Shared Decision Making in Pediatrics: A Systematic Review and Meta-analysis

Exploring the ethical complexity of pediatric organ transplant candidates and COVID-19 vaccination: Tensions between autonomy and beneficence, children and parents

BACKGROUND

POT is emotionally sensitive due to cohort vulnerability, their lack of decisional capacity, and waitlist mortality. The COVID-19 pandemic has added complexity to the setting of pediatric transplantation, as well as living donation, due to tensions about COVID-19 vaccination for recipients, donors, and parent-caregivers.

METHODS

In the context of COVID-19 vaccination, two ethicists present four pediatric donation and transplant dilemmas for ethical exploration and offer guidance to clinical teams, noting that mandates are controversial, and there is no global harmonization regarding requirements.

RESULTS

As with all vaccinations, they are a tool of organ stewardship aimed to optimize outcomes and, in the setting of pediatrics, ensure optimal caregiving for these vulnerable recipients. Current evidence supports the ethical permissibility of COVID-19 vaccination mandates for transplant candidates aged 6 months and older.

CONCLUSION

Our guidance considers the tensions of autonomy and beneficence and the ethical duty of organ stewardship. The harms of being unvaccinated and risking the harms of COVID-19 and long-COVID post-transplant support the ethical permissibility of vaccination mandates in countries where the vaccine has pediatric regulatory approval.

Reviewing next of kin regrets in surgical decision-making: cross-sectional analysis of systematically searched literature

BACKGROUND

Decision-making concerning relatives undergoing surgery is challenging. It remains unclear to what extent implicated next of kin eventually regret their decisions and how this regret is assessed. Our aim was to systematically review the literature on decisional regret of next of kin and to describe the assessment tools used and the surgical populations studied.

METHODS

We included interventional or observational, quantitative or qualitative studies reporting the measurement of decisional regret of next of kin concerning relatives undergoing surgery. We searched a variety of databases without restriction on publication year. We assessed the quality of reporting of quantitative studies using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and of qualitative studies using the Critical Appraisal Skills Program Checklist.

RESULTS

Thirteen cross-sectional, five prospective cohorts and five qualitative studies matched our inclusion criteria. In 18 studies (78%), patients were children, in five (22%), young or middle-aged adults. No study included elderly or frail patients. Thirteen studies (57%) used the original Decision Regret Scale which was validated for patients, but not for next of kin. Only 3 of the 18 (17%) quantitative studies and only one of the 4 (25%) qualitative studies were rated as "good" in the quality assessment.

CONCLUSION

None of the retrieved studies used validated tools to assess the decisional regret of next of kin and none of them examined this issue in elderly or frail surgical patients.

How do we best engage young people in decision-making about their health? A scoping review of deliberative priority setting methods

INTRODUCTION

International organisations have called to increase young people's involvement in healthcare and health policy development. We currently lack effective methods for facilitating meaningful engagement by young people in health-related decision-making. The purpose of this scoping review is to identify deliberative priority setting methods and explore the effectiveness of these in engaging young people in healthcare and health policy decision-making.

METHODS

Seven databases were searched systematically, using MeSH and free text terms, for articles published in English before July 2021 that described the use of deliberative priority setting methods for health decision-making with young people. All titles, abstracts and full-text papers were screened by a team of six independent reviewers between them. Data extraction followed the Centre for Reviews and Dissemination guidelines. The results are presented as a narrative synthesis, structured around four components for evaluating deliberative processes: 1) representation and inclusion of diverse participants, 2) the way the process is run including levels and timing of participant engagement, 3) the quality of the information provided to participants and 4) resulting outcomes and decisions.

FINDINGS

The search yielded 9 reviews and 21 studies. The more engaging deliberative priority setting tools involved young people-led committees, mixed methods for identifying and prioritising issues and digital data collection and communication tools. Long-term and frequent contact with young people to build trust underpinned the success of some of the tools, as did offering incentives for taking part and skills development using creative methods. The review also suggests that successful priority setting processes with young people involve consideration of power dynamics, since young people's decisions are likely to be made together with family members, health professionals and academics.

DISCUSSION

Young people's engagement in decision-making about their health is best achieved through investing time in building strong relationships and ensuring young people are appropriately rewarded for their time and contribution. If young people are to be instrumental in improving their health and architects of their own futures, decision-making processes need to respect young people's autonomy and agency. Our review suggests that methods of power-sharing with young people do exist but that they have yet to be adopted by organisations and global institutions setting global health policy.

Teaching the Skill of Shared Decision Making Utilizing a Novel Online Module: A Pilot Randomized Controlled Study

OBJECTIVES

In this pilot study, we developed and tested an online educational module for the purpose of teaching optimal shared decision making (SDM) behaviors for physicians in training. We hypothesized that those who received this intervention would show significant improvement in SDM behaviors afterward as compared with those who had not received the intervention.

METHODS

Pediatric subspecialty fellows (pediatric critical care medicine, neonatology, hematology and oncology, and pulmonology) at the Monroe Carell Jr Children's Hospital at Vanderbilt were eligible to participate, if approved by their respective program directors. Design was a randomized crossover trial of an online educational module to promote behaviors essential to SDM. Participants were randomized by subspecialty. Experts in clinical communication blinded to participants' study arms evaluated SDM behaviors in video-taped clinical simulations with standardized parent dyads. The study protocol was approved by the Vanderbilt University Institutional Review Board.

RESULTS

Participants receiving the intervention were approximately 40 times more likely to improve their subsequent total score when compared with simply repeating the simulation alone (95% confidence interval, 1.72-919.29; P = .022).

CONCLUSIONS

This pilot study demonstrates that an online, interactive module can be an effective way of teaching the skill of SDM to pediatric subspecialty trainees. Tools like this one could help overcome the limitations inherent in currently published SDM resources and meet the need for interventions with demonstrated effectiveness, helping to increase the utilization of SDM skills by providing primary or supplemental education at institutions across the resource spectrum.

Experiences with the end-of-life decision-making process in children with cancer, their parents, and healthcare professionals: A systematic review and meta-ethnography

BACKGROUND

Decision-making during the end-of-life (EOL) phase for children with cancer is extremely difficult for parents. We synthesized the qualitative experiences of children with cancer, parents, and healthcare professionals (HCPs), and their social interactions during the EOL decision-making process in the pediatric oncology setting.

METHODS

Meta-ethnography was used to conduct a systematic review and meta-synthesis. We searched four online databases to identify original studies published in English and Japanese and examined 21 relevant studies. Two Japanese reviewers discussed the differences/relationships and included studies that synthesized the translated qualitative findings. A conceptual model of social interactions was created.

RESULTS

We identified four themes regarding children's, parents', and HCPs' experiences: hope and confrontation with the child's death, guidance and support during uncertainty, awareness of being protected and having hope, and mutual unspoken integration of values.

CONCLUSIONS

These themes evince the experiences of children, parents, and HCPs during the EOL decision-making process and suggests a complex three-way social interaction model. While considering such distinctive social interactions during a child's EOL, this study revealed the sharing of prudent information and psychosocial support by HCPs. The findings indicate that hope and uncertainty are key elements for effectively understanding the experiences of children and parents and that EOL decision-making should not be rushed but should be supported by leaving room for uncertainty and acknowledging parents' emotional needs and fostering new hope. Further research into how hope can be further supported in situations that are rife with uncertainty is needed.

