1
|
Wren B, Ruck Keene A. Can the courts be viewed as an appropriate vehicle to settle clinical unease? JOURNAL OF MEDICAL ETHICS 2024; 50:452-459. [PMID: 37620135 DOI: 10.1136/jme-2023-109260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/12/2023] [Indexed: 08/26/2023]
Abstract
This paper is an exploration of the state of 'clinical unease' experienced by clinicians in contexts where professional judgement-grounded in clinical knowledge, critical reflection and a sound grasp of the law-indicates that there is more than one ethically defensible way to proceed. The question posed is whether the courts can be viewed as an appropriate vehicle to settle clinical unease by providing a ruling that clarifies the legal and ethical issues arising in the case, even in situations where there is no dispute between the patient (or her proxies) and the healthcare team.The concept of 'clinical unease' is framed with reference to the broader experience of clinical decision-making, and distinguished from other widely discussed phenomena in the healthcare literature like moral distress and conscientious objection. A number of reported cases are briefly examined where the courts were invited to rule in circumstances of apparent 'unease'. The respective responsibilities of clinicians and courts are discussed: in particular, their capability and readiness to respond to matters of ethical concern.Four imagined clinical scenarios are outlined where a clinical team might welcome a court adjudication, under current rules. Consideration is given to the likelihood of such cases being heard, and to whether there may be better remedies than the courts. There are final reflections on what clinicians may actually wish for in seeking court involvement, and on whether a willingness to engage with the experience of clinical unease may lead to greater sensitivity towards the value perspectives of others.
Collapse
Affiliation(s)
- Bernadette Wren
- Children, Young Adults and Families Directorate, Tavistock and Portman NHS Foundation Trust, London, UK
| | - Alexander Ruck Keene
- 39 Essex Chambers, London, UK
- Dickson Poon School of Law, Kings College London, London, UK
| |
Collapse
|
2
|
Pértega E, Holmberg C. A systematic mapping review identifying key features of restraint research in inpatient pediatric psychiatry: A human rights perspective. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2023; 88:101894. [PMID: 37244128 DOI: 10.1016/j.ijlp.2023.101894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/30/2023] [Accepted: 05/02/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Restraints, a highly regulated and contentious measure in pediatric psychiatry, have significant negative impacts on children. The application of international human rights standards, such as the Convention of the Rights of the Child (CRC) and the Convention of the Rights of Persons with Disabilities (CRPD), has spurred global efforts to reduce or eliminate the use of restraints. However, a lack of consensus on definitions and terminology, as well as quality indicators in this field, hinders the ability to compare studies and evaluate interventions consistently. AIM To systematically map existing literature on restraints imposed upon children in inpatient pediatric psychiatry against a human rights perspective. Specifically, to identify and clarify gaps in literature in terms of publication trends, research approaches, study contexts, study participants, definitions and concepts being used, and legal aspects. These aspects are central to assess whether published research is contributing to achieve the CRPD and the CRC in terms of interpersonal, contextual, operational, and legal requirements of restraints. METHODS A systematic mapping review based on PRISMA guidelines was conducted, adopting a descriptive-configurative approach to map the distribution of available research and gaps in the literature about restraints in inpatient pediatric psychiatry. Six databases were searched for literature reviews and empirical studies of all study designs published between each database's inception and March 24, 2021, manually updated on November 25, 2022. RESULTS The search yielded 114 English-language publications, with a majority (76%) comprising quantitative studies that relied primarily on institutional records. Contextual information about the research setting was provided in less than half of the studies, and there was an unequal representation of the three main stakeholder groups: patients, family, and professionals. The studies also exhibited inconsistencies in the terms, definitions, and measurements used to examine restraints, with a general lack of attention given to human rights considerations. Additionally, all studies were conducted in high-income countries and mainly focused on intrinsic factors such as age and psychiatric diagnosis of the children, while contextual factors and the impact of restraints were not adequately explored. Legal and ethical aspects were largely absent, with only one study (0.9%) explicitly referencing human rights values. CONCLUSIONS Research on restraints of children in psychiatric units is increasing; however, inconsistent reporting practices hinder the understanding of the meaning and frequency of restraints. The exclusion of crucial features, such as the physical and social environment, facility type, and family involvement, indicates inadequate incorporation of the CRPD. Additionally, the lack of references to parents suggests insufficient consideration of the CRC. The shortage of quantitative studies focusing on factors beyond patient-related aspects, and the general absence of qualitative studies exploring the perspectives of children and adolescents regarding restraints, suggest that the social model of disability proposed by the CRPD has not yet fully penetrated the scientific research on this topic.
