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Place and Provision of Palliative Care for Children With Progressive Cancer: A Study by the Paediatric Oncology Nurses’ Forum/United Kingdom Children's Cancer Study Group Palliative Care Working Group

Jan Vickers, Anne Thompson, Gary S. Collins, Margaret Childs, Richard Hain

From Oncology Outreach and Palliative Care, Oncology Unit, Royal Liverpool Children's Hospital, Liverpool; Paediatric Macmillan Unit, Children & Young Peoples Cancer Unit, Royal Victoria Infirmary, Newcastle; UK Children's Cancer Study Group, University of Leicester, Leicester; and the Paediatric Palliative Medicine, Department of Child Health, Cardiff University School of Medicine, Wales, United Kingdom

Address reprint requests to Richard Hain, MBBS, MSc, MD, MRCP (UK), FRCPCH, Dip Pall Med, Senior Lecturer in Paediatric Palliative Medicine and Oncology, Department of Child Health, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, United Kingdom; e-mail: hainrd{at}cardiff.ac.uk

	ABSTRACT

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Purpose The purpose of this study was to describe and show effectiveness of the outreach team model of palliative care (PC) in allowing home death for children with incurable cancer.

Patients and Methods Over 7 months, 185 children from 22 United Kingdom oncology centers were recruited to a prospective questionnaire survey.

Results One hundred sixty-four children from 22 centers died (median age, 8.7 years; 88 boys, 76 girls). One hundred twenty-six families completed two or more questionnaires. One hundred twenty (77%) of 155 with complete data died at home. Preference for home death was recorded in 90 (68%) of 164 and 132 (80%) 164 at study entry and last month of life, respectively. Death occurred in preferred place for 84 (80%) of 105 with recorded preference at entry. Forty-one (25%) of 164 and 68 (41.5%) of 164 needed no outpatient or inpatient hospital visits, respectively. A named individual provided on-call PC advice by phone or home visit in 22 (100%) and 18 (82%) of 22 oncology centers, respectively. As PC progressed, involvement of oncologist and social worker appeared less, whereas pediatric oncology outreach nurse specialists (POONSs) remained prominent.

Conclusion Preference for home death expressed by families in our study is similar to others, but the proportion of children actually able to die there is higher. Home death is facilitated by this model. Key components are POONSs, pediatric palliative and/or oncology specialist, and general practitioner. Professional roles change during PC and after death. An ongoing role for the oncology team in bereavement support is highlighted.

	INTRODUCTION

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Childhood cancer affects approximately one in 600 children in the United Kingdom (UK). Approximately 70% are now cured (unpublished data, United Kingdom Children's Cancer Study Group [UKCCSG]), but this still leaves large numbers of deaths annually.

Children's palliative care (PC) is a younger specialty than in adults. While some underlying philosophies and even therapeutic principles can be extrapolated to children, the pediatric specialty is quite distinct. There is a comparative dearth of evidence basis.^1,2 Care is rarely hospice centered, but typically provided at home, with support from a hospital-based oncology team. Liaising between oncology center, primary health care team (PHCT) and family is the responsibility of the pediatric oncology outreach nurse specialist (POONS). During curative treatment, POONSs often give chemotherapy or perform routine blood tests at home. After cure is deemed impossible, this link role of POONSs means that they are well-placed to coordinate PC at home to keep hospital visits to the minimum consonant with preferences of child and family.

At the time of the study, there was little access to specialist pediatric palliative medicine (PPM). Medical support for POONSs, particularly with respect to prescribing medications such as opioids, was provided by the oncologist and/or general practitioner (GP), depending on distance from the oncology center and clinician confidence managing dying children.

This article describes a model of providing broader PC for children with cancer, including complementary therapy (CT) and bereavement support, and demonstrates its effectiveness in allowing most children to be cared for, and to die, at home.

	PATIENTS AND METHODS

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Over a 7-month period, all UKCCSG centers registered children for whom, in the view of the treating oncologist, cure was no longer possible because of recurrence/progression despite maximal therapy. Discontinuation of chemo- or radiotherapy was not a criterion for study entry; either may be prescribed for palliative or experimental indications. As with all prospective studies of a PC population, there was an unavoidable element of subjectivity at study entry. The point at which a patient's care becomes palliative cannot be always be defined. This accurately reflects clinical practice.