Collaborative decision-making: A framework for decision-making about life-sustaining treatments in children with medical complexity

OBJECTIVE

Caregivers of children with medical complexity (CMC) face decisions about life-sustaining treatments (LST) like tracheostomy. We sought to develop a clinically relevant and realistic model for decision-making about tracheostomy placement that might apply to other LST in CMC.

DESIGN

This qualitative study, conducted between 2013 and 2015, consisted of 41 interviews with 56 caregivers of CMC who had received tracheostomies and 5 focus groups of 33 healthcare providers (HCPs) at a tertiary-care children's hospital in North Carolina. Participants were asked about their perspectives on the tracheostomy decision-making process. Data were transcribed, and coded. Using thematic content analysis, we inductively developed a tracheostomy decision-making framework and process.

RESULTS

Many factors influenced caregivers' decisions, including children's well-being and caregivers' values, faith, knowledge, experience, emotional state, and social factors; preserving the child's life was the most important. HCPs consider many clinical and nonclinical factors; recommending tracheostomy for children with limited survival, perceived poor functioning and quality of life, and progressive conditions is ethically difficult. The framework of tracheostomy decision-making has inter-related caregiver- and HCP-level factors that influence the process. The framework contains elements not captured in a shared decision-making model, but better fits a collaborative decision-making (CDM) model. The tracheostomy CDM process that emerged from the data has two nonsequential components that HCPs could use: (1) gaining understanding and (2) holding decision-making conversations.

CONCLUSIONS

CDM could be a useful model for clinicians guiding families about tracheostomy for CMC. The applicability of CDM for decision-making about other LSTs needs further exploration.

Fertility preservation for transgender children and young people in paediatric healthcare: a systematic review of ethical considerations

BACKGROUND

While fertility preservation is recommended practice for paediatric oncology patients, it is increasingly being considered for transgender children and young people in paediatric care. This raises ethical issues for clinicians, particularly around consent and shared decision-making in this new area of healthcare.

METHODS

A systematic review of normative literature was conducted across four databases in June 2020 to capture ethical considerations related to fertility counselling and preservation in paediatric transgender healthcare. The text of included publications was analysed inductively, guided by the Qualitative Analysis Guide of Leuven.

RESULTS

Twenty-four publications were identified for inclusion. Four key ethical considerations emerged from this literature: access to fertility preservation, conscientious objection, decision-making capacity of children and young people, and shared decision-making.

CONCLUSION

In the identified literature, there is consensus that transgender children and young people should not be refused access to fertility preservation services solely due to their gender identity, and that clinicians with conscientious objections to fertility preservation for this group have an obligation to refer on to willing providers. Factors that create ethical complexity in this area of paediatric care include the child's age, mental health, and parents' views.

Exploring Ethical Dimensions of Physician Involvement in Requests for Organ Donation in Pediatric Brain Death

Pediatric organ transplantation remains a life-saving therapy, with donated organs being absolutely scarce resources. Efforts to both increase pediatric organ donation authorization by families of children declared dead by neurologic criteria and mitigate perception of conflicts of interest have resulted in frequent exclusion of physicians from this process. This article provides of focused review of pediatric organ donation in the setting of brain death, explores the breadth of consequences of physician exclusion in donation authorization requests, and provides an ethical framework defending physician involvement in the organ donation process for this patient population.

Practical Guidance for the Use of Voxelotor in the Management of Sickle Cell Disease

Sickle cell disease (SCD) is one of the most common inherited blood disorders. Deoxygenated hemoglobin S (HbS) polymerizes and causes anemia and various end organ effects. Voxelotor acts by increasing HbS oxygen affinity, decreasing anemia and hemolysis. Voxelotor is approved for use in individuals with SCD age 4 years and older. Phase 3 trials demonstrated an increase in hemoglobin levels and a decrease in markers of hemolysis; however, data or benefits related to clinical and quality of life outcomes are relatively limited and varied across different studies. This review summarizes the published clinical trials and research studies focused on the use of voxelotor in SCD to provide an evidence-based practical guide for hematology providers on its utilization in clinical settings, including physicians and independent licensed practitioners.

Pediatric Caregiver Version of the Shared Decision Making Process Scale: Validity and Reliability for ADHD Treatment Decisions

OBJECTIVE

Shared decision making (SDM) is recommended for common pediatric conditions; however, there are limited data on measures of SDM in pediatrics. This study adapted the SDM Process scale and examined validity and reliability of the scale for attention-deficit/hyperactivity disorder (ADHD) treatment decisions.

METHODS

Cross-sectional survey of caregivers (n = 498) of children (aged 5-13) diagnosed with ADHD, who had made a decision about ADHD medication in the last 2 years. Surveys included the adapted SDM Process scale (scores range 0-4, higher scores indicate more SDM), decisional conflict, decision regret, and decision involvement. Validity was assessed by testing hypothesized relationships between these constructs. A subset of participants was surveyed a week later to assess retest reliability.

RESULTS

Pediatric Caregiver version of the SDM Process scale (M = 2.8, SD = 1.05) showed no evidence of floor or ceiling effects. The scale was found to be acceptable (<1% missing data) and reliable (intraclass correlation coefficient = 0.74). Scores demonstrated convergent validity, as they were higher for those without decisional conflict than those with decisional conflict (2.93 vs 2.46, P < .001, d = 0.46), and higher for caregivers who stated they made the decision with the provider than those who made the decision themselves (3.0 vs 2.7; P = .003). Higher scores were related to less regret (r = -0.15, P < .001), though the magnitude of the relationship was small.

CONCLUSIONS

The adapted Pediatric Caregiver version of the SDM Process scale demonstrated acceptability, validity and reliability in the context of ADHD medication decisions made by caregivers of children 5-13. Scores indicate pediatricians generally involve caregivers in decision making about ADHD medication.

Pediatric Shared Decision-Making for Simple and Complex Decisions: Findings From a Delphi Panel

OBJECTIVE

To develop recommendations for pediatric shared decision-making (SDM).

METHODS

We conducted a Delphi method study from 2020 to 2021 with an international panel (n = 21) of clinicians, researchers, and parents with expertise in pediatric SDM. We conducted semistructured interviews to identify the key processes of pediatric SDM. We coded the interviews using content analysis and developed a questionnaire on the potential processes of pediatric SDM. Using a Likert scale, panelists evaluated each process twice, once for simple decisions and once for complex decisions. Panelists were provided with a summary of the results and evaluated each process again. The processes that were agreed on for simple and complex decisions were reported as "fundamental processes." The processes that were agreed on for complex decisions were reported as "additional processes."

RESULTS

A total of 79 recommendations were developed, including 29 fundamental processes and 14 additional processes for complex decisions. A recurring theme was the importance of personalizing the decision-making process. For example, the panel recommended that physicians should assess the family and child's desired roles in the decision-making process, assess their desired level of directiveness, and elicit and clarify their values, preferences, and goals. The panel also disagreed on several subprocesses, such as how to determine the child's role and the appropriate level of directiveness.

CONCLUSIONS

An international expert panel developed recommendations for pediatric SDM for both simple and complex decisions. The recommendations highlight the importance of personalizing the decision-making process.

