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Mueller R. Prognostic imagination: Genetic counseling amidst therapeutic innovation and evolving futures. J Genet Couns 2023; 32:762-767. [PMID: 36575577 PMCID: PMC10851581 DOI: 10.1002/jgc4.1660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/24/2022] [Accepted: 11/11/2022] [Indexed: 12/29/2022]
Abstract
Despite the moniker "precision medicine," genetic diagnoses are often imprecise with respect to prognosis. In a period when prognoses are evolving in lockstep with advances in genetic diagnostics and therapeutics, it is critical that clinicians and researchers consider how prognosis is communicated beyond the moment of diagnosis. Research has shown that genetic diagnoses are described differently in pre- and postnatal contexts, but we know relatively little about how patients and families make sense of prognostic information as affected children grow up. Here, I draw on research and personal narratives to describe how prognostic information impacts individuals' conceptions of the future. A deeper understanding of how patients and families view prognosis is important because parents may need support as prognostic conversations arise and because perceptions of prognosis may influence ideas about the future, psychological health, decisions, and planning. By exploring how specific ideas about an individuals' future take hold, clinicians and researchers may begin to identify the benefits, harms, and accuracy of varied sources of prognostic information, opening new areas of bioethical investigation. In closing, I propose prognostic imagination as a useful concept for considering how patients and families experience prognostic information amidst therapeutic innovations and evolving futures.
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Affiliation(s)
- Rebecca Mueller
- Department of Medical Ethics and Health Policy and Master of Science in Genetic Counseling Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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2
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Mueller R, Lee BM, Callahan KP. Managing Prognosis in Precision Medicine: Utility, Imagination, and Communication. CHILDREN 2023; 10:children10040664. [PMID: 37189913 DOI: 10.3390/children10040664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
Research on how physicians predict and communicate prognosis focuses primarily on end-of-life care. Unsurprisingly, as genomic technology gains traction as a prognostic tool, the focus has also been on terminality, with research focused on how genetic results may be used to terminate pregnancies or redirect care towards palliation for neonates. However, genomic results also have powerful impacts on how patients who live prepare for their futures. Genomic testing provides broad-reaching and early—albeit complex, uncertain, and shifting—prognostic information. In this essay, we argue that as genomic testing occurs earlier and increasingly in a screening context, researchers and clinicians must strive to understand and manage the prognostic implications of results. While our understanding of the psychosocial and communicational aspects of prognosis in symptomatic populations is incomplete, it has progressed further than our understanding in a screening context and therefore provides useful lessons and feasible opportunities for further research. By providing an interdisciplinary and inter-specialty perspective on the psychosocial and communicational aspects of prognosis in genetics, we discuss prognostication with respect to genetics from the neonatal period through adulthood, highlighting medical specialties and patient populations that are especially informative for considering the longitudinal management of prognostic information in genomic medicine.
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Affiliation(s)
- Rebecca Mueller
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA 19104, USA
- Masters Genetic Counseling Program, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Brittany M. Lee
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
- Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Katharine Press Callahan
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA 19104, USA
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
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3
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Prieur MG, Christon LM, Mueller A, Smith BA, Georgiopoulos AM, Boat TF, Filigno SS. Promoting emotional wellness in children with cystic fibrosis, Part I: Child and family resilience. Pediatr Pulmonol 2021; 56 Suppl 1:S97-S106. [PMID: 32658376 DOI: 10.1002/ppul.24958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 01/06/2023]
Abstract
Attention should be given to individual and family well-being from a child's first interaction with the medical team and continuing throughout development, especially for families who experience chronic illnesses, such as cystic fibrosis (CF). While much attention has been given to the mental health of people with CF 12 years and older, this paper explores various areas for CF teams to assess and provide additional resources during the first 12 years of a child's life to promote child and family wellness. In this paper, we discuss parental mental health, social determinants of health, adherence/self-care, nutrition, attention to family lifestyle factors, engagement with school and peers, and modulator therapy for this age group of people with CF. This is the first of two companion papers which examines emotional wellness of children during the early years. The second paper examines mental health assessment and intervention for children under 12. Both encourage teams to strive to promote optimal child and family emotional health and wellness, emphasizing holistic health promotion and prevention, early identification, and intervention.