Data on symptoms, pharmacologic management, palliative treatment and service provision were collected using an instrument developed by the Paediatric Oncology Nurses’ Forum/UKCCSG PC working group. Minor layout modifications were made after a month-long pilot in three centers. Every month, until death or a maximum of 20 months, data were collected by clinical staff and coordinated by an identified link person at each center, who also completed a service provision questionnaire at study commencement.

The study was carried out simultaneously with two other studies in this population.^3,4 There is no duplication of data presented in this article.

	RESULTS

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One hundred eighty-five children from 22 UKCCSG centers were registered. Twenty-one children remained alive at the end of the study and were excluded. Data were analyzed for 164 (Table 1) from 20 UKCCSG centers (median of 8 patients per center). Thirty-eight died within 4 weeks of entry, completing only one data form.

Sixty-eight (41.5%) of 164 families had no overnight hospital stays. Forty-one (25%) of 164 needed no outpatient visits; 75% had at least one. Blood, platelets, radiotherapy, and chemotherapy were the commonest reasons. During their last month, children with leukemia/lymphoma (17 of 41, 41%) were more likely to visit the hospital (Table 2) than those with CNS (16 of 59, 27%) or other solid tumors (23 of 64, 36%). These differences did not reach statistical significance.

Ninety-eight (68%) of 164 families recorded a preference for home death at the outset. By the last month of life, this had risen to 132 (80%) of 164, including 28 families whose children died within a month of beginning PC. Eighty-six percent 86% of children for whom a preference for home death was recorded at any point (120 of 140) actually died at home (Table 3). There were six centers in which all registered children (n = 29) died at home.

All 22 centers identified a specific oncology team member whose role was to provide 24-hour on-call PC telephone advice. In 18 (82%) of 22, that individual also offered 24-hour home visits. Among patients surviving 4 weeks or longer, at commencement of PC, core PC providers from the oncology team were oncologist 105 of 126 (83%), POONS 110 of 126 (87%), and social worker 77 of 126 (61%). These figures became 97 of 164 (59%), 137 of 164 (84%), and 79 of 164 (48%), respectively in the month before death. Core involvement of GPs and district nurses (DNs; ie, PHCT) was 64 of 126 (51%) and 35 of 126 (28%) at the start of PC and became 116 of 164 (71%) and 72 of 164 (44%) respectively at the end. Children's community nurses (CCNs) were core providers in 43 of 126 cases (34.1%) at the beginning of PC and 59 of 164 (36%) at the time of death.

One hundred nine of 164 (66%) used a CT (relaxation, 49 [30%]; massage, 70 [43%]; physiotherapy, 50 [30.5%]; hypnosis, 4 [2.5%]). Among patients surviving at least 4 weeks, 41 of 126 (35%) were using more than one CT at study entry. At death, this had risen to 89 of 164 (54%). Fifty-five (34%) used no CT during PC, 57 (35%) used one CT, and 52 (32%) used two or more CTs.

Most UKCCSG centers provide immediate contact after a child's death, including funeral attendance, sending flowers, and bereavement support (Table 4). POONSs were the main contact with PHCT in 19 of 22 centers. Along with social workers, the POONSs were also the main providers of contact with families, including bereavement support, for parents and siblings. Contact immediately after death was provided by POONSs (22 of 22), social workers (18 of 22), physicians (10 of 22) and ward nurses (eight of 22).

	DISCUSSION

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Children's PC is an emerging specialty rooted in a multidimensional approach that addresses spiritual and psychosocial needs of children as well as physical. This requires the skills of a variety of professionals, trained to work with children and working as a team.^7,8

Funding for health care in the UK is national, and always free at the point of need. At the time of the study, commissioning of tertiary pediatric oncology services was regional. Provision of PC was seen as part of the oncology service and covered by the same commissioning arrangements. No funding distinction was, or is, made between care provided at home or in hospital. Both are subsumed in commissioned oncology services. By avoiding financial penalties for home care, this avoids one important potential barrier to providing flexible PC services for children.