"Every Little Furrow of Her Brow Makes Me Want To Stop": An Interpretative Phenomenologic Analysis of Mothers' Experiences With Juvenile Idiopathic Arthritis Treatments

OBJECTIVE

Children with juvenile idiopathic arthritis (JIA) are faced with a complex medical journey requiring consistent adherence to treatments to achieve disease management. Parents are intimately involved in JIA treatments; however, little is known about their experiences in this role. This is relevant as many treatments necessitate procedural pain (e.g., self-injections) or side effects (e.g., nausea), which may impact a parents' ability to follow treatment plans. The objective of this study was to explore the lived experiences of parents who identified challenges with their child's JIA treatments.

METHODS

Parents of children with JIA who identified challenges with their child's treatments were invited to take part in semistructured interviews. Data were analyzed using interpretative phenomenological analysis.

RESULTS

Ten mothers of children with JIA (60% female with a mean age of 11.83 years [range 4-16 years]) participated. Four superordinate themes were present in mothers' experiences: 1) treatments altered mothers' roles within the family, increasing their caregiver burden and advocacy; 2) treatments positively and negatively impacted their relationships (e.g., increased support from others, decreased time with others); 3) treatments elicited various emotional responses (e.g., frustration, grief), which affected their well-being; and 4) treatments were at times a source of internal conflict, affecting mothers' actions and adherence.

CONCLUSION

Mothers' experiences with their child's JIA treatments affects them in various ways that can subsequently impact treatment adherence. Results highlight the value of supporting parents through these complex treatment regimens and incorporating their experiences in treatment decisions to help promote optimal outcomes for children with JIA and their families.

Pilot trial of iBDecide: Evaluating an online tool to facilitate shared decision making for adolescents and young adults with ulcerative colitis

INTRODUCTION

This pilot, randomized controlled trial aimed to evaluate the usability, among adolescents and young adults (AYAs) with ulcerative colitis (UC), of a web-based tool ('iBDecide') designed to facilitate shared decision making (SDM).

METHODS

AYAs with UC (n = 35) were randomized to intervention (iBDecide, n = 14) and control (n = 12) arms before a scheduled clinic visit. We measured the usability of iBDecide, SDM, preferred decision-making style, decision conflict and intervention use.

RESULTS

Participants in the intervention group found iBDecide easy to use and agreed that it made them feel ready to participate in decision making and that they would use it to prepare for appointments. There were 130 visits to iBDecide, lasting on average 3 min, 41 s. The medication and nutrition trackers were among the most-viewed pages. Pages specifically designed to facilitate SDM were viewed only four times. Across groups, too few participants reported making decisions during clinic visits for decision-related measures to be reported.

CONCLUSIONS

This pilot trial provides evidence for the usability of iBDecide and guidance for developing a larger-scale trial of a combined web-based and in-clinic SDM intervention. Overall, iBDecide shows promise in engaging AYAs with UC in SDM and condition management.

PATIENT OR PUBLIC CONTRIBUTION

Patients, specifically AYAs with UC, and healthcare providers were involved in the design of this study's intervention, iBDecide. Additionally, the research team, from study conception to manuscript writing, included a young adult with inflammatory bowel disease.

CLINICAL TRIAL REGISTRATION

This study was registered at clinicaltrials.gov (NCT04207008).

Day-to-Day Decision Making by Adolescents and Young Adults with Cancer

Background: Adolescents and young adults (AYAs) with cancer must negotiate the transition between childhood and adulthood while dealing with a life-threatening illness. AYA involvement in decision making varies depending on the type of decision and when decisions occur during treatment, and evidence suggests that AYAs want to be involved in decision making. Objective: To explore involvement of AYAs with cancer in day-to-day decisions affected by their cancer and treatment. Methods: This qualitative study used interpretive focused ethnography within the sociologic tradition, informed by symbolic interactionism. Semi-structured interviews and informal participant observation took place at two quaternary pediatric oncology programs. Results: Thirty-one interviews were conducted with 16 AYAs ages 15 to 20 years. Major day to day decision-making categories identified included: (1) mental mindset, (2) self-care practices, (3) self-advocacy, and (4) negotiating relationships. Participants described how they came to grips with their illness early on and decided to fight their cancer. They described decisions they made to protect their health, how they advocated for themselves and decisions they made about relationships with family and friends. Conclusions: Through day-to-day decisions, participants managed the impact of cancer and its treatment on their daily lives. Research should focus on developing and implementing interventions to empower AYAs to participate in day-to-day decisions that will affect how they manage their cancer, its treatment and ultimately their outcomes. Implications for Practice: Healthcare providers can facilitate AYA's participation in day-to-day decision making through encouraging autonomy and self-efficacy by providing support and through effective communication.

Integrated guidance to enhance the care of children and adolescents with familial hypercholesterolaemia: Practical advice for the community clinician

Familial hypercholesterolaemia (FH) is a highly penetrant monogenic disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL)-cholesterol (LDL-C) concentration and, if untreated, leads to premature atherosclerosis and coronary artery disease (CAD). At a prevalence of 1:250 individuals, with over 90% undiagnosed, recent estimates suggest that there are approximately 22 000 children and adolescents with FH in Australia and New Zealand. However, the overwhelming majority remain undetected and inadequately treated until adulthood or after their first cardiac event. The guidance in this paper aims to increase awareness about paediatric FH and provide practical advice for the diagnosis and management of FH in children and adolescents. Recommendations are given on the detection, diagnosis, assessment and management of FH in children and adolescents. Recommendations are also made on genetic testing, including counselling and the potential for universal screening programmes. Practical guidance on management includes treatment of non-cholesterol risk factors, and safe and appropriate use of LDL-C lowering therapies, including statins, ezetimibe, PCSK9 inhibitors and lipoprotein apheresis. Models of care for FH need to be adapted to local and regional health care needs and available resources. Targeting the detection of FH as a priority in children and young adults has the potential to alter the natural history of atherosclerotic cardiovascular disease and recognise the promise of early detection for improving long-term health outcomes. A comprehensive implementation strategy, informed by further research, including assessments of cost-benefit, will be required to ensure that this new guidance benefits all families with or at risk of FH.

Perspectives of Clinicians on Shared Decision Making in Pediatric CKD: A Qualitative Study

RATIONALE & OBJECTIVE

Clinical decision-making priorities may differ among children, their parents, and their clinicians. This study describes clinicians' perspectives on shared decision making in pediatric chronic kidney disease (CKD) and identifies opportunities to improve shared decision making and care for children with CKD and their families.

STUDY DESIGN

Semistructured interviews.

SETTING & PARTICIPANTS

Fifty clinicians participated, including pediatric nephrologists, nurses, social workers, surgeons, dietitians, and psychologists involved in providing care to children with CKD. They worked at 18 hospitals and 4 university research departments across 11 countries (United States of America, Canada, Australia, People's Republic of China, United Kingdom, Germany, France, Italy, Lithuania, New Zealand, and Singapore).

ANALYTICAL APPROACH

Interview transcripts were analyzed thematically.

