Children's rights in pediatrics

What does the best interests principle of the convention on the rights of the child mean for paediatric healthcare?

The present review analyses the implications of the best interests of the child principle, which is one of the most widely discussed principles of medical ethics and human rights, for paediatric healthcare. As a starting point, it presents the interpretation of the best interests principle by the United Nations Committee on the Rights of the Child. On this basis, it points out possible fields of application of the best interests principle with regard to paediatric healthcare and discusses the potential difficulties in the application of the best interests principle. Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing.   Conclusion: The best interests principle requires action, inter alia, by health policymakers, professional associations, hospital managers and medical teams to ensure children receive the best possible healthcare. Whilst the best interests principle does not provide a conclusive solution to all ethical dilemmas in paediatric healthcare (as illustrated by the case studies), it provides children, medical teams, parents and families, and clinical ethicists with an indispensable framework for health care centred on the rights of the child. What is Known: • The best interests principle is one of the most widely discussed principles of medical ethics and human rights and one of the four general principles of the Convention on the Rights of the Child. What is New: • The present review discusses possible fields of application and potential difficulties of the best interests principle with regard to paediatric healthcare. • Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing.

Combining the best interest standard with shared decision-making in paediatrics-introducing the shared optimum approach based on a qualitative study

Paediatric decision-making is the art of respecting the interests of child and family with due regard for evidence, values and beliefs, reconciled using two important but potentially conflicting concepts: best interest standard (BIS) and shared decision-making (SD-M). We combine qualitative research, our own data and the normative framework of the United Nations Convention on the Rights of Children (UNCRC) to revisit current theoretical debate on the interrelationship of BIS and SD-M. Three cohorts of child, parent and health care professional interviewees (N_total = 47) from Switzerland and the United States considered SD-M an essential part of the BIS. Their responses combined with the UNCRC text to generate a coherent framework which we term the shared optimum approach (SOA) combining BIS and SD-M. The SOA separates different tasks (limiting harm, showing respect, defining choices and implementing plans) into distinct dimensions and steps, based on the principles of participation, provision and protection. The results of our empirical study call into question reductive approaches to the BIS, as well as other stand-alone decision-making concepts such as the harm principle or zone of parental discretion.Conclusion: Our empirical study shows that the BIS includes a well-founded harm threshold combined with contextual information based on SD-M. We propose reconciling BIS and SD-M within the SOA as we believe this will improve paediatric decision-making. What is Known: • Parents have wide discretion in deciding for their child in everyday life, while far-reaching treatment decisions should align with the child's best interest. • Shared decision-making harbours potential conflict between parental authority and a child's best interest. What is New: • The best interest standard should not be used narrowly as a way of saying "Yes" or "No" to a specific action, but rather in a coherent framework and process which we term the shared optimum approach. • By supporting this child-centred and family-oriented process, shared decision-making becomes crucial in implementing the best interest standard.

Children's rights as law in Sweden-every health-care encounter needs to meet the child's needs

Background

In 2020, the United Nations Convention on the Rights of the Child (UNCRC) became law in Sweden. This puts extra demands on Swedish health care for children in need. This study aimed to investigate children's experiences and paediatric nurses' experiences of caring in accordance with the UNCRC.

Methods

Interviews were conducted in 2019 with 10 children and 13 nurses at a paediatric clinic in western Sweden. Child and nurse data were analysed separately with qualitative content analysis. The results are presented as a synthesis of the combined analysis of both data sets.

Results

Children did not always meet health‐care professionals with the necessary competence to care for them, and they were not always cared for in a child‐friendly environment. Even though nurses in paediatric care had the competence necessary to meet children's rights in health care, organizational issues made it challenging. Providing health care in accordance with the UNCRC principles required time and competence. Sufficient time to help children participate in their care and ensure that they feel secure was considered necessary—regardless of the health‐care context.

Conclusion

Health‐care encounters without the necessary time or competence can affect children and future encounters negatively. Instruments to safeguard children's rights in health care need to be developed and implemented, such as a documentation system to make children's rights visible and/or UNCRC certification. Implementation of UNCRC principles in all health‐care situations for children as standardized care requires competence, involvement, strong leadership and economic support. Children's voices in research can assist in guiding care.

