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

Children's participation rights and the role of pediatric healthcare teams: A critical review

AIM

A critical review examined how childrens participation rights as represented in the United Nations Convention on the Rights of the Child inform the work of pediatric teams in healthcare settings.

METHODS

We systematically searched peer-reviewed literature on the enactment of child participation rights, within the context of pediatric teams. Articles were evaluated using the LEGEND (Let Evidence Guide Every New Decision) tool. Data extraction and analysis highlighted themes and disparities between articles, as well as gaps. A total of 25 studies were selected.

RESULTS

We reviewed studies from around the globe, with the majority of papers from the UK. Qualitative and mixed methods approaches were administered. The following observations were made: (1) limited language of children's rights exists in the literature, (2) lack of information regarding the composition of pediatric healthcare teams and how they work with children, (3) children's perspectives on what constitutes good interactions with healthcare providers are replicated, (4) minimal references to theory or philosophical underpinnings that can guide practice.

CONCLUSION

Explicit references to children's participation rights are lacking in the literature which may reflect the absence of rights language that could inform pediatric practice. Descriptive understandings of the tenets of pediatric interprofessional team composition and collaboration are necessary if we are to imagine the child as part of the team along with their family. Despite these shortcomings, the literature alludes to children's ability to discern desirable interactions with healthcare providers.

The Barriers to Shared Decision-making in Exercise Prescription for Children With Asthma: A Qualitative Study From Parents' Perspective

INTRODUCTION

The knowledge of barriers from the parental perspective is essential for facilitating shared decision-making in the field of pediatric asthma.

METHOD

Participants who were parents of children with a diagnosis of asthma were recruited, and in-depth, semistructured interviews were conducted. The interview transcripts were analyzed thematically using framework methods.

RESULTS

Seventeen participants undertook interviews. Three themes and nine subthemes emerged: (1) decision-making need level-limited understanding of decision-making knowledge, ambiguity regarding self-empowerment roles, and lack of family member support; (2) decision-making support level-insufficient ability to evaluate information, inefficient communication with health care professionals, and excessive use of professional terminology; and (3) decision-making outcome level-doubts about the final decision-making choices, time constraints on decision-making, and absence of mechanisms to track decisions made.

DISCUSSION

The findings would serve as crucial foundations for the development of decision-aid programs within the context of pediatric asthma.

Shared decision-making between paediatric haematologists, children with sickle cell disease and their parents: an exploratory study

Children with sickle cell disease (SCD) face various healthcare choices to be made during the disease process that may impact their lives. Shared decision-making (SDM) could improve their health outcomes. We assessed if, and to what extent, paediatricians engage children with SCD and/or their parents in the decision-making process. In this observational cross-sectional study, paediatric SCD patients and their parents visiting the outpatient paediatrics clinic of a university hospital participated in a SDM baseline measurement. Two evaluators independently and objectively analysed the level of patient involvement in decision-making from the audio-recordings of the consultations using the OPTION-5 instrument, a 0-20-point scale from which scores are usually expressed as a percentage of ideal SDM. The level of SDM, as perceived by patients, parents and paediatricians, was appreciated using the SDM-Q-9 and SDM-Q-Doc questionnaires, respectively. Scores could range from 0% (no SDM) to 100% (exemplary SDM). Twenty-four consultations in which a decision needed to be made about SCD treatment were audiotaped and analysed; six were from each paediatrician. The group consisted of 17 male and 7 female patients from various cultural backgrounds between 2 and 17 years old, with a mean age of 9.4 years (SD 4.2). Median OPTION-5 scores were 25.0% [IQR] 20.0-40.0%; range 0-55%). Median SDM-Q-9 and SDM-Q-Doc scores were 56.7% (IQR 39.4-88.9%) and 68.9% (IQR 57.8-77.8%), respectively.

CONCLUSION

Although subjective scores of SDM were fair, the objectively scored level of SDM among children suffering from SCD leaves room for improvement. This may be realized by increasing knowledge about the benefits of SDM, child-centred SDM interventions and SDM-training for paediatricians that takes into account the complexity of intercultural challenges and risk communication between stakeholders.

WHAT IS KNOWN

• Children that suffer from sickle cell disease (SCD) are more vulnerable to factors that negatively impact the care that they receive as well as suboptimal health outcomes. • Shared decision-making (SDM) can help children participate in a collaborative decision-making process about their preferred treatment options and improve their health outcomes.