RESULTS

We identified 4 themes: (1) striving to blend priorities (minimizing treatment burden, emphasizing clinical long-term risks, achieving common goals), (2) focusing on medical responsibilities (carrying decisional burden and pressure of expectations, working within system constraints, ensuring safety is foremost concern), (3) collaborating to achieve better long-term outcomes (individualizing care, creating partnerships, encouraging ownership and participation in shared decision making, sensitive to parental distress), and (4) forming cumulative knowledge (balancing reassurance and realistic expectations, building understanding around treatment, harnessing motivation for long-term goals).

LIMITATIONS

Most clinicians were from high-income countries, so the transferability of the findings to other settings is uncertain.

CONCLUSIONS

Clinicians reported striving to minimize treatment burden and working with children and their families to manage their expectations and support their decision making. However, they are challenged with system constraints and sometimes felt the pressure of being responsible for the child's long-term outcomes. Further studies are needed to test whether support for shared decision making would promote strategies to establish and improve the quality of care for children with CKD.

Using hybrid consistent fuzzy preference relations-importance-performance analysis model to improve shared decision-making quality based on orthopaedic nurses' perceptions

PURPOSE

To understand key factors for shared decision-making (SDM) and the quality improvement of nursing decisions in the orthopaedic clinical environment.

METHOD

This study applied the consistent consistent fuzzy preference relations (CFPRs) and importance-performance analysis (IPA) methods to explore the attribute weights and SDM performance, respectively. The dataset was collected from 16 orthopaedic clinical nurses' experiences in a third-grade and first-level general hospital in Taizhou, China. This study was performed according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines.

RESULTS

The results showed that "I made clear to my patient or patient's family that a nursing care decision needs to be made", "I explained the advantages and disadvantages of the nursing care options to my patient or patient's family" and "I told my patient or patient's family that there are different nursing care options for caring his/her medical condition" were key factors for affecting SDM. The statistical significance confidence and difference error of weight results were 98.321% and 1.679%, respectively. In addition, "I asked my patient or patient's family which nursing care option he/she prefers" was the key factor for improving orthopaedic clinical nursing in the case hospital.

CONCLUSION

The hybrid CFPRs-IPA model can help hospital managers effectively understand the key factors of SDM quality and improve the orthopaedic clinical nursing performance from nurses' perspectives.

RELEVANCE TO CLINICAL PRACTICE

A quantitative decision-making model can help nurses understand the key factors affecting the quality of SDM in nursing decision-making and promote nursing decision-making and patient-centred nursing service quality. A series of corresponding SDM training courses (i.e. concepts, knowledge and skills) can be provided for hospital and nursing department managers to maximise the potentially available resources.

PATIENT OR PUBLIC CONTRIBUTION

The clinical care process should be committed to involving patients in their care decisions and also provide an opportunity for patients to gain a comprehensive understanding of the care decision-making process in order to inform future patient contributions to care decisions.

Moving shared decision-making forward in Iran

Although there have been breakthroughs in patients' rights and informed consent legislation in Iran during the last few years, there is still no policy regarding shared decision-making (SDM). Besides, SDM training and clinical implementation initiatives remain scarce within the country. In this article, we aim to provide an update on the current state of SDM in Iran and discuss future directions. Lastly, we propose an SDM model adapted to the Iranian context, through a consensus-building process with Iranian clinicians and SDM experts, to assist in its implementation in a culturally sensitive manner.

Assessing the extent of shared decision making in Pediatrics: Preliminary psychometric evaluation of the German CollaboRATEpediatric scales for patients aged 7-18 years, parents and parent-proxy reports

OBJECTIVE

To conduct a preliminary evaluation of psychometric properties of CollaboRATE^pediatric, a set of three scales to assess shared decision making (SDM) with pediatric patients, parents and parents on behalf of their children (parent-proxy reports). As secondary objectives we examined the scales' distributional characteristics, acceptability, and agreement between scales.

METHODS

Patients aged ≥ 7 years and parents were recruited in two outpatient facilities providing healthcare services for children with neurological and behavioral health conditions. We collected 46, 169 and 227 pediatric patient, parent-proxy and parent reports, respectively. Convergent, divergent and discriminative validity were investigated. Acceptability of the scales and agreement between patient and parent-proxy reports were explored by assessing item nonresponse and Bland-Altman plots.

RESULTS

While convergent and divergent validity were established for the parent scale, discriminative validity was not demonstrated for any of the scales. The scales showed good to excellent acceptability. Parent-proxy reports agreed to a moderate extent with patients' self-reports of SDM.

CONCLUSION

CollaboRATE^pediatric offers a starting point for parsimoniously assessing SDM in Pediatrics, however further psychometric testing is warranted.

PRACTICE IMPLICATIONS

Given limited psychometric support for the pediatric patient scale, we recommend using both the pediatric patient and parent-proxy report scales to assess SDM in pediatric patients until further psychometric testing is concluded.

iBDecide: A web-based tool to promote engagement in shared decision-making among adolescents with ulcerative colitis

BACKGROUND

Adolescents and young adults (AYAs) seek increased autonomy and self-efficacy. AYAs must learn to manage their medical care in preparation for transition to adult healthcare. Our team's research found that AYAs need more information about their disease and treatment OBJECTIVE: To develop and test the usability of a decision tool "iBDecide" to promote shared decision-making among AYAs with ulcerative colitis (UC) who are beginning to manage their treatment and medications METHODS: Using design thinking, 14 AYAs, 6 healthcare providers, 4 designers, a social worker, and a human factors researcher developed a shared decision-making tool. The System Usability Scale (SUS) assessed usability RESULTS: AYAs preferred an application with information on treatment, medication, nutrition, and symptom tracking. A web-based application, 'iBDecide', was developed to include these options. SUS results indicated that participants on average "agree" that: 'they would use iBDecide' and that 'it was easy to use and streamlined'. The mean SUS score was 78.25 (+/-12.91), range 70-90 DISCUSSION: Including AYAs in tool development helps ensure usability and improves engagement in shared decision-making. Co-designed tools may remove barriers for engagement and skill-building needed for the transition to adult care.

CONCLUSION

iBDecide can stimulate AYA engagement in shared decision-making in treating UC.

Barriers and facilitators to shared decision-making in neonatal medicine: A systematic review and thematic synthesis of parental perceptions

OBJECTIVES

Systematically review parental perceptions of shared decision-making (SDM) in neonatology, identifying barriers and facilitators to implementation.

METHODS

Electronic database (Medline, PsycINFO, CINAHL and Scopus) and follow-up searches were conducted to identify qualitative studies. Data were extracted, thematically analysed and synthesised.

RESULTS

Searches yielded 2445 papers, of which 25 were included. Thematic analysis identified six key themes. Key barriers included emotional crises experienced in the NICU setting, lack of medical information provided to parents to inform decision-making, inadequate communication of information, poor relationships with caregivers, lack of continuity in care, and perceived power imbalances between HCPs and parents. Key facilitators included clear, honest and compassionate communication of medical information, caring and empathetic caregivers, continuity in care, and tailored approaches that reflected parent's desired level of involvement.

CONCLUSION

The highly specialised environment, and the emotional crises experienced by parents impact significantly on their perceived capacity to engage in surrogate decision-making.

PRACTICE IMPLICATIONS

Complex and multi-factorial interventions that address the training needs of HCPs, and the emotional, informational and decision support needs of parents are needed. SDM skills training, improved information delivery, and integrated emotional and decisional support could help parents to become more involved in SDM for their infant.