This study describes care for children in the palliative phase of cancer in the UK. It complements other publications regarding physical management of symptoms.^3,9 The nature of PC in children with cancer can be contrasted both with PC in adults with cancer and with PC delivered to children with nonmalignant life-limiting conditions. Children with cancer are few compared with these,^7,8,10-12 but as end of life approaches, the needs of the family are intense, making heavy demands on the team caring for them. This is particularly true if the preference of families for home death is to be accommodated.

In contrast with an earlier study,¹³ all centers identified staff whose role was specifically to provide a 24-hour on-call service in PC. The data show a marked change in professional involvement between the start of PC and the last month of life. At the beginning of PC, the POONS and oncology consultants are seen as more or less equally involved in providing palliation. By the last month of life, many consultant oncologists have become less involved while POONSs are more often seen as core providers. This recognizes changing priorities of care during the palliative phase, when medical investigations and medications become less important. Few oncology consultants in this study withdrew entirely from the family's care.

The importance of a key worker in coordinating PC for children is emphasized in a number of authoritative publications.^5,7,8,14 Our study suggests that POONSs are well placed to take on this role for most families. Their role has developed to address inexperience in delivering pediatric palliative care within the PHCT.^6,15 Such inexperience is inevitable, given the rarity of most life-limiting conditions, including cancer, in children. The role of POONSs now encompasses empowering PCHT through advice and direct patient care¹⁵; providing an interface between primary, secondary, and tertiary care services; and coordinating services.^6,16

More recently, there has been an expansion in the number of physicians interested or specializing in palliative medicine in children.^17,18 The impact of this on quality of life for children dying from cancer has yet to be evaluated.

CCNs were involved in the care of approximately one third of children, and this did not change over the course of PC. Access to this potentially important resource remains limited in some areas, and it may be that more families would choose to involve CCNs if the option were available.

During PC, in contrast with earlier phases of treatment, home is the principal location for care. Twenty-five percent of children did not visit the hospital outpatient department at all, and 41.5% required no hospital admission during the palliative phase.

Of 155 children with complete records, 120 (77%) died at home. It is not known whether death at home is more or less likely to be comfortable than death in hospital. What is clear, however, is that most families prefer their child to die at home if possible.^19-22 The opportunity to choose place of care and death is emotionally important.^23,24 One of the most important discussions the oncology team will have with the family of a dying child is where they would prefer death to occur.²⁵

The proportion of children able to die at home in the UK is significantly greater than those indicated in studies in other countries^9,26-32 (range, 49% to 60%). Many factors can affect parental decision making,^24,33 including cultural differences. Recent studies^9,13,34 suggest that a country's health care funding is a particularly strong influence. The outreach-based model may allow families to remain at home under circumstances that would make it impractical were no such model in place.

Our results also contrast with studies in adults³⁵ showing that most die in hospital or hospice, although this trend may be slowing³⁶ perhaps as a result of national initiatives aimed at facilitating choice in the location of PC.^35,37,38

At entry to our study, a significant minority (18%) of families (Table 3) had not yet decided where they wished their child to die. It is likely that this included some who had not yet been given the opportunity to consider the question, underlining the importance of proactively raising the issue early with families. In accordance with earlier studies,^19,20,22 those who had made a decision showed an overwhelming preference for death to occur at home—68% in our study.

It might be anticipated that, as the child's condition deteriorates and the end of life approaches, families would lose confidence in their ability to care for the child at home. In our study, the reverse was true. During the final month, the proportion of families preferring home had risen to 80%. This suggests that families felt empowered by the support given to them by the POONSs, supported in turn by the oncologist and GP and respective tertiary and community teams.

The palliative needs of children with cancer are different from those with other life-limiting conditions, and it has been suggested that children's hospices may not be suitable locations.^13,39 Most oncology centers in the UK have an infrastructure in place for such children to be cared for at home. In this study, only a small number of children dying with cancer were reported to have spent time in a children's hospice. They may represent a more important resource in the future, as their working links with oncology units become closer.