Collapse
Affiliation(s)
- Elvira Pértega
- Faculty of Law, University of Technology Sydney, Sydney, Australia; Child and Adolescens Mental Health Department, Hospital Lucus augusti, Lugo, Spain.
| | - Christopher Holmberg
- Department of Psychotic Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Health and Care Science, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
3
|
Birchley G, Thomas-Unsworth S, Mellor C, Baquedano M, Ingle S, Fraser J. Factors affecting decision-making in children with complex care needs: a consensus approach to develop best practice in a UK children's hospital. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2022-001589. [PMID: 36645756 PMCID: PMC9528619 DOI: 10.1136/bmjpo-2022-001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/20/2022] [Indexed: 02/02/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Giles Birchley
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | | | - Charlotte Mellor
- Paediatric Palliative Care and Bereavement Support, Bristol Royal Hospital for Children, Bristol, UK
| | - Mai Baquedano
- Translational Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Susanne Ingle
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - James Fraser
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK.,Paediatric Critical Care Society, London, UK
| |
Collapse
|
4
|
Abdin S, Heath G, Neilson S, Byron‐Daniel J, Hooper N. Decision-making experiences of health professionals in withdrawing treatment for children and young people: A qualitative study. Child Care Health Dev 2022; 48:531-543. [PMID: 34994015 PMCID: PMC9306775 DOI: 10.1111/cch.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/20/2021] [Accepted: 12/31/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore factors that influence professionals in deciding whether to withdraw treatment from a child and how decision making is managed amongst professionals as an individual and as a team. STUDY DESIGN Semi-structured interviews were conducted with a purposive sample of health professionals working at a UK Children's Hospital, with children with life-limiting illnesses whose treatment has been withdrawn. Data were transcribed verbatim, anonymized and analysed using a thematic framework method. RESULTS A total of 15 participants were interviewed. Five interrelated themes with associated subthemes were generated to help understand the experiences of health professionals in decision making on withdrawing a child's treatment: (1) understanding the child's best interests, (2) multidisciplinary approach, (3) external factors, (4) psychological well-being and (5) recommendations to support shared decision making. CONCLUSION A shared decision-making approach should be adopted to support professionals, children and their families to make decisions collectively.
Collapse
Affiliation(s)
- Shanara Abdin
- Faculty of Health and Applied SciencesUniversity of the West of EnglandBristolUK,Public Health and WellbeingCity of Wolverhampton CouncilWolverhamptonUK
| | - Gemma Heath
- School of PsychologyAston UniversityBirminghamUK
| | - Susan Neilson
- School of NursingUniversity of BirminghamBirminghamUK
| | - James Byron‐Daniel
- Faculty of Health and Applied SciencesUniversity of the West of EnglandBristolUK
| | - Nic Hooper
- School of PsychologyCardiff UniversityCardiffUK
| |
Collapse
|
5
|
März JW. What does the best interests principle of the convention on the rights of the child mean for paediatric healthcare? Eur J Pediatr 2022; 181:3805-3816. [PMID: 36083315 PMCID: PMC9546983 DOI: 10.1007/s00431-022-04609-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 12/01/2022]
Abstract
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.
Collapse
Affiliation(s)
- Julian W. März
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| |
Collapse
|
6
|
Nieder TO, Mayer TK, Hinz S, Fahrenkrug S, Herrmann L, Becker-Hebly I. Individual Treatment Progress Predicts Satisfaction With Transition-Related Care for Youth With Gender Dysphoria: A Prospective Clinical Cohort Study. J Sex Med 2021; 18:632-645. [PMID: 33642235 DOI: 10.1016/j.jsxm.2020.12.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/26/2020] [Accepted: 12/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The number of adolescents presenting with gender dysphoria (GD) in healthcare services has increased significantly, yet specialized services offering transition-related care (TRC) for trans youth is lacking. AIM To investigate satisfaction with TRC, regret, and reasons for (dis)satisfaction with transition-related medical interventions (TRMIs) in trans adolescents who had presented to the Hamburg Gender Identity Service for children and adolescents (Hamburg GIS). METHODS Data were collected from a clinical cohort sample of 75 adolescents and young adults diagnosed with GD (81% assigned female at birth) aged 11 to 21 years (M = 17.4) at baseline and follow-up (on a spectrum of ongoing care, on average 2 years after initial consultation). To determine progress of the youth's medical transitions, an individual treatment progress score (ITPS) was calculated based on number of desired vs received TRMIs. OUTCOMES Main outcome measures were satisfaction with TRC at the time of follow-up, ITPS, social support, reasons for regret and termination of TRC, and (dis)satisfaction with TRMIs. RESULTS Participants underwent different stages of TRMIs, such as gender-affirming hormone treatment or surgeries, and showed overall high satisfaction with TRC received at the Hamburg GIS. Regression analysis indicated that a higher ITPS (an advanced transition treatment stage) was predictive of higher satisfaction with TRC. Sex assigned at birth, age, and time since initial consultation at the clinic showed no significant effects for satisfaction with TRC, while degree of social support showed a trend. No adolescents regretted undergoing treatment at follow-up. Additional analysis of free-text answers highlighted satisfaction mostly with the physical results of TRMI. CLINICAL IMPLICATIONS Because youth were more satisfied with TRC when their individual transition (ITPS) was more progressed, treatment should start in a timely manner to avoid distress from puberty or long waiting lists. STRENGTHS AND LIMITATIONS This study is one of the first to report on treatment satisfaction among youth with GD from Europe. The ITPS allowed for a more detailed evaluation of TRMI wishes and experiences in relation to satisfaction with TRC and may close a gap in research on these treatments in adolescent populations. However, all participants were from the same clinic, and strict treatment eligibility criteria may have excluded certain trans adolescents from the study. Low identification rates with non-binary identities prevented comparisons between non-binary and binary genders. CONCLUSION The study highlights the role of TRMI and individual treatment or transition progress for youth's overall high satisfaction with TRC received at the Hamburg GIS. Nieder TO, Mayer TK, Hinz S, et al. Individual Treatment Progress Predicts Satisfaction With Transition-Related Care for Youth With Gender Dysphoria: A Prospective Clinical Cohort Study. J Sex Med 2021;18:632-645.
