title: Understanding of prognosis among parents of children who died of cancer: impact on treatment goals and integration of palliative care.
abstract: BACKGROUND
  Parents' understanding of prognosis or decision making about palliative care for children who die of cancer is largely unknown. However, a more accurate understanding of prognosis could alter treatment goals and expectations and lead to more effective care.
  
  
  OBJECTIVE
  To evaluate parental understanding of prognosis in children who die of cancer and to assess the association of this factor with treatment goals and the palliative care received by children.
  
  
  METHODS
  Survey, conducted between September 1997 and August 1998, of 103 parents of children who received treatment at the Dana-Farber Cancer Institute and Children's Hospital, Boston, Mass, and who died of cancer between 1990 and 1997 (72% of those eligible and those located) and 42 pediatric oncologists.
  
  
  METHODS
  Timing of parental understanding that the child had no realistic chance for cure compared with the timing of physician understanding of this prognosis, as documented in the medical record.
  
  
  RESULTS
  Parents first recognized that the child had no realistic chance for cure a mean (SD) of 106 (150) days before the child's death, while physician recognition occurred earlier at 206 (330) days before death. Among children who died of progressive disease, the group characterized by earlier recognition of this prognosis by both parents and physicians had earlier discussions of hospice care (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06; P =.01), better parental ratings of the quality of home care (OR, 3.31; 95% CI, 1.15-9.54; P =.03), earlier institution of a do-not-resuscitate order (OR, 1.03; 95% CI, 1.00-1.06; P =.02), less use of cancer-directed therapy during the last month of life (OR, 2.80; 95% CI, 1.05-7.50; P =.04), and higher likelihood that the goal of cancer-directed therapy identified by both physician and parent was to lessen suffering (OR, 5.17; 95% CI, 1.86-14.4; P =.002 for physician and OR, 6.56; 95% CI, 1.54-27.86; P =.01 for parents).
  
  
  CONCLUSIONS
  Considerable delay exists in parental recognition that children have no realistic chance for cure, but earlier recognition of this prognosis by both physicians and parents is associated with a stronger emphasis on treatment directed at lessening suffering and greater integration of palliative care. JAMA. 2000;284:2469-2475.
authors.affiliation: Center for Outcomes and Policy Research and Department of Pediatric Oncology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115, USA. joanne_wolfe@dfci.harvard.edu
authors.forename: J
authors.initials: J
authors.lastname: Wolfe
authors.forename: N
authors.initials: N
authors.lastname: Klar
authors.forename: H E
authors.initials: HE
authors.lastname: Grier
authors.forename: J
authors.initials: J
authors.lastname: Duncan
authors.forename: S
authors.initials: S
authors.lastname: Salem-Schatz
authors.forename: E J
authors.initials: EJ
authors.lastname: Emanuel
authors.forename: J C
authors.initials: JC
authors.lastname: Weeks
mesh_terms: D000328:Adult; D001293:Attitude to Death; D002648:Child; D003625:Data Collection; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D009369:Neoplasms / Q000401:mortality / Q000628:therapy; D010166:Palliative Care; D010290:Parents / Q000523:psychology*; D010820:Physicians / Q000523:psychology; D011379:Prognosis; D012044:Regression Analysis; D019452:Terminally Ill