A fundamental principle of PC is that interventions should be offered only if their potential benefit outweighs their probable burden to the patient. For a child close to the end of life, avoiding unwelcome hospital visits should be considered a priority. Diagnosis and social class, as well as patient choice, have been identified as factors influencing how far this is possible in practice.^28,36

Facilitating care at home inevitably means providing some interventions there that are more traditionally carried out in hospital. Transfusion of blood or platelets, for example, can confer significant improvements in quality of life. Over the course of PC, POONSs administered at-home interventions that included chemotherapy (32.3%), platelets (7.3%), and blood (1.8%). Facilitating such interventions in the home allows children to experience symptom benefits with smaller burden. Our data suggest that it was most difficult to achieve in children with leukemia or neuroblastoma (Table 2), who were also children most likely to need blood and/or platelet support.

During the palliative phase, CTs offer an important modality for treatment for many families. CTs typically impose little burden: most are painless and nontoxic in most patients. They can usually be done at home and do not require uncomfortable trips to hospital. This makes many CTs ideal palliative interventions, independently of any evidence of effectiveness.⁴⁰ Most are not, however, covered by the National Health Service and, in the UK, financial costs must usually be borne by the family. The proportion of families using CT rose from approximately one third at study entry to more than half during the last month of life, emphasizing the importance of acknowledging and discussing openly the use of CT with families. In our study, massage and physiotherapy were the two most popular therapies, with relaxation becoming increasingly popular towards the end of life.

The family of a child who dies as a result of cancer will often describe a sense that they have been multiply bereaved, losing not only their child and any children he or she might have had but also the routine of caring and relationships with those who have gathered during the illness to provide support. Clearly, the relationship between the family and the professionals caring for them must change at the point of the child's death. Involvement beyond a certain stage would be unnecessary and intrusive as well as impractical.

Our study suggests that most members of the multidisciplinary team take some part in bereavement support (Table 4). Again, it is the POONSs who tended to remain the most engaged with families after death. Although some units provided support for a specified period after death, others provided it for as long as was required. POONSs, social workers, and ward nurses were particularly proactive in the immediate period after death had occurred, attending the funeral, sending flowers and making contact with the family. The POONS often went on to engage proactively with the family and with the PHCT. Group bereavement support for parents and for siblings of the child was provided both by the social workers and the POONSs. Interestingly, few physicians engaged in this process (Table 4). Doctors can provide valuable support to such groups, because misunderstandings and lack of information can be factors in complicated grief.

Our study describes a model for providing PC to children dying as a result of cancer. A coordinated pediatric oncology network has existed in the UK for many years, and the model has developed in that context. It is characterized by a change as death approaches, both in the professionals involved in providing PC and in the location where care and ultimately death take place. Care led by physicians in the tertiary center gives way to care coordinated by specialist nurses in the home.

Thus POONSs are pivotal in effecting a gradual transfer of care for the family from the tertiary oncology center back to the GP, without sacrificing the specialist skills of either team. Together with the social workers, POONSs are also well placed to provide ongoing bereavement support for the family, whom, by the time of death, they typically know very well.

Our study also confirms that the great majority of families would prefer their child to die at home if possible. Our data suggest that the flexible model we describe here facilitates this. Furthermore, the provision of specialist outreach nurses allows some palliative interventions such as transfusion, which might otherwise require a hospital visit, to be administered at home. In this way, home care before and at the time of death is made more likely.

Developments since this study that will influence, and potentially further improve the effectiveness of this model, include an expansion in the number of specialist pediatricians in PC and a closer relationship with children's hospices.

	AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

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The author(s) indicated no potential conflicts of interest.