Design and Validation of an Instrument To Measure a Minor's Maturity When Faced with Health Decisions

Decision-making capacity in children and adolescents in healthcare requires thorough assessment: the minor's maturity, understanding of the decision, risk of the situation and contextual factors needs to be explored. The intention was to design and validate a test-the Maturtest-to assess the maturity of minors in decision-making processes in healthcare. A reasoning test on moral conflicts for adolescents was designed to infer the degree of maturity of minors applied to decision-making regarding their own health. The test was completed by a sample of 441 adolescents aged from twelve to sixteen, with a corresponding analysis of their psychometric skills to measure feasibility, viability, reliability, validity, and sensitivity to change. Psychometric test results showed viability, reliability, validity, and sensitivity to change. High correlation (correlation index = 0.74) between the test score and the reference method were notable. A high stability was obtained with an intraclass correlation coefficient (r = 0.77). The average response time of the test was twenty-three minutes. This test measures the moral maturity of adolescents. It is presented as an objective, useful, valid, reliable tool, easy to fill out, edit and apply in a healthcare context. It helps to assess the maturity of minors faced with a decision.

Managing discomfort and developing participation in non-emergency MRI: Children's coping strategies during their first procedure

INTRODUCTION

Building on existing work, this paper aims to develop a detailed analysis of the practical coping strategies developed by children who had not previously experienced an MRI, regarding a non-emergency examination of the brain.

METHODS

Semi-structured interviews with 22 children, aged between eight and sixteen years, were conducted immediately post-procedure. Emergent data were thematically analysed in line with the core precepts of Grounded Theory, and triangulated against interview data with their parents where pertinent.

RESULTS

The primary concern among interviewees related to how they had coped with the discomfort of an unfamiliar medical procedure; this was recurrently managed through a process herein termed Participation Development. This comprised three phases. The first, preparative participation, describes the children's reported attempts to ready themselves for the examination (with parents) ahead of arriving in hospital. The second, enabling participation, describes how the children (with input from parents and radiographers) endeavoured to understand what was to come, and select viable distraction techniques. Finally, sustaining participation describes the children's reports of actualizing their preparations during the examination itself. Where the overall process of participation development was successful, the children reported a sense of mastery, growth and even joy.

CONCLUSION

While much work in the domain portrays children as relatively 'passive' agents during an MRI procedure, the findings herein point to how they can (with varying degrees of success) actively and constructively work with others. This, it is contended, has direct import for the improvement of support, both prior to and within a procedure itself.

Self-determination, healthcare treatment and minors in Italian clinical practice: ethical, psychological, juridical and medical-legal profiles

Background and aim: The social role of the minor, as indeed that of the physician, has changed markedly. This transformation has given rise to new patterns and responsibilities in the management of healthcare procedures that involve minors. Discussion: According to international legislation, in the clinical setting, as in other areas of social life, minors have the right to be heard and to have their opinions taken into consideration as an increasingly determining factor, in accordance with their age and degree of maturity and discernment. The authors describe the right to information and the decision-making process when the patient is a minor and underline the role of the parties involved (physicians, parents, under-age patient, judge) in various circumstances. Specifically, the paper analyzes the ethical and legal issues relating to the entitlement to decisions concerning the medical treatment of children and assesses the importance that Italian law attaches to the will of minors in the healthcare choices that affect them. Conclusions: Healthcare workers are called upon to face new challenges in order to ensure that healthcare services are able to safeguard the interests of minors while, at the same time, respecting their will. How to evaluate children’s competence to consent and how to balance the autonomy of parents and minors are crucial questions which the law courts in the various countries are increasingly being asked to address. These issues require close collaboration among various figures (parents, doctors, psychologists, judges) and imply the ethical need to undergo continuous training. (www.actabiomedica.it)

Pediatric nurses’ ethical difficulties in the bedside care of children

Background:

Pediatric nurses experience ethically difficult situations in their everyday work. Several studies have been conducted to reveal ethical issues among pediatric nurses; we do not think their ethical difficulties have been explored sufficiently from their own perspective.

Objectives:

This study aimed to explore the ethical difficulties faced by pediatric nurses during bedside care for hospitalized children.

Methods:

A phenomenological approach was used to collect and analyze interview data from 14 female pediatric nurses in South Korea.

Ethical considerations:

Ethical review was obtained from an ethics committee. The participants were informed about the aim of the study, and voluntary participation, anonymous response, and confidentiality were explained to them.

Findings:

Three themes emerged from the analysis: ethical numbness in a task-oriented context, negative feelings toward family caregivers, and difficulty in expressing oneself in an authoritative climate. Conclusion and implications: We need to develop strategies to manage ethical difficulties at an institutional level. Furthermore, it is important that pediatric nurses have the opportunity to communicate with fellow nurses and other medical staff regarding ethical difficulties. In addition, cultivation of pediatric nurses’ moral, ethical, and philosophical thinking patterns requires the immediate provision of continuous education in nursing ethics at the site of clinical nursing, time to discuss ethical difficulties, and other supportive measures. Findings indicated that, to provide high-quality patient-centered care, we should enhance nurses’ ethical sensitivity and autonomy and improve the ethical climate in hospitals.