Collapse
Affiliation(s)
- T O Nieder
- Institute For Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T K Mayer
- Institute For Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Hinz
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Fahrenkrug
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L Herrmann
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Inga Becker-Hebly
- Department of Child and Adolescent Psychiatry, Psychotherapy, and Psychosomatics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
7
|
Streuli JC, Anderson J, Alef-Defoe S, Bergsträsser E, Jucker J, Meyer S, Chaksad-Weiland S, Vayena E. Combining the best interest standard with shared decision-making in paediatrics-introducing the shared optimum approach based on a qualitative study. Eur J Pediatr 2021; 180:759-766. [PMID: 32809079 PMCID: PMC7886834 DOI: 10.1007/s00431-020-03756-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 11/25/2022]
Abstract
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 (Ntotal = 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.
Collapse
Affiliation(s)
| | - James Anderson
- Department of Bioethics, The Hospital for Sick Children, Toronto, Canada
| | - Sierra Alef-Defoe
- Institute of Biomedical Ethics and History, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| | - Eva Bergsträsser
- University Children’s Hospital and Children’s Research Center, Zurich, Switzerland
| | - Jovana Jucker
- Institute of Biomedical Ethics and History, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| | - Stephanie Meyer
- University Children’s Hospital and Children’s Research Center, Zurich, Switzerland
| | - Sophia Chaksad-Weiland
- Institute of Biomedical Ethics and History, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| | - Effy Vayena
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| |
Collapse
|
8
|
Nieder TO, Güldenring A, Woellert K, Briken P, Mahler L, Mundle G. Ethical Aspects of Mental Health Care for Lesbian, Gay, Bi-, Pan-, Asexual, and Transgender People: A Case-based Approach. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2020; 93:593-602. [PMID: 33005124 PMCID: PMC7513438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The lives of lesbian, gay, bi-, pan-, asexual, and transgender (LGBTA+/LGBT) people are not considered to be standard in society, unlike those of heterosexual cisgender people. This can lead to prejudices against LGBT people and may negatively influence their access to high-quality health care. Medical and mental health care have been characterized by attitudes (psycho-)pathologizing LGBT lives and therefore supported the stigmatization of LGBT people in the service of heteronormativity. Mental health professionals (MHPs) largely have transferred principles guiding counseling and psychotherapy with heterosexual (straight) cisgender persons to treatment of LGBT individuals without considering the specific features of LGBT lives. This is true even if the treatment is not exclusively LGBT-related, but can address LGBT-unrelated issues. To counteract this, the present paper aims to provide an insight into ethically sound mental health care for LGBT people. By applying the principles of biomedical ethics, we have analyzed how LGBT individuals can be discriminated against in mental health care and what MHPs may need to offer LGBT-sensitive high-quality mental health care. We argue that MHPs need LGBT-related expertise as well as LGBT-related sensitivity. MHPs should acquire specialist knowledge for the diverse lives and the challenges of LGBT people. We encourage MHPs to develop an understanding of how their own implicit attitudes towards LGBT people can affect treatment. However, the demand for special training should not be mistaken as a demand for a specific type of mental health care. The principles of general psychotherapy are equally the basis of psychotherapy with LGBT people.
Collapse
Affiliation(s)
- Timo O Nieder
- Institute for Sex Research, Sexual Medicine und Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annette Güldenring
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Westküstenklinikum Heide, Heide, Germany
| | - Katharina Woellert
- Institute for History and Ethics of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine und Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lieselotte Mahler
- Charité University Clinic for Psychiatry and Psychotherapy, Berlin, Germany
| | - Götz Mundle
- Zentrum für Seelische Gesundheit, Oberberg City, Berlin, Germany
| |
Collapse
|
9
|
Aubugeau-Williams P, Brierley J. Consent in children's intensive care: the voices of the parents of critically ill children and those caring for them. JOURNAL OF MEDICAL ETHICS 2020; 46:482-487. [PMID: 31776178 DOI: 10.1136/medethics-2019-105716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 06/10/2023]
Abstract
Despite its invasive nature, specific consent for general anaesthesia is rarely sought-rather consent processes for associated procedures include explanation of risk/benefits. In adult intensive care, because no one can consent to treatments provided to incapacitated adults, standardised consent processes have not developed. In paediatric intensive care, despite the ready availability of those who can provide consent, no tradition of seeking it exists, arguably due to the specialty's evolution from anaesthesia and adult intensive care. With the current Montgomery-related focus on consent, this seems untenable. We undertook a qualitative study in a specialist children's hospital colocated paediatric/neonatal intensive care (same medical team) in which parental acceptance of admission and entailed procedures is considered implied by virtue of that admission. Semistructured interviews were carried out with both staff and parents to investigate their views about consent, the current system and a proposed blanket consent system, in which parents actively consent at admission to routine procedures. Divergent views emerged: staff were worried that requiring consent at admission might prove a further emotional burden, whereas parents found providing consent a way of coping, feeling empowered and maintaining control. Inconsistencies were found in the way consent is obtained for your routine procedures. Practice does seem inconsistent with contemporary consent standards for medical intervention. Our findings support the introduction of a blanket consent system at admission together with ongoing bedside dialogue to ensure continuing consent. Both parents and staff expressed concern about avoiding possible harmful delays to children due to parental emotional overload and language difficulties.