WHAT IS NEW

• The level of participation in the decision-making process for patients suffering from SCD and the families that they belong to leaves room for improvement. The impact of intercultural challenges and the quality and consistency of risk-communication between stakeholders in paediatric SDM needs further exploration. • Paediatricians are more confident about their ability to involve the child and parents compared to how children and their parents experience their level of involvement in a shared decision-making process.

Ethical Considerations in Critically Ill Neonatal and Pediatric Patients

The care of critically ill neonates and pediatric patients can be particularly emotionally and ethically challenging. Emerging evidence suggests that we can improve the patient, family, and care team experience in the critical care setting through a better understanding and application of ethical frameworks and communication strategies. We conducted a multidisciplinary panel session at the American Academy of Pediatrics National Conference and Exhibition in the fall of 2022 wherein we explored a myriad of ethical and communication considerations in this unique patient population, with congenital diaphragmatic hernia (CDH) as the congenital anomaly/disease framework. In this review, we will cover state of the art topics in ethics, communication, and palliative care including basic terminology, communication strategies such as trauma-informed communication, establishing/evolving goals of care, futility, medically inappropriate treatment, ethical frameworks, parental discretion, establishing milestones, internal/external intentions, and re-direction of care. These topics will be helpful to many specialties who are involved in the care of critically ill neonates and children including maternal fetal medicine, pediatrics, neonatology, pediatric critical care, palliative care, and pediatric surgery, along with the pediatric surgical subspecialties. We use a theoretical CDH case as an example and include the live audience responses from the interactive session. This primer provides overarching educational principles, as well as practical communication concepts, that can cultivate compassionate multidisciplinary teams, equipped to optimize family-centered, evidence-based compassionate communication and care.

Pediatric neuropalliative care

Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.

Healthcare professional and professional stakeholders' perspectives on vaccine mandates in Switzerland: A mixed-methods study

BACKGROUND

There currently are no mandatory vaccines in Switzerland. However, Swiss federal legislation allows for vaccination mandates in settings where the risk of transmission to vulnerable groups is high, such as healthcare professionals (HCPs) working with vulnerable patients. Since HCPs are trusted information sources, a priority population for COVID-19 vaccination, and potentially subjected to mandates, we investigated HCP perspectives on mandates.

METHODS

A national online survey was administered to HCPs (October 2020-March 2021), including vaccine mandates questions concerning patients (measles) and HCPs (influenza). We qualitatively investigated HCP mandate perspectives through: (1) 34 interviews with HCPs, HCP professional society representatives, and health authorities; (2) a focus group discussion (FGD) with complementary medicine (CM) and biomedical physicians, and Swiss Federal Vaccination Commission members.

RESULTS

1933 participants (496 physicians, 226 pharmacists, 607 nurses, 604 midwives) responded to the survey. Quantitative results show all professional groups preferred shared parent-HCP measles vaccine decisions (65%, 54%, 50%, 48%, respectively; p for trend < 0.001). Midwives (87%) and nurses (70%) preferred individual influenza vaccination decisions for HCPs, while physicians (49%) and pharmacists (44%) preferred shared employee-employer decisions (p for trend < 0.001). Physicians (p < .001) and pharmacists (p < .01) with CM training favored individual influenza vaccination decisions. Qualitative results show general HCP opposition to vaccine mandates, mainly because participants argued how other approaches, such as HCP training and better information, could encourage uptake. Arguments against COVID-19 mandates included insufficiently documented long-term safety/efficacy data. From participants' perspectives, mandated vaccination should be used as a last resort. Some participants expressed fear that with mandates, notably for influenza and COVID-19, some HCPs might leave their jobs. HCPs were unsure what vaccine mandates would concretely look like in practice, particularly regarding sanctions for non-compliance and enforcement.

CONCLUSION

In Switzerland, HCPs generally were opposed to vaccination mandates. Clarity and guidance are needed from health authorities to better inform discussions around vaccine mandates.

Factors affecting decision-making in children with complex care needs: a consensus approach to develop best practice in a UK children's hospital

BACKGROUND

Children with complex care needs are a growing proportion of the sick children seen in all healthcare settings in the UK. Complex care needs place demands on parents and professionals who often require many different healthcare teams to work together. Care can be both materially and logistically difficult to manage, causing friction with parents. These difficulties may be reduced if common best practice standards and approaches can be developed in this area.

