- Psychology, Child and Adolescent
Fellowship: Stanford University Child Psychology Postdoctoral Fellowship (2001) CA
PhD Training: Yale School Of Medicine (2000) CT
Internship: Boston Children's Hospital (2000) MA
Home Milrinone in Pediatric Hospice Care of Children with Heart Failure.
Journal of pain and symptom management
CONTEXT: The symptom profile of children dying from cardiac disease, especially heart failure, differs from those with cancer and other non-cardiac conditions. Treatment with vasoactive infusions at home may be a superior therapy for symptom control for these patients, rather than traditional pain and anxiety management with morphine and benzodiazepines.OBJECTIVES: We report our experience using outpatient milrinone in children receiving hospice care for end-stage heart failure.METHODS: Retrospective review of a contemporary cohort of all patients at Lucile Packard Children's Hospital, Stanford who were discharged on intravenous milrinone and hospice care between 2008-2021. Clinical data, including cardiac diagnosis, milrinone dose and route of administration, total milrinone days, symptoms reported, rehospitalization rates, concurrent therapies and complications were analyzed.RESULTS: Among 8 patients, median duration of home milrinone infusion was 191 (33, 572) days with the longest support duration 1054 days. All (100%) patients were also receiving diuretics at the time of death. Five (63%) were receiving no other pain control medications until the active phase of dying. From milrinone initiation to last outpatient assessment, a reduction in the number of patients reporting respiratory discomfort, abdominal pain, weight loss/lack of appetite, and fatigue was observed. Six (75%) died at home.CONCLUSION: We used milrinone with oral diuretics effectively for symptom control in children with heart failure on palliative care. Our experience was that this combination can be used safely in the outpatient setting for long-term use without the addition of opiates, benzodiazepines, or supplemental oxygen in most cases.
View details for DOI 10.1016/j.jpainsymman.2022.11.014
View details for PubMedID 36417945
Bereaved Caregiver Perspectives on the End of Life in Pediatric Patients With Ventricular Assist Devices.
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
OBJECTIVES: Ventricular assist devices (VADs) are increasingly used in pediatric heart failure as bridges to heart transplantation, although 25% will die with VADs. Family experiences in this population are not well-described. The objective is to understand bereaved families' perspectives on VAD and end-of-life decision-making.DESIGN: Semistructured interviews with bereaved caregivers of pediatric VAD patients.SETTING: Tertiary children's hospital.PATIENTS: Families of six pediatric VAD patients who died from 2014 to 2020.INTERVENTIONS: Not available.MEASUREMENTS AND MAIN RESULTS: Applying a grounded theory framework, interviews were coded by two independent readers using qualitative software. Themes were discussed in iterative multidisciplinary meetings. Participants were interviewed at a median 2.4 years after their child died. Three major themes emerged: 1) "lack of regret" for VAD implantation despite the outcome; 2) "caregiver-child accord" (via patient's verbal assent or physical cues) at implantation and end-of-life was important in family decision-making; and 3) development of a "local surrogate family" (medical team and peer families) provided powerful support.CONCLUSIONS: Bereaved families' perspectives provide insight into quality decision-making for major interventions and end-of-life care in pediatric patients with chronic illness who face decisions regarding technology dependence.
View details for DOI 10.1097/PCC.0000000000003089
View details for PubMedID 36194025
- A Framework for Navigating Requests for Nondisclosure in Pediatric Palliative Care CLINICAL PRACTICE IN PEDIATRIC PSYCHOLOGY 2021; 9 (3): 296-307
Psychotherapy in pediatric palliative care
CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA
2006; 15 (3): 585-?
Psychotherapy for children who have life-threatening illness is unique in its challenges and rich in its rewards. Most of these children enter into psychotherapy because of the stress engendered by the illness rather than more general intrapsychic or interpersonal concerns. The facilitation of psychological adjustment is a common goal and brought about by managing anxiety related to great un-certainty and anticipatory grief. Siblings and other family members are incorporated into the work as they play a pivotal role in sustaining and strengthening emotional resources. Critical losses.around control, personal identity, and interpersonal relationships are common themes throughout the therapeutic process.
View details for DOI 10.1016/j.chc.2006.02.004
View details for Web of Science ID 000239131600005
View details for PubMedID 16797440
Improved pain management in pediatric postoperative liver transplant patients using parental education and non-pharmacologic interventions
2006; 10 (2): 172-177
A pain management intervention, consisting of pretransplant parental education and support, pre- and postoperative behavioral pediatrics consultation, postoperative physical and occupational therapy consultation, and implementation of non-pharmacologic pain management strategies, was introduced to all pediatrics patients receiving liver transplants at Lucile Packard Children's Hospital beginning August 2001. Children receiving transplants pre-intervention (May, 2000 to February, 2001) and post-intervention (August, 2001 to March, 2002) were compared using pain scores, parent perception of pain ratings, length of stay, ventilator days, total cost, and opioid use. A total of 27 children were evaluated (13 historical control, 14 intervention). The two populations did not differ on age at transplant (mean age 53.8 vs. 63.6 months), sex (46.1% vs. 50% male), ethnicity (53.8% vs. 57.1% white, non-Hispanic) weight at transplant (17.5 vs. 24.7 kg), percent with biliary atresia as the primary reason for transplant (42.9% vs. 69.2%), percent with status 1 transplant listing score (38.5% vs. 50.0%), or public insurance status (30.8 vs. 57.2% with Medicaid). No differences were found in mean pediatric intensive care unit (PICU) postoperative length of stay (6.7 vs. 5.3 days), total postoperative length of stay (17.5 vs. 17.5 days), total inpatient length of stay (27.0 vs. 24.4 days), time to extubation (30 vs. 24.3 h), total cost (dollar 147,983 vs. dollar 157,882) or opioid use through postoperative day (POD) 6 (0.24 vs. 0.25 mg/kg/day morphine equivalent). A decrease in mean pain score between POD 0 and 6 (2.82 vs. 2.12; p = 0.047), a decrease in mean parental pain perception score (3.1 vs. 2.1; p = 0.001), and an increase in number of pain assessments per 12 h shift (3.43 vs. 6.79; p < 0.005) were seen. A comprehensive non-pharmacologic postoperative pain management program in children receiving a liver transplant was associated with decreased pain scores, improved parent perception of pain, and an increased number of pain assessments per 12 h shift. No increases in lengths of stay (PICU, postoperative, total), time to extubation, or total cost were found.
View details for DOI 10.1111/j.1399-3046.2005.00438.x
View details for PubMedID 16573603
Food, toys, and love: pediatric palliative care.
Current problems in pediatric and adolescent health care
2005; 35 (9): 350-386
View details for PubMedID 16301200