Collapse
Affiliation(s)
- Phoebe Aubugeau-Williams
- University College London Medical School, University of London, London, UK
- Paediatric Bioethics Centre, University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Joe Brierley
- Paediatric Bioethics Centre, University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| |
Collapse
|
10
|
Gray C, Fordyce P. Legal and Ethical Aspects of 'Best Interests' Decision-Making for Medical Treatment of Companion Animals in the UK. Animals (Basel) 2020; 10:ani10061009. [PMID: 32526900 PMCID: PMC7341271 DOI: 10.3390/ani10061009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Making decisions about medical treatment for animal patients involves two key decision-makers, the animal owner and the veterinary surgeon. We aim to show that these decisions should and can be based on the ‘best interests’ of the animal, with both human decision-makers acting as advocates for the animal requiring treatment. We suggest that the role of the animal owner is similar to that of a parent in making decisions for a child, drawing on legal cases to demonstrate the limits of parental (and owner) decision-making. To provide a firmer basis for ‘best interests’ decision-making, we adapt the factors included in the United Nations Convention on the Rights of the Child and demonstrate how these could be used with a typical clinical situation. Finally, we analyse the decisions from an ethical point of view. Abstract Medical decisions for young children are made by those with parental responsibility, with legal involvement only if the decision is potentially detrimental to the child’s welfare. While legally classified as property, some argue that animals are in a similar position to children; treatment decisions are made by their owners, posing a legal challenge only if the proposed treatment has the potential to cause harm or unnecessary suffering, as defined by animal protection legislation. This paper formulates the approach to a ‘best interests’ calculation, utilising the factors included in the United Nations Convention on the Rights of the Child and relying on exchange of information between the human parties involved. Although this form of decision-making must primarily protect the animal from unnecessary suffering, it recognises that the information provided by the owner is critical in articulating the animal’s non-medical interests, and hence in formulating what is in the animal’s best overall welfare interests. While statute law does not mandate consideration of ‘best interests’ for animals, this approach might reasonably be expected as a professional imperative for veterinary surgeons. Importantly, this version of a ‘best interests’ calculation can be incorporated into existing ethical frameworks for medical decision-making and the humane treatment of animals.
Collapse
Affiliation(s)
- Carol Gray
- School of Law and Social Justice, University of Liverpool, Liverpool L69 7ZR, UK
- Correspondence:
| | - Peter Fordyce
- Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, UK;
| |
Collapse
|
11
|
Uncertainty Management and Decision Making: Parents' Experiences During their First Visit to a Multidisciplinary Clinic for their Child's Vascular Anomaly. J Pediatr Nurs 2020; 52:18-24. [PMID: 32106036 DOI: 10.1016/j.pedn.2020.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To gain a better understanding of parental decision making in situations of uncertainty and multidisciplinary care, we explored parents' decision-making experiences while seeking care for their child's vascular anomaly at a multidisciplinary clinic at a large Midwestern children's hospital. DESIGN AND METHODS We collected data using semi-structured interviews with 29 parents after they met with multiple specialists for the care of their child's vascular anomaly. RESULTS The findings revealed parents' attempts to manage decision-related uncertainty about their child's vascular anomaly included seeking information, avoiding information, and seeking support from the specialists. Parents described how information management both facilitated and obstructed decision making. CONCLUSIONS Overall, the study reveals several benefits and challenges of making decisions about the management of uncertain childhood conditions, like vascular anomalies, in a multidisciplinary context. The information-rich environment produces information-management dilemmas that challenge parents' decision making efforts. Therefore, parents relied on the support of the team of specialists to make decisions about their child's treatment. PRACTICE IMPLICATIONS The study offers practical implications concerning the barriers of autonomy in decision making. Healthcare professionals should acknowledge the potential for parents' to have shifting information and decision-making goals and preferences, and should explicitly support parents throughout the decision-making process.
Collapse
|
12
|
Uveges MK, Hamilton JB, DePriest K, Boss R, Hinds PS, Nolan MT. The Influence of Parents' Religiosity or Spirituality on Decision Making for Their Critically Ill Child: An Integrative Review. J Palliat Med 2019; 22:1455-1467. [PMID: 31369318 DOI: 10.1089/jpm.2019.0154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Religion and/or spirituality are important values for many parents of critically ill children; however, how religion and/or spirituality may influence which treatments parents accept or decline for their child, or how they respond to significant events during their child's illness treatment, remains unclear. Objective: To summarize the literature related to the influence of parents' religiosity or spirituality on decision making for their critically ill child. Design: Integrative review, using the Whittemore and Knafl approach. Setting/Subjects: Data were collected from studies identified through PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL plus), Embase, Scopus, and PsychInfo. Databases were searched to identify literature published between 1996 and 2016. Results: Twenty-four articles of variable methodological quality met inclusion criteria. Analysis generated three themes: parents' religiosity or spirituality as (1) guidance during decision making, (2) comfort and support during the decision-making process, and (3) a source of meaning, purpose, and connectedness in the experience of decision making. Conclusion: This review suggests that parents' religiosity and/or spirituality is an important and primarily positive influence on their decision making for a critically ill child.