Decision making about anti-TNF therapy: A pilot trial of a shared decision-making intervention

OBJECTIVE

We conducted a pre-post pilot trial to determine the feasibility and acceptability of a multi-component intervention (pre-clinic letter, shared decision making cards and follow-up phone call) designed to facilitate SDM in pediatric inflammatory bowel disease (IBD).

METHODS

We recruited physicians (n = 11) caring for IBD patients and families (n = 36) expected to discuss anti-tumor necrosis treatment. We measured feasibility and acceptability of the intervention, observed SDM, perceived SDM, decision conflict, and regret. Medical records were used to assess clinical outcomes, time to decision and adherence. We compared all outcomes between the usual care and intervention study arms.

RESULTS

Two out of three intervention components were feasible. Visit length increased significantly in the intervention arm. Parents and patients rated the intervention as acceptable, as did most physicians. The intervention was associated with a higher-level of observed SDM. There was no difference perceived SDM, decision conflict, regret or quality of life outcomes between arms. Physician global assessment improved over time in the intervention arm.

CONCLUSIONS

This pilot trial provides important guidance for developing a larger scale trial of a modified intervention.

PRACTICE IMPLICATIONS

Overall, our intervention shows promise in supporting SDM and engaging both parents and patients in pediatric IBD decisions.

Pain management after third molar extractions in adolescents: a qualitative study

Background

Understanding how adolescent patients make decisions about pain management after complex dental procedures could help reduce the use of opioid medications and the potential for future opioid misuse in this population. This qualitative study explores how adolescents manage pain, including how decision making with parents and providers affect their experience with opioid and non-opioid analgesics after third molar dental extractions.

Methods

We used a qualitative approach for the analysis of 30 telephone-based semi-structured interviews completed by 15 dyads between May and August 2019, which included 15 adolescents (15–17 years) who underwent a dental extraction, and a parent or guardian for each adolescent. The total sample included 30 participants. Interviews were conducted separately for patients and parents. De-identified interview transcripts were analyzed using qualitative analysis software using a directed content analysis approach.

Results

A total of 15 patient/parent dyads were interviewed. Key themes associated with pain management included sources of information, pain management behaviors engaged in by the adolescents and their caregivers, and the use of medication. In addition to conversations with their dental provider, most patients and their parents discussed pain management plans that included non-medication options, over-the-counter medications, and opioid medications to be taken as needed, which guided their post-extraction behaviors. All participants reported that the adolescent received an opioid prescription for post-extraction pain management, to be taken on an “as needed” basis, but most only took it the day of the extraction and up to 2 days following, usually based on the patient’s reported pain levels and perceptions of over-the-counter medication adequacy. Participants said they did not receive guidance from their provider concerning disposal of unused opioid medications.

Conclusions

Involving adolescents in the pain management decision making process and allowing them to carry out the plan with some caregiver support was acceptable and well executed following third molar extractions. Providers may have an opportunity to reduce the number of opioids prescribed, since respondents reported little to no use of opioids that they were prescribed. Providers should educate patients and their parents about safe disposal of opioids to mitigate the potential for diversion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03261-x.

Parents' Perspectives on Diagnosis and Decision-Making regarding Ventilator Support in Children with SMA Type 1

Spinal muscular atrophy (SMA) is a rare neuromuscular disorder with a broad clinical spectrum. The most severe phenotype-SMA type 1-is characterized by marked muscle weakness also affecting bulbar and respiratory function. Life expectancy of children with SMA type 1 is expected to be less than 2 years without ventilator support or disease-specific drug treatment. The aim of this study was to evaluate parents' perspectives on the process of decision-making regarding ventilator support in children with SMA type 1. Fourteen semi-structured interviews were performed with parents of children with SMA type 1 that decided either for or against ventilator support for their child. All children were diagnosed prior to the approval of SMA-specific drug treatment. Interviews were recorded and transcribed verbatim. Data analysis was performed using a qualitative content analysis approach according to Mayring. Parents experienced that they were not adequately informed about the disease and treatment options in first informed consent discussions. Especially regarding ventilator support, parents perceived that they were not offered ventilator support as an actual option for treatment. Regarding the decision of whether or not to offer ventilator support, parents reported that their attitude toward ventilator support and contact with other affected families or patient advocacy groups were more likely to influence the decision than the content of informed consent discussions with physicians. Our results underline the importance of an interdisciplinary team not only to provide parents with relevant information but also to consider the criteria of a patient-centered medicine.

When opinions differ: the development of a reflection tool for youth professionals to support shared decision-making with parents

The importance of shared decision-making (SDM) in youth care is increasingly emphasised. Professional reflection on the decision-making process is an important means to improve the use of SDM in practice. In this study, we report on the development of a reflection tool for youth professionals primarily to use when they hold a different opinion then parents about referral to specialised youth care services. In co-creation with local youth professionals and parent representatives from the South of the Netherlands, the tool was developed and tested in practice. This process was guided by a three-stage cyclical research project. First, reflective group discussions provided an initial understanding of professionals' needs, interests and experiences. This input then was analysed and documented into a draft tool with reflective questions. Next, this tool was tested on fictive and real life cases and adjusted with input from youth professionals and parents. This process resulted in an online reflection tool covering 16 overarching reflective questions to support youth professionals' reflection on their shared decision-making in practice. The tool can be used and adapted by others in the field of youth care to improve the process of making shared decisions with parents in complex cases.

Decisional conflicts, anxiety, and perceptions of shared decision-making in cancer treatment trajectory among adolescents with cancer: A longitudinal study

PURPOSE

To examine the trajectory of decisional conflict and anxiety experienced by adolescents after the cancer diagnosis, and explore their perceptions on participation in shared decision-making (SDM).

DESIGN

This longitudinal study used incorporated data from questionnaires and interviews.

METHODS

Participants recruited from an academic hospital in southern Taiwan ranged in age from 13 to 20 years with a cancer diagnosis within 1 month and received cancer treatment. Each participant completed questionnaires on decisional conflict and anxiety at diagnosis, 1, 3, and 6 months later. Individual interviews were to gain an in-depth understanding of SDM.

FINDINGS

Total scores on decisional conflict changed significantly over time (F = 2.98, p = 0.039); the scores at 1 month were higher than 3 months (t = 2.18, p = 0.04) and 6 months (t = 2.97, p = 0.008). Participants perceived significantly different levels of values clarify (F = 9.49, p < 0.01) and support (F = 8.46, p < 0.01) over time. Only 27.3% of participants were anxiety-free. No significant differences were found in anxiety over time. The perception of SDM was a situational involvement.

CONCLUSIONS

Decisional conflict changed over time. Participants experienced greater decisional conflict at 4-8 weeks after diagnosis and their anxiety did not decrease over time. The different levels of participation in SDM during their treatment trajectory were found.

CLINICAL RELEVANCE

Participants experienced the highest decisional conflict during diagnosis, and highlighted how their roles in healthcare discussions varied from direct participation to indirect involvement. Further research is needed to develop an SDM model which accommodates different levels of needs and implements timely support.

