Inequities in Pediatric Palliative Care: Where Are the Consults?*

Abstract

Racial and ethnic inequities are well documented in medicine (1). Patients from historically marginalized groups have consistently reported medical mistrust, poor communication, and perceived discrimination as barriers to the care that they receive (2, 3). Pediatrics is no exception with racial and ethnic differences noted in the treatment of numerous conditions, including cancer and conditions treated in the PICU (4, 5).Pediatric palliative care (PPC) is a specialty that strives to prevent or ease distress while maximizing quality of life for children with life-threatening conditions, as well as their families, throughout the trajectory of a child's illness (6). Though PPC is not specific to end of life (EOL), the utilization of these resources at EOL leads to improved outcomes for families (6). In children who undergo hematopoietic stem cell transplantation (HSCT), PPC is associated with less intervention-focused care and greater opportunity for improved EOL communication and advance preparation (6).In this issue of Pediatric Critical Care Medicine, McKee et al (7) report their findings from a retrospective cohort study using the Pediatric Health Information System database to investigate racial and ethnic differences in the utilization of inpatient palliative care consultation for children that underwent HSCT. The authors found that pediatric Hispanic/Latinx patients were 59% less likely to receive inpatient palliative care consultation compared with non-Hispanic White patients (7). Non-Hispanic Black patients also had lower odds of receiving inpatient palliative care consultation, but this result did not achieve significance (7). In contrast, high-acuity patients such as those with a malignant condition or those placed on mechanical ventilation had roughly two times increased odds of receiving inpatient palliative care consultation (7).Hispanic/Latinx children incur lower expenditures in hospice care than non-Hispanic/Latinx children, suggesting barriers to receiving PPC services or delays in care (8). In a review of PPC for Hispanic/Latinx children and their families, Muñoz-Blanco et al (9) explain that Hispanic/Latinx patients and families face numerous barriers to PPC including poverty, lack of access to health insurance, language barriers, discrimination, and cultural differences. These barriers are further perpetuated by scarce and underfunded clinical initiatives and research that target the needs of Hispanic/Latinx families.McKee et al (7) are to be commended for acknowledging racism that exists in medicine throughout their discussion. They provide historical context by referencing segregated hospital systems in the era of Jim Crow and describe persistent resource rationing within the U.S. healthcare system today (7).

Editor’s Choice Articles for April

“…The accompanying editorial is a landmark publication in my view–please read (20). Finally, finish your review of PCCM ’s recent literature on SDOH by exploring our articles about socioeconomic disadvantage with racial and ethnic differences in access for pediatric critical care (21), mechanical ventilation (22), pediatric ECMO (23), and inpatient palliative care for pediatric stem cell transplant (24)–and don’t overlook the three editorials accompanying this material (25–27).…”