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Affiliation(s)
- Mary G Prieur
- Departments of Psychiatry and Pediatricsm School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lillian M Christon
- Department of Psychiatry and Behavioral Science, Medical University of South Carolina, Charleston, South Carolina
| | | | - Beth A Smith
- Division of Child & Adolescent Psychiatry, University at Buffalo-The State University of New York, Buffalo, New York
| | | | - Thomas F Boat
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stephanie S Filigno
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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4
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Palliative Care for Children with Lung Diseases. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Evans AM, Jonas M, Lantos J. Pediatric Palliative Care in a Pandemic: Role Obligations, Moral Distress, and the Care You Can Give. Pediatrics 2020; 146:peds.2020-1163. [PMID: 32461261 DOI: 10.1542/peds.2020-1163] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2020] [Indexed: 11/24/2022] Open
Abstract
Many ethical issues arise concerning the care of critically ill and dying patients during the coronavirus disease 2019 (COVID-19) pandemic. In this issue's Ethics Rounds, we present 2 cases that highlight 2 different sorts of ethical issues. One is focused on the decisions that have to be made when the surge of patients with respiratory failure overwhelm ICUs. The other is focused on the psychological issues that arise for parents who are caring for a dying child when infection-control policies limit the number of visitors. Both of these situations raise challenges for caregivers who are trying to be honest, to deal with their own moral distress, and to provide compassionate palliative care.
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Affiliation(s)
- Amanda M Evans
- John Hunter Children's Hospital, New Lambton Heights, New South Wales, Australia;
| | - Monique Jonas
- Department of General Practice, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; and
| | - John Lantos
- Bioethics Center, Children's Mercy Hospital, Kansas City, Missouri
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Cooley L, Hudson J, Potter E, Raymond KF, George C, Georgiopoulos AM. Clinical communication preferences in cystic fibrosis and strategies to optimize care. Pediatr Pulmonol 2020; 55:948-958. [PMID: 31977168 DOI: 10.1002/ppul.24655] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 01/10/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND The importance of optimizing communication between clinicians and individuals and families living with cystic fibrosis (CF) about daily care, adherence, and related psychosocial concerns is well documented. The purpose of this study was to gain an understanding of interpersonal communication experiences and preferences among individuals and families living with CF as they engage with the clinical team. The study also aimed to reveal opportunities for enhancing future interpersonal communication practices. METHODS Five U.S. CF care centers participated in the following activities: (a) On-site observation of clinic interactions during outpatient visits; (b) On-site 1:1 interviews with individuals living with CF, their family members, and CF clinicians; (d) Focus groups conducted in person with CF care team members; (d) Focus groups conducted virtually with adults and family members with CF. Content analysis of transcripts and constant comparative methods were used to identify emergent themes. RESULTS Four themes related to participants' needs and preferences for clinic interactions emerged during analysis: (a) eliciting psychosocial concerns, (b) addressing childhood development and transitions, (c) negotiating agendas and sharing decisions, and (d) educating to enhance CF conversations. CONCLUSION CF clinicians and individuals and families living with CF expressed the need for resources and training to engage in better conversations with each other. Participants identified areas of high priority, including working together around social, psychological, and economic challenges, preparation for transition to adulthood, and sustaining daily care. Findings point to the value of developing advanced communication skills that foster trust-building, negotiating agendas, active listening, and collaborative goal-setting.