OBJECTIVE

To develop a consensus approach to the management of complexity among healthcare professionals, we used a modified Delphi process. The process consisted of a meeting of clinical leaders to develop candidate statements, followed by two survey rounds open to all professionals in a UK children's hospital to measure and establish consensus recommendations.

RESULTS

Ninety-nine professionals completed both rounds of the survey, 69 statements were agreed. These pertained to seven thematic areas: standardised approaches to communicating with families; processes for interprofessional communication; processes for shared decision-making in the child's best interests; role of the multidisciplinary team; managing professional-parental disagreement and conflict; the role of clinical psychologists; and staff support. Overall, the level of consensus was high, ranging from agreement to strong agreement.

CONCLUSIONS

These statements provide a consensus basis that can inform standardised approaches to the management of complexity. Such approaches may decrease friction between parents, children and healthcare professionals.

No wrong decisions in an all-wrong situation. A qualitative study on the lived experiences of families of children with diffuse intrinsic pontine glioma

BACKGROUND

Diffuse intrinsic pontine glioma (DIPG) is a rare, but lethal pediatric brain tumor with a median survival of less than 1 year. Existing treatment may prolong life and control symptoms, but may cause toxicity and side effects. In order to improve child- and family-centered care, we aimed to better understand the treatment decision-making experiences of parents, as studies on this topic are currently lacking.

PROCEDURE

The data for this study came from 24 semistructured interviews with parents whose children were diagnosed with DIPG in two children's hospitals in Switzerland and died between 2000 and 2016. Analysis of the dataset was done using reflexive thematic analysis.

RESULTS

For most parents, the decision for or against treatment was relatively straightforward given the fatality of the tumor and the absence of treatment protocols. Most of them had no regrets about their decision for or against treatment. The most distressing factor for them was observing their child's gradual loss of independence and informing them about the inescapability of death. To counter this powerlessness, many parents opted for complementary or alternative medicine in order to "do something." Many parents reported psychological problems in the aftermath of their child's death and coping strategies between mothers and fathers often differed.

CONCLUSION

The challenges of DIPG are unique and explain why parental and shared decision-making is different in DIPG compared to other cancer diagnoses. Considering that treatment decisions shape parents' grief trajectory, clinicians should reassure parents by framing treatment decisions in terms of family's deeply held values and goals.

International Standards for Pediatric Palliative Care: From IMPaCCT to GO-PPaCS

CONTEXT

Since the publication of the IMPaCCT project in 2007, much effort has been made to develop new approaches to pediatric palliative care (PPC). Fifteen years later, it is time to redefine the standards in PPC.

OBJECTIVES

An international group of experts in PPC has revised the standards in PPC through the GO-PPaCS project (Global Overview - PPC Standards). The goal was to update the PPC standards considering the specificity of different settings, resources, and emerging challenges. The present document is intended to reach all people directly or indirectly involved in PPC.

METHODS

A literature review in MEDLINE was conducted to expand on the fundamental points and current standards on PPC and to cover an international setting. The literature search (updated on the 15th of April 2021) was carried out using different combinations of keywords and focusing on papers published in English over the past 5 years (2016-2020), but older articles were considered when relevant. The consensus on the fundamental points, standards of care and paper contents was reached by open discussion.

RESULTS

Fundamental points were defined regarding the definition of PPC, eligibility criteria and the magnitude of the need for PPC, while standards were redefined for the following six areas: 1) clinical, developmental, psychological, social, ethical and spiritual needs; 2) end-of-life care; 3) care models and settings of care; 4) PPC in humanitarian emergencies; 5) care tools; and 6) education and training for healthcare providers.

CONCLUSION

The present document, developed with the contribution of an international group of experts from different countries, experiences and models of care, provides fundamental points and standards for a wider implementation of PPC worldwide.

Moral equivalence theory in neonatology

This article explores the ethical concept of "the equivalence thesis" (ET), or the idea that withdrawing and withholding life sustaining treatments are morally equivalent practices, within neonatology. We review the historical origins, theory, and clinical rationale behind ET, and provide an analysis of how ET relates to literature that describes neonatal mode of death and healthcare professional and parent attitudes towards end-of-life care. While ET may serve as an ethical tool to optimize resource allocation in theory, its clinical utility is limited given the complexity of end-of-life care decisions.