Child care and health rights: perspectives of adolescent mothers

AbstractOBJECTIVETo analyze child health care and the defense of their rights from the perspective of adolescent mothers.METHODSAn exploratory study with qualitative thematic analysis of data, based on conceptual aspects of care and the right to health, from semi-structured interviews with 20 adolescent mothers ascribed by Family Health teams.RESULTSMaternal reports indicate that child health care requires responsibility and protection, with health practices that promote child advocacy. Gaps in assistance which preclude the full guarantee of the right to child health care were also highlighted.CONCLUSIONThe right to health care assumed different meanings, and the forms to guarantee them were linked to individual behavior in detriment to broader actions that consider health as a social product, connected to the guarantee of other fundamental rights.

Primerjava poznavanja otrokovih pravic med starši hospitaliziranih otrok in medicinskimi sestrami

Uvod: Pravice bolnih otrok imajo v modernih družbah status samostojnih pravic, ki jih je potrebno upoštevati in ustrezno varovati. Odvisne so od razvitosti družbe in zmogljivosti zdravstvenega sistema in bi jih morali poznati zdravstveni delavci, starši, skrbniki in otroci. Namen raziskave je bila primerjava poznavanja pravic otrok v bolnišnici med starši hospitaliziranih otrok in medicinskimi sestrami. Metode: Uporabljena je bila neeksperimentalna metoda raziskovanja, podatki so bili zbrani z strukturiranim vprašalnikom na vzorcu staršev hospitaliziranih otrok (n = 49) in medicinskih sester (n = 60). Vprašalnik je bil predhodno testiran. Za analizo zbranih podatkov smo uporabili osnovno deskriptivno statistiko ter bivariatno analizo (test hi-kvadrat, t-test). Rezultati: Raziskava pokaže statistično značilne razlike med starši in medicinskimi sestrami v stopnji seznanjenosti s pravicami bolnih otrok, ki temeljijo na Listini Evropskega združenja za pravice otrok v bolnišnicah (t = 5,828, p < 0,001). Diskusija in zaključek: Poznavanje pravic otrok v bolnišnici je višje pri medicinskih sestrah kot pri starših hospitaliziranih otrok. Razlike so največje glede poznavanja načina komunikacije medicinskih sester s starši, glede razporeditve otrok na oddelke in ustvarjanja pogojev za igro ter izobraževanje v času bivanja v bolnišnici in glede pogojev sprejema v bolnišnico. Med obema skupinama ni razlik v oceni tega, v kolikšni meri se pravice otrok, ki temeljijo na Listini Evropskega združenja za pravice otrok v bolnišnicah, spoštujejo, obe skupini ocenjujeta, da je stopnja spoštovanja pravic dokaj visoka.

Actual implementation of sick children's rights in Italian pediatric units: a descriptive study based on nurses' perceptions

Background

Several charters of rights have been issued in Europe to solemnly proclaim the rights of children during their hospital stay. However, notwithstanding such general declarations, the actual implementation of hospitalized children’s rights is unclear. The purpose of this study was to understand to which extent such rights, as established by the two main existing charters of rights, are actually implemented and respected in Italian pediatric hospitals and the pediatric units of Italian general hospitals, as perceived by the nurses working in them.

Methods

Cross-sectional study. A 12-item online questionnaire was set up and an invitation was sent by email to Italian pediatric nurses using professional mailing lists and social networks. Responders were asked to score to what extent each right is respected in their hospital using a numeric scale from 1 (never) to 5 (always).

Results

536 questionnaires were returned. The best implemented right is the right of children to have their mothers with them (mean score 4.47). The least respected one is the right of children to express their opinion about care (mean 3.01). Other rights considered were the right to play (4.29), the right to be informed (3.95), the right to the respect of privacy (3.75), the right to be hospitalized with peers (3.39), the right not to experience pain ever (3.41), and the right to school (3.07). According to the majority of nurses, the most important is the right to pain relief.

Significant differences in the implementation of rights were found between areas of Italy and between pediatric hospitals and pediatric units of general hospitals.

Conclusion

According to the perception of pediatric nurses, the implementation of the rights of hospitalized children in Italian pediatrics units is still limited.