Background
Despite medical advancements and intensive research into therapy and treatment, some children’s illnesses such as cancer, neurological conditions, and other progressive, life-threatening disorders remain incurable even in developed countries. Worldwide, children with progressive, serious illnesses estimate one-third of yearly child mortalities [
1]. International mortality rates for these disorders vary between hundreds of children per year for small-population countries and thousands of children per year for largely populated countries [
1]. Moreover, prevalence of children dying due to serious illness seems to be on the rise: an increase of 25 to 32 per 10,000 population was reported in England between 2000 and 2010 [
2].
The symptom burden at the end of life in these children is found to be very high [
3‐
6]. Symptoms and care needs at the end of life have been studied extensively for malignancies [
3,
5,
6], with pain, fatigue, dyspnea, and anorexia often cited, but less so for other disease trajectories [
4], where the scarce research seems to show distinct symptoms at the end of life such as numbness and breathing problems [
4]. The most frequently reported symptoms are not only physical, such as pain and dyspnea, but also psychological, such as nervousness and worrying [
4‐
6]. Due to high symptom burden, many researchers and clinicians advocate more extensive development of supportive and end-of-life care for this population.
According to the American Academy of Pediatrics, family-centered, child- and disease-specific supportive care for children should be broadly available, and well-integrated within the disease trajectory [
7]. However, there are indications children often do not receive supportive care when dying, among which care at the end of life. A recent systematic review indicated almost half of children with cancer did not receive palliative care at the end of life [
8], even though palliative care is indicated to improve patient outcomes [
9,
10]. Children tend to receive intense aggressive care in the last weeks of life [
11‐
14], while symptom control for pain, fatigue, and dyspnea has been shown to be insufficient [
5]. Increased attention for supportive care measures for children in recent decades may have spurred improvement: a 1997–2004 US follow-up cohort of children suffered less from pain and dyspnea than a cohort from 1990 to 1997, possibly due to improvement in end-of-life care management for children [
5]. Nevertheless, various studies have reported ongoing issues for children at the end of life such as low accessibility to pediatric palliative care services [
15], lack of communication between care professionals [
16], insufficient resources and training [
17], and absence of children-specific quality measures [
11,
18]. Children globally lack access to supportive care measures [
19], and while low access to palliative care is associated in general with low-income countries [
20,
21], also high-income countries such as Canada can struggle with accessibility to supportive care due to, e.g., wide geography [
22]. Challenges for supportive care for children at the end of life differ overall between high-, middle-, and low-income countries, with low-income country challenges often relating to the lack of resources and finances, and high-income countries focusing on improvement and continuity of care [
22].
To further improve quality of life at the end of life for seriously ill children, we need more insight into the health interventions that influence quality of life at the end of life. However, there is a lack of knowledge about what health interventions, e.g., medication or palliative care, can influence quality of life at the end of life exactly, e.g., outcomes such as pain or anxiety. Knowing what health interventions are appropriate and inappropriate will enable the development of quality indicators of this care. Quality indicators are measurable items referring to the outcomes, processes, or structure of care. They can be used to monitor, assess, benchmark, and eventually improve appropriate and inappropriate end-of-life care for children. Multiple quality indicators were already established for adult end-of-life care, and one such indicator for inappropriate care for cancer patients is a blood transfusion in the last month before death [
23].
A first step in developing validated sets of quality indicators is to systematically review the literature describing the health interventions that influence quality of life in seriously ill children at the end of life. To our knowledge, there is no systematic overview to date of known health interventions that have an influence—whether negative, neutral, or positive—on quality of life at the end of life in children’s care. Available reviews in seriously ill children are limited in that they mainly focus on health interventions and associated quality-of-life outcomes in a curative phase, but not terminal or end-of-life phase [
3,
24,
25], or they focus only on the association between one health intervention and quality of life, such as the identification of benefits of specialized pediatric palliative care services [
4] and do not provide an overview of other health interventions at the end of life. Individual studies of various health interventions and associations or impact on quality of life at the child’s end of life are available but have not yet been systematically reviewed, summarized, or assessed for quality or bias. This makes it difficult to scan the entire body of evidence for quality, gaps, and effects for subgroups. For instance, the influence of health interventions could differ in terms of disease and age—differences are likely to arise between cancer patients and those suffering of neurological disorders, or between toddlers and teenagers. Therefore, we will conduct this comprehensive systematic review on the influence of various health interventions for seriously ill children at the end of life, identifying all available evidence that associates health interventions with quality of life at the end of life in seriously ill children in quantitative empirical designs. The results of the systematic review will become one pool of candidate quality indicators from which final quality indicators will be chosen and face-validated using the RAND/UCLA (Research ANd Development corporation/University of California Los Angeles) Appropriateness Method, a modified Delphi panel method.
This study protocol has drawn upon the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines for the reporting of systematic review protocols. Any updates will be provided through the PROSPERO registry of systematic reviews.
Discussion
To our knowledge, no systematic review of studies has yet been conducted that looks into the influence of health interventions on quality of life at the end of life in seriously ill children. This systematic review will add to the construction of a reliable and valid evidence base to be utilized in children’s end-of-life research and in health care policy to improve quality of life and care. As part of a larger project on quality indicators, the review is a primary step in the construction of a set of quality indicators for care for children at the end of life for multiple disease groups, pending face-validation, and expert consensus. Quality indicators are regarded as a valid tool to monitor care standards with the use of population-level data [
33]. We will apply the quality indicators to population-level data for deceased seriously ill children in Flanders and compare results on quality indicators for the different populations, settings, and regions. Additionally, we will benchmark care between different health regions for all indicators to set performance standards and norms that can eventually lead to actual improvement of care. This review protocol is published to allow other researchers to compare previously established methods to the final review, promoting quality adherence, and to facilitate future updates of the review to keep quality indicators up-to-date by identifying any new potential quality indicators arising in future quantitative empirical studies.
Expected limitations of the review are differences in patient and disease characteristics, and the exclusion of qualitative studies and process- and structure-related outcomes. Care for children at the end of life is a heterogeneous field in terms of disease etiology, progression, and age—for instance, the developmental gap between young children and adolescents is likely to lead to differences in the influence of health interventions. Due to limited patient availability, study samples are often likely to contain children with various etiologies and in various disease stages. We will ensure subgroup analyses in our narrative and numerical analyses whenever possible. Our exclusion criteria omit qualitative studies and process- and structure-related quality-of-life outcomes, and this omission may bias the evaluation of the evidence base. However, we believe the analysis of the qualitative studies requires a distinctly different approach than the analysis of the quantitative studies, and systematic reviews are regularly limited to the synthesis of quantitative papers. As quantitative outcomes will already provide sufficient material for synthesis, qualitative studies are therefore better discussed and synthesized in a separate study. We acknowledge, however, that the addition of qualitative designs can only broaden our understanding of the current evidence base of the influence of health interventions on quality of life in seriously ill children, and therefore, we plan on conducting an additional scoping review that summarizes outcomes found in qualitative studies. We urge that process and structure outcomes be looked into systematically as well, as these outcomes could also significantly implicate end-of-life care in children at the end of life.
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