	AUTHOR CONTRIBUTIONS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION AUTHORS' DISCLOSURES OF... AUTHOR CONTRIBUTIONS REFERENCES

 
Conception and design: Jan Vickers, Anne Thompson

Provision of study materials or patients: Jan Vickers, Anne Thompson, Richard Hain

Collection and assembly of data: Jan Vickers, Ann Thompson, Gary Collins, Richard Hain

Data analysis and interpretation: Jan Vickers, Anne Thompson, Gary S. Collins, Richard Hain

Manuscript writing: Jan Vickers, Anne Thompson, Gary S. Collins, Richard Hain

Final approval of manuscript: Jan Vickers, Anne Thompson, Gary S. Collins, Margaret Childs, Richard Hain

	NOTES

 
The UKCCSG is now known as the Children's Cancer and Leukaemia Group.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

	REFERENCES

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1. Cooley C, Adeodu S, Aldred H, et al: Paediatric palliative care: A lack of research-based evidence. Int J Palliat Nurs 6:346-351, 2000[Medline]

2. Graham R, Dussel V, Wolfe J: Research, in Goldman A, Hain RDW, Liben S (eds): Oxford Textbook of Palliative Care in Children (ed 1). Oxford, United Kingdom, Oxford University Press, 2006, pp 615-647

3. Goldman A, Hewitt M, Collins GS, et al: Symptoms in children/young people with progressive malignant disease: A UKCCSG/PONF survey. Pediatrics 117:e1179-1186, 2006[Abstract/Free Full Text]

4. Hewitt M, Goldman A, Collins GS, et al: Opioid use in progressive cancer in children/young people: A survey by United Kingdom Children's Cancer Study Group and Paediatric Oncology Nurses’ Forum. J Peds (in press)

5. National Collaborating Centre for Cancer: Improving Outcomes in Children and Young People With Cancer: The Manual. London, United Kingdom, National Institute for Health and Clinical Excellence, 2005

6. Bignold S, Ball S, Cribb A: Nursing families with children with cancer: The work of the Paediatric Oncology Outreach Nurse Specialists. Kings College, United Kingdom, London Cancer Relief Macmillan Fund and Department of Health, 1994

7. ACT/RCPCH: A Guide to the Development of Children's Palliative Care Services (ed 1). Bristol and London, United Kingdom, ACT/RCPCH, 1997

8. ACT/RCPCH: A Guide to the Development of Children's Palliative Care Services (ed 1). Bristol and London, United Kingdom, ACT/RCPCH,, 2003

9. Wolfe J, Holcombe E, Grier E, et al: Symptoms and suffering at the end of the life in children with cancer. N Engl J Med 342:326-333, 2000[Abstract/Free Full Text]

10. Hain RDW: Palliative care in children in Wales: A study of provision and need. Palliat Med 19:137-142, 2005[Abstract/Free Full Text]

11. Lenton S, Goldman A, Eaton N, et al: Development and epidemiology, in Goldman A, Hain RDW, Liben S (eds): Oxford Textbook of Palliative Care in Children (ed 1). Oxford, United Kingdom, Oxford University Press, 2006, pp 3-13

12. Mallinson J, Jones PD: A 7-year review of deaths on the general paediatric wards at John Hunter Children's Hospital, 1991-97. J Paediatr Child Health 36:252-255, 2000[CrossRef][Medline]

13. Morgan ER, Murphy SB: Care of children who are dying of cancer. N Engl J Med 342:347-348, 2000[Free Full Text]

14. Committee on Bioethics and Committee on Hospital Care: Palliative care for children. Pediatrics 106:351-357, 2000[Abstract/Free Full Text]

15. Hunt J: The paediatric oncology community nurse specialist: The influence of employment location and funders on models of practice. J Adv Nurs 22:126-133, 1995[CrossRef][Medline]

16. Evans M, Thompson A: The role of the Macmillan Paediatric Nursing Service, in Glasper A, Lowson S (eds): Innovations in Paediatric Ambulatory Care. London, United Kingdom, Macmillan 1998

17. Hain RD: Paediatric palliative medicine: A unique challenge. Pediatr Rehabil 7:79-84, 2004[CrossRef][Medline]

18. Hutchinson F, King N, Hain RD: Terminal care in paediatrics: Where we are now. Postgrad Med J 79:566-568, 2003[Abstract/Free Full Text]

19. Cribb A, Bignold S, Ball SJ: Linking the parts: An exemplar of philosophical and practical issues in holistic nursing. J Adv Nurs 20:233-238, 1994[CrossRef][Medline]

20. Goldman A, Beardsmore S, Hunt J: Palliative care for children with cancer–home, hospital, or hospice? Arch Dis Child 65:641-643, 1990[Free Full Text]

