physician perspectives on EOL care for children after SCT. III. Methods. Retrospective cross-sectional sur- vey of 141 parents of children who died of cancer, and primarily received care at one of two tertiary care pediatric institutions (re- sponse rate 64%). Children for whom SCT was the last cancer therapy (n ¼ 31) were com- pared with those for whom it was not (non- SCT, n ¼ 110). IV. Results. The SCT group included 22/31 (71%) allogeneic and 9/31 (29%) autologous SCT. Median (IQR) interval between last cancer treatment and death was 65 (30e127) days (SCT group) and 25 (8e59) days (non-SCT) (P < .001). SCT children were more likely to die from toxicity and be intubated at EOL, with less opportunity to plan location of death (LOD) (all P < .001). Their resuscitation discus- sions occurred later (P < .001) and resulted in fewer DNR orders (P ¼ .028). SCT children were more likely to suffer highly from their last cancer therapy (P ¼ .007) and experienced more physical and psychological symptoms (both P ¼ .005). SCT parents and physicians were more likely to list cure as their primary goal at EOL (both P < .001) and time of death (parents: P ¼ .013, physicians: P ¼ .03). They also recognized no realistic chance for cure (RCC) later (parents: median [IQR] 4 [1e822] days prior to death vs. 84 [29-237], P < .001, phy- sicians: 16 [2e30] days vs. 84 [29e166], P < .001). For the 13 SCT children whose parents and physicians recognized no RCC > 7 days be- fore death, intubation was less likely (P ¼ .05) and resuscitation discussion and LOD planning more likely (both P ¼ .02). V. Conclusion. SCT is associated with significant suffering and less opportunity to prepare for EOL. VI. Implications for Research, Policy, or Practice. Pal- liative care and SCT may be complementary in providing care focused simultaneously on cure and relief of suffering. Domains Structure and Processes of Care; Physical Aspects of Care; Psychological Aspects of Care: Care of the Imminently Dying Patient Opioid Tapering in Children: A Critical Review of the Literature Deborah Fisher, MS RN CS PNP CPON, VCU Medical Center, Richmond, VA. (Fisher has disclosed no relevant financial relationships.) Objectives 1. Name two validated pediatric opioid withdrawal assessment tools. 2. List five opioid withdrawal symptoms com- mon in pediatric withdrawal. I. Background. In the pediatric intensive care unit, routine sedation and/or analgesia for mechani- cally-ventilated children is considered standard practice. This therapeutic aim of providing ade- quate analgesia and sedation quite often results in days to weeks of continuous opioid and/or sed- ative exposure. Continuous exposure results in iatrogenic opioid and sedative dependence. In children, physical dependence has been found to occur as soon as 2e3 days of continuous opioid therapy. Physical tolerance to opioids has been shown to develop sooner in neonates and infants. Opioid and sedative tapering is begun once the medical team assesses readiness. Since tapering routines vary among practitioners, it is not un- common to witness symptoms of opioid with- drawal in this vulnerable population. II. Aims. To synthesize and critically analyze liter- ature related to pediatric opioid withdrawal. III. Method/Session Description. Studies published in peer-reviewed journals were systematically searched using PubMed, CINAHL, and PsychINFO. IV. Conclusion. The scope of research on pediatric opioid withdrawal is limited. The majority of pub- lished research has focused on the episodic na- ture of withdrawal symptoms during opioid tapering. Studies examining the effect of an opi- oid taper algorithm on occurrence and nature of withdrawal symptoms in children are sorely needed. Further validation of the two withdrawal assessment tools for children is warranted. Domain Physical Aspects of Care Quality of End-of-Life Care in the Hospital Anne Walling, MD, University of California Los An- geles, Los Angeles, CA. Steven Asch, MD MPH, VA Greater Los Angeles Healthcare System, Los An- geles, CA. Karl Lorenz, MD MSHS. VA Greater Los Angeles, and Los Angeles, CA. Carol Roth, 332 Schedule with Abstracts Vol. 39 No. 2 February 2010
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Transcript of Opioid Tapering in Children: A Critical Review of the Literature