Whom are we seeking to protect? Extremely preterm babies and moral distress

Advances in perinatal care bring with them ethical challenges and difficult questions. When should we provide life-sustaining interventions, and who should decide? Particularly at the edges of viability, some clinicians may feel required to provide a level of care that they believe is not in the patient's interests, resulting in moral distress. This article will discuss the complex nature of moral distress arising during the care of extremely preterm babies. It will describe the challenges and cognitive biases present when contemplating potential harms to the baby and recognize the possible costs to both healthcare provider and baby when moral distress arises. Both clinicians caring for extremely preterm babies and the families themselves can experience moral distress. This article argues that for clinicians, recognizing the range of possible sources of moral distress is vital in order to appropriately address moral distress. Moral distress may arise from a desire to protect the baby, but also from an impulse to protect oneself from the emotional burdens of care. Addressing moral distress requires reflection on the factual beliefs, experiences and personal values which lie behind the distress, both within oneself and in discussion with colleagues. Moral distress indicates that a situation is ethically challenging, but it does not necessarily mean that a wrong decision has been made.

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.

Good enough? Parental decisions to use DIY looping technology to manage type 1 diabetes in children

People are using innovative internet of things technologies to gain individualised management of their type 1 diabetes. The #WeAreNotWaiting movement supports them to build their own hybrid closed loop systems and access their real time blood sugar data via any web connected device. A small number of parents in Australia use such DIY looping systems to manage their child's type 1 diabetes, but these systems have not been approved by the Therapeutic Goods Administration in Australia, creating ethical dilemmas for clinicians about how to respond to the use of medical devices that are not registered on the Australian Register of Therapeutic Goods. This article considers whether the use of DIY looping is in the best interests of the child and, if not, whether intervention in parental decision making is justified to prevent harm to the child. It addresses the ongoing duty of healthcare professionals to provide care to children who are 'looping.' Reference is made to findings from a study, Personalised Closed Loop Systems for Childhood Diabetes, to illustrate stakeholders' perceptions of benefits and harms of DIY looping systems. I conclude that the decision of parents to use DIY looping technology could be considered to be in a child's best interests, broadly defined, and falls within the Zone of Parental Discretion, however healthcare practitioners who support parents may have professional concerns in doing so.

The theorisation of 'best interests' in bioethical accounts of decision-making

BACKGROUND

Best interests is a ubiquitous principle in medical policy and practice, informing the treatment of both children and adults. Yet theory underlying the concept of best interests is unclear and rarely articulated. This paper examines bioethical literature for theoretical accounts of best interests to gain a better sense of the meanings and underlying philosophy that structure understandings.

METHODS

A scoping review of was undertaken. Following a literature search, 57 sources were selected and analysed using the thematic method.

RESULTS

Three themes emerged. The first placed best interests within the structure of wider theory, noting relationships with consequentialism, deontology, prudential value theory, rights and political philosophy. The second mapped a typology of processes of decision-making, among which best interests was ambiguously positioned. It further indicated factors that informed best interests decision-making, primarily preferences, dignity and quality of life. The final theme considered best interests from a relational perspective.

CONCLUSIONS

Characterisation of best interests as strictly paternalist and consequentialist is questionable: while accounts often suggested a consequentialist basis for best interests, arguments appeared philosophically weak. Deontological accounts, found in law and Kantianism, and theories of political liberalism influenced accounts of best interests, with accounts often associating best interests with negative patient preferences (i.e. individual refusals). There was much more emphasis on negative interests than positive interests. Besides preference, factors like dignity and quality of life were held to inform best interests decisions, but generally were weakly defined. To the extent that preferences were unable to inform decision making, decisions were either made by proxy authority or by an intersubjective process of diffuse authority. Differing approaches reflect bifurcations in liberal philosophy between new liberalism and neo-liberalism. Although neither account of authority appears dominant, bias to negative interests suggests that bioethical debate tends to reflect the widespread ascendancy of neo-liberalism. This attitude was underscored by the way relational accounts converged on private familial authority. The visible connections to theory suggest that best interests is underpinned by socio-political trends that may set up frictions with practice. How practice negotiates these frictions remains a key question.

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.