21. Martinson I, Armstrong G, Geis D, et al: Home care for children dying of cancer. Pediatrics 62:106-113, 1978[Abstract/Free Full Text]

22. Vickers JL, Carlisle C: Choices and control: Parental experiences in pediatric terminal home care. J Pediatr Oncol Nurs 17:12-21, 2000[Abstract/Free Full Text]

23. Hinds PS, Oakes L, Furman W, et al: End-of-life decision making by adolescents, parents and healthcare providers in pediatric oncology. Cancer Nurs 24:122-136, 2001[CrossRef][Medline]

24. Hannan J, Gibson F: Advanced cancer in children: How parents decide on final place of care for their dying child. Int J Palliat Nurs 11:284-291, 2005[Medline]

25. Brook L, Vickers J, Barber M: Place of care, in Goldman A, Hain RDW, Liben S (eds): Oxford Textbook of Palliative Care in Children (ed 1). Oxford, United Kingdom, Oxford University Press, 2006, pp 533-548

26. Foley GV, Whittam EH: Care of the child dying of cancer: Part I. CA Cancer J Clin 40:327-354, 1990[Medline]

27. Friedrichsdorf SJ, Menke A, Brun S, et al: Status quo of palliative care in pediatric oncology-a nationwide survey in Germany. J Pain Symptom Manage 29:156-164, 2005[CrossRef][Medline]

28. Klopfenstein KJ, Hutchison C, Clark C, et al: Variables influencing end-of-life care in children and adolescents with cancer. J Pediatr Hematol Oncol 23:481-486, 2001[CrossRef][Medline]

29. Kopecky EA, Jacobson S, Joshi P, et al: Review of a home-based palliative care program for children with malignant and non-malignant diseases. J Palliat Care 13:28-33, 1997[Medline]

30. Kurashima AY, Latorre Mdo R, Teixeira SA, et al: Factors associated with location of death of children with cancer in palliative care. Palliat Support Care 3:115-119, 2005[Medline]

31. Martinson IM, Cohen MM: Themes from a longitudinal study of family reactions to childhood cancer. J Psychosoc Oncol 6:81-98, 1988[CrossRef]

32. Sirkiä K, Hovi L, Pouttu J, et al: Pain medication during terminal care of children with cancer. J Pain Symptom Manage 15:220-226, 1998[CrossRef][Medline]

33. Chvetzoff G, Garnier M, Perol D, et al: Factors predicting home death for terminally ill cancer patients receiving hospital-based home care: The Lyon comprehensive cancer center experience. J Pain Symptom Manage 30:528-535, 2005[CrossRef][Medline]

34. Gemke RJ, Zwaan CM, Revesz T: Symptoms and suffering at the end of life in children with cancer. N Engl J Med 342:1997-1998, 2000[CrossRef][Medline]

35. Ellershaw J, Ward C: Care of the dying patient: The last hours or days of life. BMJ 326:30-34, 2003[Free Full Text]

36. Higginson IJ, Thompson M: Children and young people who die from cancer: Epidemiology and place of death in England (1995-9). BMJ 327:478-479, 2003[Free Full Text]

37. Ellershaw J, Foster A, Murphy D, et al: Developing an integrated care pathway for the dying patient. Eur J Palliat Care 4:203-207, 1997

38. Pemberton C, Storey L, Howard A: The preferred place of care document: An opportunity for communication. Int J Palliat Nurs 9:439-441, 2003[Medline]

39. Chambers TL: Hospices for children? BMJ (Clin Res Ed) 294:1309-1310, 1987[Free Full Text]

40. Richardson J, Smith JE, McCall G, et al: Hypnosis for procedure-related pain and distress in pediatric cancer patients: A systematic review of effectiveness and methodology related to hypnosis interventions. J Pain Symptom Manage 31:70-84, 2006[CrossRef][Medline]

Submitted April 4, 2007; accepted July 10, 2007.

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This Article Abstract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vickers, J. Articles by Hain, R. Search for Related Content PubMed PubMed Citation Articles by Vickers, J. Articles by Hain, R. Social Bookmarking                            What's this?