Clinician Identified Barriers and Strategies for Advance Care Planning in Seriously Ill Pediatric Patients.

CONTEXT: Parents desire more opportunities for advance care planning (ACP), however, large-scale adoption of ACP for seriously ill children remains unrealized. Little is known about current approaches to ACP and strategies to circumvent existing barriers to ACP provision. OBJECTIVE: To explore multidisciplinary clinician perceptions about perceived barriers and strategies to improve ACP provision. DESIGN: Qualitative study including focus groups conducted with multidisciplinary clinicians at two centers from December 2018-April 2019. Iterative multi-stage thematic analyses were utilized to identify key contexts and themes pertaining to current approaches to ACP, as well as clinician perspectives on ACP barriers and improvement strategies. RESULTS: Thirty-five clinicians (physicians, nurses, and psychosocial clinicians) participated in identifying both clinician and perceived patient and family barriers to initiating and engaging in ACP discussions, including mixed messaging, lack of knowledge of patient and family goals, prognostic uncertainty, poor prognostic awareness, unstandardized documentation, and family dynamics. Clinicians also identified strategies to overcome these barriers and to facilitate ACP discussions, including enhancing multidisciplinary communication, creation of a shared ACP communication framework, and formal training in ACP communication to normalize ACP throughout a child's disease trajectory. CONCLUSION: Despite ubiquitous recognition of the importance of ACP communication, various clinician- and parent-level barriers were identified which impede ACP in children with serious illness and their families. Improvement strategies should focus on formal clinician training on how to conduct and document longitudinal ACP discussions to ensure care is aligned with family goals and values.

Plastid osmotic stress activates cellular stress responses in Arabidopsis.

Little is known about cytoplasmic osmoregulatory mechanisms in plants, and even less is understood about how the osmotic properties of the cytoplasm and organelles are coordinately regulated. We have previously shown that Arabidopsis (Arabidopsis thaliana) plants lacking functional versions of the plastid-localized mechanosensitive ion channels Mechanosensitive Channel of Small Conductance-Like2 (MSL2) and MSL3 contain leaf epidermal plastids under hypoosmotic stress, even during normal growth and development. Here, we use the msl2 msl3 mutant as a model to investigate the cellular response to constitutive plastid osmotic stress. Under unstressed conditions, msl2 msl3 seedlings exhibited several hallmarks of drought or environmental osmotic stress, including solute accumulation, elevated levels of the compatible osmolyte proline (Pro), and accumulation of the stress hormone abscisic acid (ABA). Furthermore, msl2 msl3 mutants expressed Pro and ABA metabolism genes in a pattern normally seen under drought or osmotic stress. Pro accumulation in the msl2 msl3 mutant was suppressed by conditions that reduce plastid osmotic stress or inhibition of ABA biosynthesis. Finally, treatment of unstressed msl2 msl3 plants with exogenous ABA elicited a much greater Pro accumulation response than in the wild type, similar to that observed in plants under drought or osmotic stress. These results suggest that osmotic imbalance across the plastid envelope can elicit a response similar to that elicited by osmotic imbalance across the plasma membrane and provide evidence for the integration of the osmotic state of an organelle into that of the cell in which it resides.