Treatment decisions after interdisciplinary evaluation for nonarthritic hip pain: A randomized controlled trial

BACKGROUND

Physical therapy and hip arthroscopy are two viable treatment options for patients with nonarthritic hip pain (NAHP); however, patients may experience considerable decisional conflict when making a treatment decision. Interdisciplinary evaluation with a physical therapist and surgeon may better inform the decision-making process and reduce decisional conflict.

OBJECTIVE

To identify the extent to which an interdisciplinary evaluation between a surgeon, physical therapist, and patient influences treatment plans and decisional conflict of persons with NAHP.

DESIGN

Randomized controlled trial.

SETTING

Hip preservation clinic.

PARTICIPANTS

Adults with primary NAHP.

INTERVENTIONS

Participants were randomized to receive a standard (surgeon) or interdisciplinary (surgeon+physical therapist) evaluation. Surgeon evaluations included patient interview, strength and range-of-motion examination, palpation, gross motor observation, and special testing. Interdisciplinary evaluations started with the surgeon evaluation, then a physical therapist evaluated movement impairments during sitting, sit-to-stand, standing, single-leg stance, single-leg squat, and walking. All evaluations concluded with treatment planning with the respective provider(s).

OUTCOME MEASURES

Treatment plan and decisional conflict were collected pre- and postevaluation. Inclusion of physical therapy in participants' postevaluation treatment plans and postevaluation decisional conflict were compared between groups using chi-square tests and Mann-Whitney U tests, respectively.

RESULTS

Seventy-eight participants (39 in each group) met all eligibility criteria and were included in all analyses. Sixty-six percent of participants who received an interdisciplinary evaluation included physical therapy in their postevaluation treatment plan, compared to 48% of participants who received a standard evaluation (p = .10). Participants who received an interdisciplinary evaluation reported 6.3 points lower decisional conflict regarding their postevaluation plan (100-point scale; p = .04). The interdisciplinary and standard groups reduced decisional conflict on average 24.8 ± 18.9 and 23.6 ± 14.6 points, respectively.

CONCLUSIONS

Adding a physical therapist to a surgical clinic increased interest in physical therapy treatment, but this increase was not statistically significant. The interdisciplinary group displayed lower postevaluation decisional conflict; however, both groups displayed similar reductions in decisional conflict from pre- to postevaluation. This study also demonstrated the feasibility of an interdisciplinary evaluation in a hip preservation clinic.

Relational Aspects of Parent and Home Health Care Provider Care Practices for Children With Complex Care Needs Receiving Health Care Services in the Home: A Narrative Review

Children with medical complexity have ongoing health needs that may require dependence on medical technologies. While hospital admissions are an important focus of care delivery for these children, a majority of the time they are cared for in their own homes. Parents' report feeling overwhelmed and stressed by the scope of their responsibilities, but they become sophisticated care providers and assume greater authority when providing their children's care at home. Communication, decision-making, and dealing with conflict with members of health care teams have been central concerns in parents' reports of their home health care experiences. The objective is to review literature on relational aspects of parent and home health care provider care practices for children with medical complexity receiving home health care services. A narrative review was conducted. A search of MEDLINE, EMBASE, EBM Reviews, PsychINFO, ERIC, and CINAHL databases for English language studies published since database inception was carried out. Eligible studies focused on relational aspects of parent and home health care provider care practices for children with medical complexity receiving home health care services. Nine empirical studies were selected for this review. Literature describes parents' and providers' experiences managing a child with medical complexity in the home and the effects for the family and the parent-health care provider relationship. Parents want to be actively involved in all aspects of care that affects their child and ultimately their family. Further investigation is needed to better understand relational aspects of parent-home health care provider care practices to support child/family health and well-being in the home setting.

American Society for Gastrointestinal Endoscopy guideline on informed consent for GI endoscopic procedures

Informed consent is the cornerstone of the ethical practice of procedures and treatments in medicine. The purpose of this document from the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee is to provide an update on best practice of the informed consent process and other issues around informed consent and shared decision-making for endoscopic procedures. The principles of informed consent are based on longstanding legal doctrine. Several new concepts and clinical trials addressing the best practice of informed consent will help guide practitioners of the burgeoning field of GI endoscopic procedures. After a literature review and an iterative discussion and voting process by the ASGE Standards of Practice Committee, this document was produced to update our guidance on informed consent for the practicing endoscopist. Because this document was designed by considering the laws and broad practice of endoscopy in the United States, legal requirements may differ by state and region, and it is the responsibility of the endoscopist, practice managers, and other healthcare organizations to be aware of local laws. Our recommendations are designed to improve the informed consent experience for both physicians and patients as they work together to diagnose and treat GI diseases with endoscopy.

A self-portrait: Design opportunities for a tool that supports children's involvement in brain-related health care

Introduction

Paediatric patients with disorders that involve brain functioning are particularly vulnerable with respect to including them in shared decision‐making. Current tools are mostly paper or digital patient information. We lay the groundwork for improving engagement with a concept that we coined ‘the Self‐Portrait’. The main goals were to identify (1) obstacles and (2) design parameters that enable patient participation.

Methods

A research‐through‐design approach was utilized in nine patients with brain‐related disorders (4–12 years), 15 parents and 15 medical professionals, involving contextual research (interviews and observations) within the paediatric hospital and patients' homes and codesign. Sensitizing materials and early instances of design solutions were deployed as catalysts for communication. Five rounds of enriched interviews and design reviews were thematically analysed to answer the research questions.

Results

Obstacles to child involvement were related to children's level of understanding, the time and energy necessary for information processing and lack of perceived relevance of the information. Patients' engagement is supported by design features that extend the time frame of interaction beyond the consultation, transfer information interactively and give control and influence during the consultation.

Conclusion

Obstacles were detected that complicate child engagement, which differ between stakeholders. Promising design features were identified that have the potential to play an important role in enabling active child involvement. These findings show that applying principles of human‐centred design research and codesign can bring together patients, parents and medical professionals around a tool that provides a shared language and focus, which are prerequisites to increase child engagement.

Patient or Public Contribution

Patients, parents and clinicians contributed as design informants during contextual research and design reviews. Clinicians provided feedback on the initial outcomes of thematic analysis. Two researchers assisted in consensus sessions during the thematic analysis.

Pediatric subspecialty telemedicine use from the patient and provider perspective

BACKGROUND

To characterize telemedicine use among pediatric subspecialties with respect to clinical uses of telemedicine, provider experience, and patient perceptions during the COVID-19 pandemic.

METHODS

We performed a mixed-methods study of telemedicine visits across pediatric endocrinology, nephrology, orthopedic surgery, and rheumatology at a large children's hospital. We used deductive analysis to review observational data from 40 video visits. Providers and patients/caregivers were surveyed around areas of satisfaction and communication.

RESULTS

We found adaptations of telemedicine including shared-screen use and provider-guided parent procedures among others. All providers felt that it was safest for their patients to conduct visits by video, and 72.7% reported completing some component of a clinical exam. Patients rated the areas of being respected by the clinical staff/provider and showing care and concern highly, and the mean overall satisfaction was 86.7 ± 19.3%.

CONCLUSIONS

Telemedicine has been used to deliver care to pediatric patients during the pandemic, and we found that patients were satisfied with the telemedicine visits during this stressful time and that providers were able to innovate during visits. Telemedicine is a tool that can be successfully adapted to patient and provider needs, but further studies are needed to fully explore its integration in pediatric subspecialty care.

