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Pediatric Palliative Care Curriculum
Blaine Pitts, MDLeslie Meadows, MA, MT-BC
Barb Greenwood, MA, ATR-BC
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What affects a child’s coping and understanding?
Developmental ageFamily dynamics
Fear of the unknown/knownIsolation
Support systemCommunication ability and style
Amount of choice availableCulture
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What is Expressive Therapy ?
A therapeutic process designed to act as a catalyst,giving an individual the ability to communicate
wants, needs and feelings.
Music Therapy, Art Therapy, Drama Therapy, Dance Therapy, Poetry Therapy
Different from performance or education
Process oriented vs. product oriented
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Expressive Therapy Goals in Pediatric Healthcare
Decrease anxiety and fear Improve coping through choice and control Alleviate pain Increase emotional expression Decrease feelings of isolation Improve socialization skills Strengthen and improve communication Improve family dynamics surrounding
treatment Experience feeling of community Provide comfort and a legacy at the end of
life
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Music Therapyis the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program (AMTA).
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Music Therapy Interventions
Improvisation Therapeutic Singing Song Choice Instrument Playing Composition/Song
Writing Guided Imagery and
Music Music Listening Lyric Analysis
GROUP
vs.
INDIVIDUAL
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Case Study
Dialysis Patient 16 years old Complex family
dynamics 11 sessions
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Case Study #1 16 y/o Hispanic AA M w/ hx of b/l renal
dysplasia s/p cadaver renal transplant 05 w/ acute rejection 08 related to non-compliance
Nephrology made CSB referral RN visits twice a day for medication
administration Palliative Care consult for family support and
care coordination6 inpt admissions in past 2 years prior to PC
Non-compliant with diet and fluid requirement Recently needed transplant nephrectomy Currently receives dialysis
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Case Study #1 Soc/Fam Hx:
Lives with mother, younger twin sisters, older half-sister and her toddler
His mother has chronic back pain from a MVAYounger sister was raped and since that time his
mother has not workedHis mother is the main caregiver for his sister’s
toddlerBoth younger twin sisters have ADHDMany financial difficulties related to pt’s illness
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Case Study #1 Soc/Fam Hx:
Talks w/ biologic father but is minimally involved secondary to being accused of younger sister’s rape
CSB referral for medical neglect but also concerns over corporal punishment threats
Mother is close to MGM who lives in Puerto Rico○ Pt is also close with MGM
Usually attends dialysis alone
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Case Study #1 Dev/School Hx:
Is developmentally delayed to level of 7 y/oAttends 9th grade w/ special ed (IEP)Frequent school absences secondary to
illness and dialysisStill having incontinence despite neg
medical work-up○ Frustrating for his mother○ Poor personal hygiene
Pressured speech & voice inappropriate for age
Difficult w/ attention span
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Case Study #1
How can music therapy bebeneficial with this patientand family?
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Therapeutic Songwriting
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Future Goals for MT
Explore relevant cultural and spiritual music
Continue to address academic issues through music interventions
Develop adapted music skills Encourage and support greater depth of
emotional expression Improve speech pacing and vocal affect
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What is Art Therapy ?
Art Therapy is a mental health profession that uses the creative process of art making to improve and enhance the physical, mental and emotional well-being of individuals of all ages. It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behavior, reduce stress, increase self-esteem and self-awareness, and achieve insight. (AATA)
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Expressive Therapy Continuum
Sensory-Kinetic Control-Fluid
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Creative Process Symbolic imagery and
metaphor
Cognitive restructuring
Increases discussion
Non threatening way to promote spontaneity
Self-satisfaction and autonomy
Safe container
Archive the story
Helps find solutions
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Case Study
Oncology Patient
7 years old 2 siblings, 2
parents 12 sessions
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Case Study #2 7 y/o male w/ Stage IV Wilm’s tumor w/
pulmonary mets (dx 1/07) s/p L nephrectomy s/p abdominal radiation & chemo
Recent RLL pulm recurrence s/p resection & radiation (6/10)
Admitted for HDCT w/ auto stem cell rescue (10/10)
No significant prior medical history
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Case Study #2 Palliative care consult for pain
management Transplant-associated mucositis
managed with Dilaudid PCA (had AE w/ morphine)
Had psychosis/agitation associated with steroids
Bacteremia x 2 episodes Otherwise did well & was D/C on
Oxycodone prn
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Case Study #2 On Day +55 s/p stem cell rescue he
presented to clinic w/ dyspnea w/ associated chest pain & emesis intermittently
Large pericardial effusion found w/ diagnosis of thrombotic microangiopathy (TMA)
PICU transfer for further managementPericardial drain placedHypertension difficult to manage
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Case Study #2 His TMA was managed w/
plasmapheresis, dialysis, Rituximab, and steroids
Palliative care was consulted for pain management Managed with scheduled/intermittent DilaudidPain was in R leg, b/l arms, and abdomen
with associated anorexiaAbdominal pain progressively became his
only source of pain ○ Not responsive to opioids ○ No clear etiology
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Case Study #2 During his course, he became more
non-compliant with staffMedication administration, obtaining vital
signs, procedures, and therapies (OT/PT) Psychosocial Hx:
Lives w/ his parents who are not marriedHas 2 sistersParents would occasionally enable
behaviors
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Case Study #2
How can art therapy bebeneficial with thispatient and family?
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