Collapse
Affiliation(s)
- Melissa Kurtz Uveges
- Department of Global Health and Social Medicine, Center for Bioethics, Harvard Medical School, Boston, Massachusetts
| | - Jill B Hamilton
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | - Kelli DePriest
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Renee Boss
- Division of Neonatal-Perinatal Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Pamela S Hinds
- Department of Nursing Research and Quality Outcomes, Children's National Health System, Washington, DC
| | - Marie T Nolan
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
13
|
Abstract
Shared decision-making (SDM) is a well-established component of patient-centered care, and yet, its application in pediatrics is poorly understood. Common features of pediatric decision-making are not completely addressed in current SDM models, such as the fact that the principal SDM participant is the patient's surrogate, who, unlike competent adult patients deciding for themselves, has limitations on decision-making authority. To address this gap and improve the practice of SDM in pediatrics, a practical 4-step framework is presented. In step 1, physicians are posed the following question for any discrete decision: does the decision include >1 medically reasonable option? If the answer is no, SDM is not indicated. If the answer is yes, physicians proceed to step 2 and answer the following question: does 1 option have a favorable medical benefit-burden ratio compared with other options? If yes, physician-guided SDM is appropriate. If no, parent-guided SDM is appropriate. For each SDM approach, the physician proceeds to step 3 and answers the following question: how preference sensitive are the options? This helps to determine the specific SDM approach in step 4, which ranges from a strong or weak version of physician-guided SDM to a strong or weak version of parent-guided SDM. Several decisional characteristics, if present, can also help calibrate the version of SDM used. Additional analyses are needed to consider the inclusion of adolescents into this SDM framework.
Collapse
Affiliation(s)
- Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute; and Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
14
|
Ray S, Brierley J, Bush A, Fraser J, Halley G, Harrop EJ, Casanueva L. Towards developing an ethical framework for decision making in long-term ventilation in children. Arch Dis Child 2018; 103:1080-1084. [PMID: 29871903 DOI: 10.1136/archdischild-2018-314997] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/24/2018] [Accepted: 04/29/2018] [Indexed: 11/03/2022]
Abstract
The use of long-term ventilation (LTV) in children is growing in the UK and worldwide. This reflects the improvement in technology to provide LTV, the growing number of indications in which it can be successfully delivered and the acceptability of LTV to families and children. In this article, we discuss the various considerations to be made when deciding to initiate or continue LTV, describe the process that should be followed, as decided by a consensus of experienced physicians, and outline the options available for resolution of conflict around LTV decision making. We recognise the uncertainty and hope provided by novel and evolving therapies for potential disease modification. This raises the question of whether LTV should be offered to allow time for a therapy to be trialled, or whether the therapy is so unlikely to be effective, LTV would simply prolong suffering. We put this consensus view forward as an ethical framework for decision making in children requiring LTV.
Collapse
Affiliation(s)
- Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK.,Respiratory, Critical Care and Anaesthesia, UCL GOS Institute of Child Health, London, UK.,Child Health Ethics and Law Special Interest Group, UK
| | - Joe Brierley
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK.,Child Health Ethics and Law Special Interest Group, UK.,Department of Bioethics, Great Ormond Street Hospital for Children, London, UK
| | - Andy Bush
- Paediatric Respiratory Medicine, Royal Brompton Hospital and Harefields NHS Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - James Fraser
- Child Health Ethics and Law Special Interest Group, UK.,Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Trust, Bristol, UK
| | - Gillian Halley
- Children's Long-term Ventilation Service, Royal Brompton Hospital and Harefields NHS Trust, London, UK
| | - Emily Jane Harrop
- Child Health Ethics and Law Special Interest Group, UK.,Department of Paediatrics, Helen and Douglas House, Oxford, UK
| | - Lidia Casanueva
- Children's Long-term Ventilation Service, Royal Brompton Hospital and Harefields NHS Trust, London, UK.,Paediatric Palliative Care, Oxford University Hospitals NHS Trust, Oxford, UK
| |
Collapse
|
15
|
Birchley G. Charlie Gard and the weight of parental rights to seek experimental treatment. JOURNAL OF MEDICAL ETHICS 2018; 44:448-452. [PMID: 29773611 PMCID: PMC6047160 DOI: 10.1136/medethics-2017-104718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/28/2018] [Accepted: 04/26/2018] [Indexed: 06/08/2023]
Abstract
The case of Charlie Gard, an infant with a genetic illness whose parents sought experimental treatment in the USA, brought important debates about the moral status of parents and children to the public eye. After setting out the facts of the case, this article considers some of these debates through the lens of parental rights. Parental rights are most commonly based on the promotion of a child's welfare; however, in Charlie's case, promotion of Charlie's welfare cannot explain every fact of the case. Indeed, some seem most logically to extend from intrinsic parental rights, that is, parental rights that exist independent of welfare promotion. I observe that a strong claim for intrinsic parental rights can be built on arguments for genetic propriety and children's limited personhood. Critique of these arguments suggests the scope of parental rights remains limited: property rights entail proper use; non-personhood includes only a small cohort of very young or seriously intellectually disabled children and the uniqueness of parental genetic connection is limited. Moreover, there are cogent arguments about parents' competence to make judgements, and public interest arguments against allowing access to experimental treatment. Nevertheless, while arguments based on propriety may raise concerns about the attitude involved in envisioning children as property, I conclude that these arguments do appear to offer a prima facie case for a parental right to seek experimental treatment in certain limited circumstances.