IMPACT

This study describes telemedicine use at the height of the COVID-19 pandemic from both a provider and patient perspective, in four different pediatric subspecialties. Prior to COVID-19, pediatric telehealth landscape analysis suggested that many pediatric specialty practices had pilot telehealth programs, but there are few published studies evaluating telemedicine performance through the simultaneous patient and provider experience as part of standard care. We describe novel uses and adaptations of telemedicine during a time of rapid deployment in pediatric specialty care.

Ethical Dilemma: Elexacaftor-Tezacaftor-Ivacaftor or Lung Transplantation in Cystic Fibrosis and End-Stage Lung Disease?

Cystic fibrosis (CF) is caused by mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR). Novel, highly effective, modulator therapies correcting and potentiating CFTR function are changing the course of this disease. We present an ethical dilemma involving an 11-year-old child with CF and end-stage lung disease. Shortly after starting treatment with elexacaftor-tezacaftor-ivacaftor, the family received notification that a matched donor lung had been allocated. Clinical decision-making in this case is challenging as definitive data to medically support one treatment option over the other are limited. A survey of CF center team members was conducted for the purpose of this article. Ethical principles that may guide us in these situations are discussed. Overall, results of the survey present a lack of agreement as to the best approach in this situation. Physicians, when compared with other team members, are more likely to provide a specific recommendation vs presenting the information to the family and letting them decide (OR, 4.0; 95% CI, 1.2-12.8; P = .021). A shared decision-making model, stressing our moral obligation as physicians to respect autonomy by appreciating family values, while offering to participate in the decision-making process and ensuring nonmaleficence, is presented. In summary, CFTR modulators affect the outcomes of CF disease and influence clinical decision-making. The current lack of data on long-term outcomes, in young patients with CF receiving effective modulator therapy, should not preclude CF team participation in decision-making. Shared decision-making, which is focused on respecting autonomy, is our preferred approach in these situations.

The Case of Billy Best: 25 Years Later

Billy Best was diagnosed with Hodgkin lymphoma in 1994 at age 16 and became well-known when he ran away from home to avoid receiving further chemotherapy. His story became national news when, with the support of his adopted parents, he returned home and opted to use complementary and alternative medicine (CAM) instead of standard chemotherapy and radiation for his cancer treatment. Now 25 years since Billy Best entered the public eye, his story is one that is frequently referenced in pediatrics, bioethics, and other related fields. Here, the authors examine the evolution of various features of this case, including treatment of Hodgkin lymphoma, the interplay between medicine and the media, the role of CAM in pediatric care, navigating entrenched disagreements and how best to integrate adolescents into health care decision-making, and the role of narrative in medical practice. The authors explore the unique role of each of these facets of Billy Best's case, describing how each has or has not changed in the quarter century since that time amid the changing landscape of pediatric health care. Ultimately, although many advances have occurred since Billy Best's time, significant work remains. Additional effort will be required in the future to optimize communication, improve treatment toxicities from Hodgkin lymphoma without decreasing survival, integrate the voice and perspective of adolescents into their treatment decisions, and navigate the roles of CAM and the media in pediatric health care.

Patient and family engagement strategies for children and adolescents with chronic diseases: A review of systematic reviews

OBJECTIVE

Patient and family engagement is important for family-centered care, particularly for children and adolescents with chronic disease. We aimed to 1) identify available evidence from systematic reviews on engagement strategies used to help children, adolescents, and their caregivers manage chronic conditions, and 2) identify gaps in the literature.

METHODS

We searched PubMed and CINAHL from January 2015 to January 2020 for systematic reviews on patient and family engagement strategies in the pediatrics population (<18 years). Strategies were categorized by direct patient care, health system, and community policy levels. We excluded reviews if interventions were unidirectional or without comparison.

RESULTS

We identified 25 systematic reviews. Twenty-two evaluated direct patient care, with 14 (279 unique studies) exclusively in pediatrics and 8 (24 unique studies) that included pediatric results with adults. Three reviews (9 unique studies) evaluated health system strategies. Direct patient care reviews focused on self-management support (n = 16) and shared decisionmaking (n = 6). Asthma was the most frequently evaluated condition (n = 14).

CONCLUSIONS AND PRACTICE IMPLICATIONS

Engagement strategies for children and adolescents with chronic disease are focused on direct patient care, particularly for asthma. More research is needed to address engagement for broader populations, expanded outcomes, and at health system and community levels.

Decision making for hematopoietic stem cell transplantation in pediatric, adolescent, and young adult patients with a hemoglobinopathy-Shared or not?

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) offers an established curative option for sickle cell disease (SCD) and thalassemia patients but is associated with significant risks. Decision making is a complex process and shared decision making (SDM) could be a fitting approach in case of such preference-sensitive decisions. This study investigated what level of SDM is used in conversations with hemoglobinopathy patients and/or their caregivers considering HSCT as a curative treatment option.

METHODS

Longitudinal, descriptive study using the Observing-Patient-Involvement-in-Decision-Making scale (OPTION⁵ ) scale to determine the level of SDM in conversations with 26 hemoglobinopathy patients and/or their caregivers.

RESULTS

The total mean OPTION⁵ score was 43%, which is a moderate SDM approach. There was no difference between conversations with thalassemia patients and SCD patients. Conversations needing an interpreter scored worse than nontranslated conversations. The best scoring OPTION⁵ item was item 3: "informing about the various treatment options" (mean score 2.3 on scale 0-4). For OPTION⁵ item 4: "eliciting patients' preferences" a more skilled effort was measured for SCD patients compared to thalassemia patients.

CONCLUSIONS

The mean OPTION⁵ score of "moderate" was achieved mainly by giving information on available options, which is primarily a one-way communication. The SDM process can be improved by actively inviting patients to deliberate about options and including their elicited preferences in decision making.

Assessing Shared Decision-Making in Cystic Fibrosis Care Using collaboRATE: A Cross-Sectional Study of 159 Programs

There are numerous opportunities for shared decision-making (SDM) in cystic fibrosis (CF) care, yet little is known about patients’ SDM experiences. This study evaluated SDM across 159 CF care programs (4024 participants) in the United States. Shared decision-making was assessed using the patient-reported collaboRATE measure, which was included in the CF Foundation’s Patient and Family Experience of Care Survey over 18 months. Overall, 69% of respondents reported experiencing SDM. Respondents at pediatric programs were more likely to experience SDM than those at adult programs (72% vs 67%, P < .001). Multivariable logistic regression analyses showed a relationship between SDM and patient age, whereby SDM was less likely to occur with patients aged 18 to 24 years, compared to some younger and older age groups (P = .02-<.001). Shared decision-making was more likely to occur at pediatric programs when patients had better general health (P = .02-<.01), and at pediatric and adult programs when patients had better mental health (P = .02-<.001). Disparities in SDM experiences highlight a need to improve decision-making processes in CF care. Interventions tailored for improving SDM among specific patient populations may be particularly advantageous.

Development of a Decision Aid for Parents Who Elect Tonsillectomy for Obstructive Sleep Apnea

OBJECTIVE

To develop a novel patient decision aid (PtDA) for parents considering tonsillectomy for their children diagnosed with obstructive sleep apnea (OSA) and compare it to validated scales related to decision making in this context. These included scales for decisional conflict (DC) and shared decision making (SDM).

