RESUMO

OBJECTIVES: To characterize delivery of goal-concordant end-of-life (EOL) care among children with complex chronic conditions and to determine factors associated with goal-concordance. STUDY DESIGN: This was a retrospective review of goals of care discussions for 272 children with at least 1 complex chronic condition who died at a tertiary care hospital between January 1, 2014, and December 31, 2017. Goals of care and code status were assessed before and within the last 72 hours of life. Goals of care discussions were coded as full interventions; considering withdrawal of interventions (palliation); planned transition to palliation; or actively transitioning/transitioned to palliation. RESULTS: In total, 158 children had documented goals of care discussions before and within the last 72 hours of life, 18 had goals of care discussions only >72 hours before death, 54 only in the last 72 hours of life, and 42 had no documented goals of care. For children with goals of care, EOL care was goal-concordant for 82.2%, discordant in 7%, and unclear in 10.8%. Black children had a greater than 8-fold greater odds of discordant care compared with White children (OR 8.34, P = .007). Comparison of goals of care and code status before and within the last 72 hours of life revealed trends toward nonescalation of care. Specifically, rates of active palliation increased from 11.7% to 63.0%, and code status shifted from 32.6% do not resuscitate to 65.2% (P < .001). CONCLUSIONS: In this cohort, a majority of children had documented goals of care discussions and received goal-concordant EOL care. However, Black children had greater odds of receiving goal-discordant care. Goals of care and code status shifted toward palliation during the last 72 hours of life.

Assuntos

Cuidados Paliativos na Terminalidade da Vida , Assistência Terminal , Humanos , Criança , Objetivos , Ordens quanto à Conduta (Ética Médica) , Doença Crônica

RESUMO

Numerous previous studies have reported positive associations between exposure to greenspace and children's physical activity, but in high-income countries only. Prior studies have also examined greenspace and obesity in children, but these have yielded inconsistent results and focused mostly on older children. The purpose of this study was to assess associations between time children spent in greenspace as the primary exposure and our outcomes of interest, including 1) minutes of physical activity, and 2) body mass index (BMI) z-score. Our sample was 102 children ages 3 to 5 years living in Ensenada and Tijuana, Mexico. We fit linear mixed models to estimate associations between greenspace and children's physical activity and BMI z-score. After adjustment for potential confounders, greater time in greenspace was associated with decreased sedentary time (-0.08 min per hour for each additional 30 min in greenspace; 95% CI -0.13, -0.04; p = 0.002) and increased moderate-to-vigorous physical activity (MVPA) (0.06; 95% CI 0.03, 0.10; p < 0.001). Results were driven primarily by children in Tijuana (-0.22; 95% CI -0.38, -0.06; p = 0.008 for sedentary time and 0.15; 95% CI 0.06, 0.38; p = 0.007 for MVPA). Time in greenspace was not associated with BMI z-score in children in Ensenada (0.001; 95% CI -0.008, 0.01; p = 0.83) or Tijuana (-0.009; 95% CI -0.02, 0.004; p = 0.17). Greater time in greenspace was associated with physical activity but not BMI in our sample of children-more so in Tijuana compared to Ensenada. Given high rates of obesity, interventions should aim to increase physical activity in young children in Northern Mexico.