Collapse
|
16
|
Huxtable R. Clinic, courtroom or (specialist) committee: in the best interests of the critically Ill child? JOURNAL OF MEDICAL ETHICS 2018; 44:471-475. [PMID: 29880659 DOI: 10.1136/medethics-2017-104706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 06/08/2023]
Abstract
Law's processes are likely always to be needed when particularly intractable conflicts arise in relation to the care of a critically ill child like Charlie Gard. Recourse to law has its merits, but it also imposes costs, and the courts' decisions about the best interests of such children appear to suffer from uncertainty, unpredictability and insufficiency. The insufficiency arises from the courts' apparent reluctance to enter into the ethical dimensions of such cases. Presuming that such reflection is warranted, this article explores alternatives to the courts, and in particular the merits of specialist ethics support services, which appear to be on the rise in the UK. Such specialist services show promise, as they are less formal and adversarial than the courts and they appear capable of offering expert ethical advice. However, further research is needed into such services - and into generalist ethics support services - in order to gauge whether this is indeed a promising development.
Collapse
|
17
|
Richards CA, Starks H, O’Connor MR, Bourget E, Hays RM, Doorenbos AZ. Physicians Perceptions of Shared Decision-Making in Neonatal and Pediatric Critical Care. Am J Hosp Palliat Care 2018; 35:669-676. [PMID: 28990396 PMCID: PMC5673589 DOI: 10.1177/1049909117734843] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Most children die in neonatal and pediatric intensive care units after decisions are made to withhold or withdraw life-sustaining treatments. These decisions can be challenging when there are different views about the child's best interest and when there is a lack of clarity about how best to also consider the interests of the family. OBJECTIVE To understand how neonatal and pediatric critical care physicians balance and integrate the interests of the child and family in decisions about life-sustaining treatments. METHODS Semistructured interviews were conducted with 22 physicians from neonatal, pediatric, and cardiothoracic intensive care units in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analysis. RESULTS We identified 3 main themes: (1) beliefs about child and family interests; (2) disagreement about the child's best interest; and (3) decision-making strategies, including limiting options, being directive, staying neutral, and allowing parents to come to their own conclusions. Physicians described challenges to implementing shared decision-making including unequal power and authority, clinical uncertainty, and complexity of balancing child and family interests. They acknowledged determining the level of engagement in shared decision-making with parents (vs routine engagement) based on their perceptions of the best interests of the child and parent. CONCLUSIONS Due to power imbalances, families' values and preferences may not be integrated in decisions or families may be excluded from discussions about goals of care. We suggest that a systematic approach to identify parental preferences and needs for decisional roles and information may reduce variability in parental involvement.
Collapse
Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Helene Starks
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - M. Rebecca O’Connor
- Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, WA, USA
| | - Erica Bourget
- Department of Immunology, Fred Hutchinson’s Cancer Research Center, Seattle, WA, USA
| | - Ross M. Hays
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Rehabilitative Medicine, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
- Palliative Care Program, Seattle Children’s Hospital, Seattle, WA, USA
- The Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA
| | - Ardith Z. Doorenbos
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
18
|
Temsah MH. Ethical considerations about changing parental attitude towards end-of-life care in twins with lethal disease. Sudan J Paediatr 2018; 18:76-82. [PMID: 30166766 DOI: 10.24911/sjp.2018.1.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Advances in critical care and technology capabilities may lead to new ethical encounters in paediatrics, especially in the paediatric intensive care unit (PICU). As each patient has unique psychosocial and clinical condition interactions, paediatricians and healthcare providers must develop and adopt a suitable approach for ethical decision-making in the PICU. The healthcare provider needs to balance the four ethical domains of autonomy, beneficence, non-maleficence and justice, and apply these principles to clinical decision-making. One chief factor for ethical decision-making is to have a patient-centered and family-oriented management that is respectful of cultural background. Healthcare providers also need to observe professional ethical conduct and the applicable national laws. Applying these ethical guidelines in paediatric care ensures a more holistic approach to care, whether in the paediatric wards or the highly technical environment of the PICU. We describe two situations in which the parents of twins with a confirmed lethal disease changed their attitude towards end-of-life from full support to "do not resuscitate" and palliative care, after experiencing the palliative care of the first twin, rather than the futile effect of cardiopulmonary resuscitation in the other twin.
Collapse
Affiliation(s)
- Mohamad-Hani Temsah
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
19
|
Gray C, Fox M, Hobson-West P. Reconciling Autonomy and Beneficence in Treatment Decision-Making for Companion Animal Patients. THE LIVERPOOL LAW REVIEW 2018; 39:47-69. [PMID: 30996497 PMCID: PMC6435006 DOI: 10.1007/s10991-018-9211-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
This article explores how the concept of consent to medical treatment applies in the veterinary context, and aims to evaluate normative justifications for owner consent to treatment of animal patients. We trace the evolution of the test for valid consent in human health decision-making, against a backdrop of increased recognition of the importance of patient rights and a gradual judicial espousal of a doctrine of informed consent grounded in a particular understanding of autonomy. We argue that, notwithstanding the adoption of a similar discourse of informed consent in professional veterinary codes, notions of autonomy and informed consent are not easily transferrable to the veterinary medicine context, given inter alia the tripartite relationship between veterinary professional, owner and animal patient. We suggest that a more appropriate, albeit inexact, analogy may be drawn with paediatric practice which is premised on a similarly tripartite relationship and where decisions must be reached in the best interests of the child. However, acknowledging the legal status of animals as property and how consent to veterinary treatment is predicated on the animal owner's willingness and ability to pay, we propose that the appropriate response is for veterinary professionals generally to accept the client's choice, provided this is informed. Yet such client autonomy must be limited where animal welfare concerns exist, so that beneficence continues to play an important role in the veterinary context. We suggest that this 'middle road' should be reflected in professional veterinary guidance.