METHODS

A parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic was conducted comparing a validated Decisional Conflict Scale (DCS) with a new PtDA that included an SDM scale, parental treatment goals, and knowledge about adenotonsillectomy and OSA. DCS scores range from 0 to 100 with values less than 25 considered to be low DC. The DQ was determined by a score on the PtDA. The PtDA was composed of a knowledge score, SDM score and 5 related values scored along a continuum (these were: resolution of symptoms, avoiding anesthesia, avoiding surgery, avoiding pain/bleeding, and resumption of normal behavior). A high score meant that all answers were consistent with choosing tonsillectomy and imply better DQ.

RESULTS

A total of 89 parents or guardians participated in the study. The mean DC score was 4.32 (95% CI: 2.57-6.07). The mean DQ score was 22.69 (95% CI: 21.86-23.51). Mean values score was 5.35 (95% CI: 5.05-5.65). The mean knowledge score was 9.00 (95% CI: 8.60-9.40). SDM score mean was 8.38 (95% CI: 7.85-8.91). Using Spearman's rho, DC versus DQ inversely correlated with a coefficient -.209 via a 2-tailed test (P = .05). Cronbach's alpha for the DQ score was .78.

CONCLUSION

DC scores overall were low for the group. DQ, as measured with the novel PtDA, had an inverse correlation with DC scores, suggesting validity of the proposed PtDA. Our instrument has potential use as a PtDA for parents who are offered tonsillectomy for their children.

Shared decision making in pediatric dermatology: context, opportunities, and practical examples

PURPOSE OF REVIEW

Shared decision making (SDM) is an important part of patient-centered care. However, it is neither widely practiced nor researched in pediatric dermatology. In this article, we provide practical examples of how to engage in SDM in pediatric dermatology, and identify future areas of research.

RECENT FINDINGS

Children and parents/guardians desire SDM in clinical encounters. The process is applicable to discussions of medical as well as surgical care. Additionally, SDM can help prepare children for the transition from pediatric to adult/general providers. Clinicians often want more guidance on its implementation, and there is a dearth of research on SDM or decision tools specific to pediatric dermatology.

SUMMARY

SDM is underused and understudied in pediatric dermatology. This article highlights how to engage in SDM and presents opportunities for research and implementation in pediatric dermatology.

Chronically ill children's participation and health outcomes in shared decision-making: a scoping review

Based on the United Nations Conventions on the Rights of the Child (CRC), it is a child's right to participate in all matters concerning its wellbeing. Little is known about chronically and/or critically ill children's participation in pediatric shared decision-making (SDM). We explored medical literature to see if and how these children participate in pediatric SDM. We searched relevant medical databases published between January 2008 and January 2020 for studies targeting children aged 4-18 years old, suffering from a chronic and/or critical disease. We found 9 relevant studies. SDM interventions mostly used were decision aids (n=8), questionnaires for caretakers/parents and children (n=4), and a SDM toolkit (n=2). Perceived involvement in SDM and knowledge increased amongst children, adolescents, and caretakers following these interventions. Decisional conflict measured using the 0-100 point DCS scale (higher scores indicate more decisional conflict) was reduced by 15.9 points in one study (p<0.01) and 17.8 points in another (95%CI: 13.3-22.9). Lower scores were associated with higher satisfaction with the decision aid by children, caretakers, and clinicians.Conclusion: Stakeholders should advocate initiatives to facilitate a child's participation preferences regarding pediatric SDM since decision support tools help chronically ill children to be more involved in SDM as they increase the children's knowledge and satisfaction and reduce decisional conflicts. What is Known: • Decision aids can help improve participation, knowledge, satisfaction, and health outcomes. • Quality and consistency of the information exchange impact quality and outcome of SDM. What is New: • Depending on a child's age, evolving capacities, and communication and participation preferences, more evidence is needed on which tools are suitable for chronically ill children to ensure their preferred participation in pediatric SDM. • Pediatricians adopt healthcare SDM tools and techniques that do not always take into account that a child's right to participate in pediatric SDM including the tendency to use interventions that are not specifically designed for pediatrics.

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders

BACKGROUND

Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment.

METHODS

This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone.

DISCUSSION

Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders.

TRIAL REGISTRATION

This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .

Telemedicine use by pediatric rheumatologists during the COVID-19 pandemic

BACKGROUND

To characterize various aspects of telemedicine use by pediatric rheumatology providers during the recent pandemic including provider acceptability of telehealth practices, clinical reliability, and clinical appropriateness.

METHODS

An electronic survey was generated and disseminated amongst the Childhood Arthritis and Rheumatology Research Alliance (CARRA) listserv (n = 547). Survey items were analyzed via descriptive statistics by question.

RESULTS

The survey response rate was 40.8% (n = 223) with the majority of respondents in an attending-level role. We observed that musculoskeletal components of the exam were rated as the most reliable components of a telemedicine exam and 86.5% of survey respondents reported engaging the patient or patient caregiver to help conduct the virtual exam. However, 65.7% of providers reported not being able to elicit the information needed from a telemedicine visit to make a complete clinical assessment. We also noted areas of disagreement regarding areas of patient engagement and confidentiality. We found that approximately one-third (35.8%) of those surveyed felt that their level of burnout was increased due to telemedicine.

CONCLUSION

In general, providers found exam reliability (specifically around focused musculoskeletal elements) in telemedicine visits but overall felt that they were unable to generate the information needed to generate a complete clinical assessment. Additionally, there were suggestions that patient engagement and confidentiality varied during telemedicine visits when compared to in-person clinical visits. Further qualitative work is needed to fully explore telemedicine use in pediatric rheumatology.

Development and validation of a novel informational booklet for pediatric long-term ventilation decision support

OBJECTIVES

To provide accessible, uniform, comprehensive, and balanced information to families deciding whether to initiate long-term ventilation (LTV) for their child, we sought to develop and validate a novel informational resource.

METHODS

The Ottawa Decision Support Framework was followed. Previous interviews with 44 lay and 15 professional stakeholders and published literature provided content for a booklet. Iterative versions were cognitive tested with six parents facing decisions and five pediatric intensivists. Ten parents facing decisions evaluated the booklet using the Preparation for Decision Making Scale and reported their decisional conflict, which was juxtaposed to the conflict of 21 parents who did not read it, using the Decisional Conflict Scale. Twelve home ventilation program directors evaluated the booklet's clinical sensibility and sensitivity, using a self-designed six-item questionnaire. Data presented using summary statistics.

RESULTS

The illustrated booklet (6th-grade reading level) has nine topical sections on chronic respiratory failure and invasive and noninvasive LTV, including the option to forgo LTV. Ten parents who read the booklet rated it as helping "Quite a bit" or more on all items of the Preparation for Decision Making Scale and had seemingly less decisional conflict than 21 parents who did not. Twelve directors rated it highly for clinical sensibility and sensitivity.

CONCLUSIONS

The LTV booklet was rigorously developed and favorably evaluated. It offers a resource to improve patient/family knowledge, supplement shared decision-making, and reduce decisional conflict around LTV decisions. Future studies should validate it in other settings and further study its effectiveness.