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Affiliation(s)
- Laura Cooley
- Division of Education and Outreach, Academy of Communication in Healthcare, Lexington, Kentucky
| | - Janella Hudson
- Division of Education and Outreach, Academy of Communication in Healthcare, Lexington, Kentucky
| | - Eileen Potter
- Department of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Katherine F Raymond
- Partnerships for Sustaining Daily Care, The Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Cynthia George
- Partnerships for Sustaining Daily Care, The Cystic Fibrosis Foundation, Bethesda, Maryland
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Savant AP, McColley SA. Cystic fibrosis year in review 2018, part 2. Pediatr Pulmonol 2019; 54:1129-1140. [PMID: 31125191 DOI: 10.1002/ppul.24365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 01/04/2023]
Abstract
Cystic fibrosis (CF) research and case reports were robust in the year 2018. This report summarizes publications related the multisystem effects of CF, pulmonary exacerbations, new and expanded therapies other than cystic fibrosis transmembrane conductance regulator modulator studies, and patient-reported priorities and outcomes.
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Affiliation(s)
- Adrienne P Savant
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Clinical and Translational Research, Stanley Manne Children's Research Institute, Chicago, Illinois.,Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Clinical and Translational Research, Stanley Manne Children's Research Institute, Chicago, Illinois.,Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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8
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Timmermans S, Stivers T. Clinical forecasting: Towards a sociology of prognosis. Soc Sci Med 2018; 218:13-20. [PMID: 30316131 DOI: 10.1016/j.socscimed.2018.09.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/15/2018] [Accepted: 09/17/2018] [Indexed: 01/28/2023]
Abstract
Much of our understanding of prognosis in clinical settings comes from end-of-life situations but prognostication is also a concern in chronic illnesses. Parents of children living with seizures wonder what the future holds: will the child outgrow their seizures, or will they remain a part of their child's life? Based on video recordings of clinic consultations between pediatric neurologists and families, we examine how clinicians convey a child's prognosis. We find that neurologists mainly communicate the prognosis indirectly through the goals they set for the child, the time frame of attaining these goals, and the uncertainties they highlight regarding the attainability of the goals. By modulating goals and erring on the side of optimism, clinicians maintain a collaborative relationship even if the prognosis turns increasingly dire.
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Dellon EP, Helms SW, Hailey CE, Shay R, Carney SD, Schmidt HJ, Brown DE, Prieur MG. Exploring knowledge and perceptions of palliative care to inform integration of palliative care education into cystic fibrosis care. Pediatr Pulmonol 2018; 53:1218-1224. [PMID: 29862668 DOI: 10.1002/ppul.24073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/05/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Individuals with cystic fibrosis (CF) face the challenges of managing a chronic, progressive disease. While palliative care is a standard of care in serious illnesses, there are no guidelines for its incorporation into CF care. Patients with CF, caregivers, and CF care providers may lack knowledge about palliative care and perceive barriers to integrated care. OBJECTIVES To: 1) explore knowledge and perceptions of palliative care among patients with CF, caregivers, and CF care providers; 2) solicit opinions about incorporating palliative care into routine CF care; and 3) solicit recommendations for CF-specific palliative care education for patients and caregivers. METHODS We conducted semi-structured interviews with adult patients with CF, parents of adolescents with CF, and CF care providers to assess knowledge and perceptions of palliative care. Discussion included suggestions for palliative care education and integration into CF care. The sample was characterized using summary statistics. Key themes were identified using qualitative content analysis. RESULTS Ten patients with CF, ten parents, and eight CF care providers participated. Many had minimal knowledge of palliative care and endorsed the association with end of life as a barrier to palliative care, but after learning more about palliative care, thought it could be helpful, and should be introduced earlier. CONCLUSIONS In this single center study, many patients with CF, caregivers, and providers lacked knowledge about palliative care. These findings warrant replication in a larger, multisite study to inform palliative care educational interventions as a step toward consistent integration of palliative care into routine CF care.
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Affiliation(s)
- Elisabeth P Dellon
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sarah W Helms
- Delores Barr Weaver Policy Center, Jacksonville, Florida
| | - Claire E Hailey
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Rosemary Shay
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Scott D Carney
- Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio
| | - Howard Joel Schmidt
- Department of Pediatrics, The Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - David E Brown
- Department of Pediatrics, University of South Carolina School of Medicine, Columbia, South Carolina
| | - Mary G Prieur
- Departments of Psychiatry and Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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