Collapse
Affiliation(s)
- Carol Gray
- School of Law, University of Birmingham, Birmingham, UK
| | - Marie Fox
- School of Law and Social Justice, University of Liverpool, Liverpool, UK
| | - Pru Hobson-West
- Centre for Applied Bioethics, School of Veterinary Medicine and Science, University of Nottingham, Nottingham, UK
| |
Collapse
|
20
|
Birchley G, Gooberman-Hill R, Deans Z, Fraser J, Huxtable R. 'Best interests' in paediatric intensive care: an empirical ethics study. Arch Dis Child 2017; 102:930-935. [PMID: 28408466 PMCID: PMC5739819 DOI: 10.1136/archdischild-2016-312076] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/30/2017] [Accepted: 03/08/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In English paediatric practice, English law requires that parents and clinicians agree the 'best interests' of children and, if this is not possible, that the courts decide. Court intervention is rare and the concept of best interests is ambiguous. We report qualitative research exploring how the best interests standard operates in practice, particularly with decisions related to planned non-treatment. We discuss results in the light of accounts of best interests in the medical ethics literature. DESIGN We conducted 39 qualitative interviews, exploring decision making in the paediatric intensive care unit, with doctors, nurses, clinical ethics committee members and parents whose children had a range of health outcomes. Interviews were audio-recorded and analysed thematically. RESULTS Parents and clinicians indicated differences in their approaches to deciding the child's best interests. These were reconciled when parents responded positively to clinicians' efforts to help parents agree with the clinicians' view of the child's best interests. Notably, protracted disagreements about a child's best interests in non-treatment decisions were resolved when parents' views were affected by witnessing their child's physical deterioration. Negotiation was the norm and clinicians believed avoiding the courts was desirable. CONCLUSIONS Sensitivity to the long-term interests of parents of children with life-limiting conditions is defensible but must be exercised proportionately. Current approaches emphasise negotiation but offer few alternatives when decisions are at an impasse. In such situations, the instrumental role played by a child's deterioration and avoidance of the courts risks giving insufficient weight to the child's interests. New approaches to decision making are needed.
Collapse
Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | | | - Zuzana Deans
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - James Fraser
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| |
Collapse
|
21
|
Abstract
In medical practice, the doctrine of informed consent is generally understood to have priority over the medical practitioner's duty of care to her patient. A common consequentialist argument for the prioritisation of informed consent above the duty of care involves the claim that respect for a patient's free choice is the best way of protecting that patient's best interests; since the patient has a special expertise over her values and preferences regarding non-medical goods she is ideally placed to make a decision that will protect her interests. In this paper I argue against two consequentialist justifications for a blanket prioritisation of informed consent over the duty of care by considering cases in which patients have imperfect access to their overall best interests. Furthermore, I argue that there are cases where the mere presentation of choice under the doctrine of informed consent is detrimental to patient best interests. I end the paper by considering more nuanced approaches to resolving the conflict between informed consent and the duty of care and consider the option of permitting patients to waive informed consent.
Collapse
Affiliation(s)
- Emma C Bullock
- Department of Philosophy, Central European University, Zrinyi u. 14., 4th Floor, Budapest, 1051, Hungary.
| |
Collapse
|
22
|
Malone H, Biggar S, Javadpour S, Edworthy Z, Sheaf G, Coyne I. Interventions for promoting participation in shared decision-making for children and adolescents with cystic fibrosis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Helen Malone
- Trinity College Dublin; School of Nursing & Midwifery; 24 D’Olier Street, College Green Dublin Ireland 2
| | - Susan Biggar
- Health Issues Centre; Consumer Partnerships; 255 Bourke Street Melbourne Victoria Australia VIC 3000
| | - Sheila Javadpour
- Our Lady's Children's Hospital, Crumlin; Department of Respiratory Medicine; Dublin Ireland 12
| | - Zai Edworthy
- Temple Street Children's University Hospital; Department of Psychology; Temple Street Dublin Ireland DO1 YC67
| | - Greg Sheaf
- The Library of Trinity College Dublin; College Street Dublin Ireland
| | - Imelda Coyne
- Trinity College Dublin; School of Nursing & Midwifery; 24 D’Olier Street, College Green Dublin Ireland 2
| |
Collapse
|
23
|
Gillam L, Wilkinson D, Xafis V, Isaacs D. Decision-making at the borderline of viability: Who should decide and on what basis? J Paediatr Child Health 2017; 53:105-111. [PMID: 28194892 PMCID: PMC5516231 DOI: 10.1111/jpc.13423] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 09/01/2016] [Accepted: 10/27/2016] [Indexed: 11/29/2022]
Abstract
Parents and medical staff usually agree on the management of preterm labour at borderline viability, when there is a relatively high risk of long-term neurodevelopmental problems in survivors. If delivery is imminent and parents and staff cannot agree on the best management, however, who should decide what will happen when the baby is delivered? Should the baby be resuscitated? Should intensive care be initiated? Three ethicists, one of whom is also a neonatologist, discuss this complex issue.
