title: Physician Perspectives on Palliative Care for Children With Neuroblastoma: An International Context.
abstract: BACKGROUND
  Studies have shown that children with cancer globally lack access to palliative care. Little is known regarding physicians' perceptions of palliative care, treatment access, and self-reported competence in providing palliative care.
  
  
  METHODS
  Members of the Global Neuroblastoma Network (online tumor board) were surveyed. Eighty-three respondents met inclusion criteria; 53 (64%) completed the survey.
  
  
  RESULTS
  Most respondents trained in high-income countries (HIC) but practice in low- and middle-income countries (LMIC), and care for more than five patients with neuroblastoma annually. WHO Essential Medicines in palliative care varied in availability, with incomplete access across LMIC centers. Nonpharmacologic therapies were inconsistently available. Contrary to international definitions, 17% of respondents inappropriately considered palliative care as that initiated only after curative therapy is stopped. Mean physician competence composite score (Likert scale 1-5, 5 = very competent) in providing symptomatic relief and palliative care across phases of care was 2.93 (95% CI 2.71-3.22). Physicians reported significantly greater competence in symptom management during cure-directed therapy than during end-of-life (P = 0.02) or when patients are actively dying (P = 0.007). Practicing in HIC, prior palliative care training, having access to radiotherapy, and not having to turn patients away due to bed shortages were significantly predictive of perceived competence in providing palliative care at end of life.
  
  
  CONCLUSIONS
  An international sample identified gaps in treatment and palliative care service availability, in understanding the definition of palliative care, and in self-reported competence in providing palliative care. Increased perceived competence was associated with training, which supports the need for increased palliative care education and advocacy, especially in LMIC.
authors.affiliation: Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California.
authors.forename: Emily M
authors.initials: EM
authors.lastname: Balkin
authors.affiliation: Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California.
authors.forename: Daria
authors.initials: D
authors.lastname: Thompson
authors.affiliation: Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California.
authors.forename: K Ellicott
authors.initials: KE
authors.lastname: Colson
authors.affiliation: Department of Oncology and International Outreach Program, St. Jude Children's Research Hospital, Memphis, Tennessee.
authors.forename: Catherine G
authors.initials: CG
authors.lastname: Lam
authors.affiliation: Division of Pediatric Hematology/Oncology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California.
authors.forename: Katherine K
authors.initials: KK
authors.lastname: Matthay
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D038622:Internationality; D008297:Male; D016743:Mental Competency; D008875:Middle Aged; D009447:Neuroblastoma / Q000628:therapy*; D010166:Palliative Care; D010820:Physicians; D011795:Surveys and Questionnaires
keywords: global oncology; neuroblastoma; palliative care; pediatric hematology/oncology; pediatric palliative care