Jill Ann Jarrell

Adolescents and young adults (AYAs) diagnosed with cancer experience unique psychosocial distress and worse clinical outcomes compared to their younger and older peers. Additionally, the developmental emergence of identity and independence for AYAs—and the effects of oncology therapy on these milestones—adds complexity to communication and medical decision-making among patients and families. Given these circumstances, AYAs require thoughtful approaches for advance care planning (ACP). In many cases, specialty palliative care (SPC) teams can provide an extra layer of support to both patients and families as well as primary oncology teams in navigating ACP and ensuring goal-concordant care. While some adult studies have recently questioned the effectiveness of standard ACP methods, other new investigations specifically in the AYA cancer population have demonstrated multifaceted benefits. With the understudied nature of both ACP techniques and the AYA population in general and the constant evolution of communication preferences in the digital technology era, pediatric oncology clinicians may be unsure of current best practices for how to guide their older patients during conversations about their illness. We aim to review the most recent evidence regarding ACP for AYAs with cancer, with an emphasis on describing practical bedside tools and the advantages of collaborating with SPC teams to promote optimal outcomes.

Background: Implicit bias pervades health care, decreases quality of care, and disproportionately affects health outcomes for persons of color. Little is known about the use of biased language in the care of seriously ill children as documented in the electronic health record (EHR). Objective: To describe the use of biased language in the EHR of critically ill pediatric patients and to assess if there is a difference based on patient demographics and clinical characteristics. Setting/Participants: A retrospective review of EHRs was conducted on patients admitted to a Pediatric Intensive Care Unit (PICU) with a palliative care consult at a large, urban academic center in the United States in 2019. Measurements: Demographics and clinical characteristics were compared between patients with and without biased language in their EHR in univariate and multivariate analyses. Frequencies of descriptor usage and health care team members using the descriptor were recorded. Exemplar quotes using biased language were recorded. Results: In 63 patients, no differences were found in demographic or clinical characteristics between patients with and without positively and negatively biased language. In adjusted analysis, there was no effect of demographics or clinical characteristics on the odds of having at least 1 instance of negatively biased language. Physicians and social workers used more biased language than other health care team members. Conclusion: Despite no statistically significant difference noted in this pilot study, linguistic biases exist in the EHR of seriously ill children, which may lead to testimonial injustice. Efforts to combat bias and racism in pediatric health care documentation may focus on revising note templates and educating across disciplines.

Cancer in adolescents and young adults is associated with an increased risk for suicidal ideation (SI). There are no reported pediatric oncology cases describing management of SI during end of life. We present the case of a 14‐year‐old male with relapsed, high‐risk, B‐cell acute lymphoblastic leukemia who received a haploidentical stem cell transplant and was suicidal at various points in his treatment. We discuss how to manage acute suicidality in this patient population, the importance of giving a voice to the adolescent patient, the impact of discordant goals of care, and potential preventive strategies for similar cases.

Background: Hospice and palliative medicine is important in the education of pediatric residents. Little is known about if and how residents' learnings during a pediatric palliative care elective fulfill core competencies and Pediatrics subcompetencies as set forth by the Accreditation Council for Graduate Medical Education (ACGME) and published subspecialty competencies for residents in pediatric hospice and palliative medicine (pHPM). Objectives: To evaluate what residents are learning on a four-week pediatric palliative care elective rotation at a single institution and how these learnings fulfill ACGME and pHPM competencies. Setting/Subjects: Prompted, written reflections were collected from residents completing a pediatric palliative care rotation at a large, urban academic center in the United States between academic years 2016–2017 and 2020–2021. Measurements: A qualitative, inductive reasoning approach was used to analyze reflections for emergent themes and codes. A deductive approach was used to map resulting codes to ACGME core competencies, Pediatric subcompetencies, and pHPM competencies. Results: Twenty-five resident reflections were collected. Inductive analysis revealed three primary themes and 102 codes. These codes were mapped to all six ACGME core competencies and mapped to most Pediatric subcompetencies with the exception of performing a physical examination, organizing and prioritizing patients, diagnostic evaluation, and community and population health. Codes mapped to most pHPM competencies with the exception of two symptom-based competencies, malignant bowel obstruction and severe fatigue. Conclusions: Residents' written reflections following a pediatric palliative care elective rotation demonstrated robust learnings that fulfill many core, specialty, and subspecialty competencies, particularly those that relate to patient- and family-centered care, communication, professionalism, and systems-based practice.

Kombucha, a domesticated consortium of several microorganisms grown on sugared tea, has been valued as a nutritive health aid for over a millennium. In this study, three cultures of kombucha were obtained from diverse sources. Different inoculation methods were compared, and the wet and dry weights of the nascent pellicles were measured when cultured on several carbon sources. In addition, the anti-bacterial properties of the fermented kombucha teas were tested against Escherichia coli and Staphylococcus epidermis. Inoculation with macerated pellicles gave the fastest kombucha growth. The best carbon sources for growth of the nascent kombucha pellicles were sucrose, glucose, and fructose. On maltose, galactose, and lactose, not only did the kombucha pellicles grow poorly but 25% were also contaminated by common airborne molds. Good growth of the kombucha cultures was correlated with low pH of the fermented tea. Antibacterial effects of concentrated fermented teas and vinegar were similar to those of 1 mmol ampicillin against Escherichia coli or 0.01 mmol penicillin against Staphylococcus epidermis. When the pH of concentrated kombucha teas was neutralized, their bactericidal effects were no better than unfermented controls.