Collapse
Affiliation(s)
- Lynn Gillam
- Children's Bioethics CentreRoyal Children's HospitalMelbourneVictoriaAustralia,School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical EthicsOxfordUnited Kingdom,John Radcliffe HospitalOxfordUnited Kingdom
| | - Vicki Xafis
- Clinical EthicsSydney Children's Hospital NetworkSydneyNew South WalesAustralia,Centre for Values Ethics and the Law in Medicine, Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - David Isaacs
- Clinical EthicsSydney Children's Hospital NetworkSydneyNew South WalesAustralia,Centre for Values Ethics and the Law in Medicine, Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia,Discipline of Child HealthUniversity of SydneySydneyNew South WalesAustralia
| |
Collapse
|
24
|
Herlitz A, Munthe C, Törner M, Forsander G. The Counseling, Self-Care, Adherence Approach to Person-Centered Care and Shared Decision Making: Moral Psychology, Executive Autonomy, and Ethics in Multi-Dimensional Care Decisions. HEALTH COMMUNICATION 2016; 31:964-973. [PMID: 26756477 DOI: 10.1080/10410236.2015.1025332] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This article argues that standard models of person-centred care (PCC) and shared decision making (SDM) rely on simplistic, often unrealistic assumptions of patient capacities that entail that PCC/SDM might have detrimental effects in many applications. We suggest a complementary PCC/SDM approach to ensure that patients are able to execute rational decisions taken jointly with care professionals when performing self-care. Illustrated by concrete examples from a study of adolescent diabetes care, we suggest a combination of moral and psychological considerations to support the claim that standard PCC/SDM threatens to systematically undermine its own goals. This threat is due to a tension between the ethical requirements of SDM in ideal circumstances and more long-term needs actualized by the context of self-care handled by patients with limited capacities for taking responsibility and adhere to their own rational decisions. To improve this situation, we suggest a counseling, self-care, adherence approach to PCC/SDM, where more attention is given to how treatment goals are internalized by patients, how patients perceive choice situations, and what emotional feedback patients are given. This focus may involve less of a concentration on autonomous and rational clinical decision making otherwise stressed in standard PCC/SDM advocacy.
Collapse
Affiliation(s)
- Anders Herlitz
- a Department of Philosophy , Rutgers University
- b Department of Philosophy , Linguistics, and Theory of Science, University of Gothenburg
| | - Christian Munthe
- b Department of Philosophy , Linguistics, and Theory of Science, University of Gothenburg
| | - Marianne Törner
- c Department of Public Health and Community Medicine , University of Gothenburg
| | - Gun Forsander
- d Institute of Clinical Sciences, Sahlgrenska Academy
- e Queen Silvia Children's Hospital, Sahlgrenska University Hospital
| |
Collapse
|
25
|
Birchley G, Jones K, Huxtable R, Dixon J, Kitzinger J, Clare L. Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty. BMC Med Ethics 2016; 17:46. [PMID: 27461340 PMCID: PMC4962460 DOI: 10.1186/s12910-016-0129-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/13/2016] [Indexed: 12/02/2022] Open
Abstract
Background In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis. Methods To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature. Results Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies. Conclusions Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0129-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
| | - Kerry Jones
- Faculty of Health and Social Care, The Open University, Milton Keynes, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Jeremy Dixon
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Jenny Kitzinger
- Coma and Disorders of Consciousness Research Centre, Cardiff University, Cardiff, UK
| | - Linda Clare
- REACH: The Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
| |
Collapse
|
26
|
Forbat L, Teuten B, Barclay S. Conflict escalation in paediatric services: findings from a qualitative study. Arch Dis Child 2015; 100:769-73. [PMID: 25940425 PMCID: PMC4518764 DOI: 10.1136/archdischild-2014-307780] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 04/03/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore clinician and family experiences of conflict in paediatric services, in order to map the trajectory of conflict escalation. DESIGN Qualitative interview study, employing extreme-case sampling. Interviews were analysed using an iterative thematic approach to identify common themes regarding the experience and escalation of conflict. PARTICIPANTS Thirty-eight health professionals and eight parents. All participants had direct experience of conflict, including physical assault and court proceedings, at the interface of acute and palliative care. SETTING Two teaching hospitals, one district general hospital and two paediatric hospices in England, in 2011. RESULTS Conflicts escalate in a predictable manner. Clearly identifiable behaviours by both clinicians and parents are defined as mild, moderate and severe. Mild describes features like the insensitive use of language and a history of unresolved conflict. Moderate involves a deterioration of trust, and a breakdown of communication and relationships. Severe marks disintegration of working relationships, characterised by behavioural changes including aggression, and a shift in focus from the child's best interests to the conflict itself. Though conflicts may remain at one level, those which escalated tended to move sequentially from one level to the next. CONCLUSIONS Understanding how conflicts escalate provides clinicians with a practical, evidence-based framework to identify the warning signs of conflict in paediatrics.
Collapse
Affiliation(s)
- Liz Forbat
- School of Health Sciences, University of Stirling, Stirling, UK
| | - Bea Teuten
- Medical Mediation Foundation, London, UK
| | | |
Collapse
|