332 Schedule with Abstracts Vol. 39 No. 2 February 2010
I. Background. The end-of-life (EOL) experienceof children undergoing SCT, intensive therapydelivered with curative intent has not beendescribed.II. Research Objectives. To evaluate patterns of par-ent and physician perspectives on EOL care forchildren after SCT.III. Methods. Retrospective cross-sectional sur-vey of 141 parents of children who died ofcancer, and primarily received care at one oftwo tertiary care pediatric institutions (re-sponse rate 64%). Children for whom SCTwas the last cancer therapy (n¼ 31) were com-pared with those for whom it was not (non-SCT, n¼ 110).IV. Results. The SCT group included 22/31(71%) allogeneic and 9/31 (29%) autologousSCT. Median (IQR) interval between last cancertreatment and death was 65 (30e127) days (SCTgroup) and 25 (8e59) days (non-SCT) (P <.001). SCT children were more likely to diefrom toxicity and be intubated at EOL, withless opportunity to plan location of death(LOD) (all P < .001). Their resuscitation discus-sions occurred later (P < .001) and resulted infewer DNR orders (P¼ .028). SCT childrenwere more likely to suffer highly from their lastcancer therapy (P¼ .007) and experiencedmore physical and psychological symptoms(both P¼ .005). SCT parents and physicianswere more likely to list cure as their primarygoal at EOL (both P < .001) and time of death(parents: P¼ .013, physicians: P¼ .03). Theyalso recognized no realistic chance for cure(RCC) later (parents: median [IQR] 4 [1e822]days prior to death vs. 84 [29-237], P < .001, phy-sicians: 16 [2e30] days vs. 84 [29e166], P <.001). For the 13 SCT children whose parentsand physicians recognized no RCC> 7 days be-fore death, intubation was less likely (P¼ .05)and resuscitation discussion and LOD planningmore likely (both P¼ .02).V. Conclusion. SCT is associated with significantsuffering and less opportunity to prepare forEOL.VI. Implications for Research, Policy, or Practice. Pal-liative care and SCT may be complementary inproviding care focused simultaneously on cureand relief of suffering.
DomainsStructure and Processes of Care; Physical Aspectsof Care; Psychological Aspects of Care: Care ofthe Imminently Dying Patient
Opioid Tapering in Children: A CriticalReview of the LiteratureDeborah Fisher, MS RN CS PNP CPON, VCUMedical Center, Richmond, VA.(Fisher has disclosed no relevant financialrelationships.)
Objectives1. Name two validated pediatric opioid withdrawal
assessment tools.2. List five opioid withdrawal symptoms com-
mon in pediatric withdrawal.
I. Background. In the pediatric intensive care unit,routine sedation and/or analgesia for mechani-cally-ventilated children is considered standardpractice. This therapeutic aim of providing ade-quate analgesia and sedation quite often resultsin days to weeks of continuous opioid and/or sed-ative exposure. Continuous exposure results iniatrogenic opioid and sedative dependence. Inchildren, physical dependence has been foundto occur as soon as 2e3 days of continuous opioidtherapy. Physical tolerance to opioids has beenshown to develop sooner in neonates and infants.Opioid and sedative tapering is begun once themedical team assesses readiness. Since taperingroutines vary among practitioners, it is not un-common to witness symptoms of opioid with-drawal in this vulnerable population.II. Aims. To synthesize and critically analyze liter-ature related to pediatric opioid withdrawal.III. Method/Session Description. Studies publishedin peer-reviewed journals were systematicallysearched using PubMed, CINAHL, andPsychINFO.IV. Conclusion. The scope of research on pediatricopioid withdrawal is limited. The majority of pub-lished research has focused on the episodic na-ture of withdrawal symptoms during opioidtapering. Studies examining the effect of an opi-oid taper algorithm on occurrence and natureof withdrawal symptoms in children are sorelyneeded. Further validation of the two withdrawalassessment tools for children is warranted.
DomainPhysical Aspects of Care
Quality of End-of-Life Care in the HospitalAnne Walling, MD, University of California Los An-geles, Los Angeles, CA. Steven Asch, MD MPH, VAGreater Los Angeles Healthcare System, Los An-geles, CA. Karl Lorenz, MD MSHS. VA GreaterLos Angeles, and Los Angeles, CA. Carol Roth,
