Parental refusal of medical treatment for a newborn

Training paediatric healthcare staff in recognising, understanding and managing conflict with patients and families: findings from a survey on immediate and 6-month impact

BACKGROUND

Conflict is a recognised component of healthcare. Disagreements about treatment protocols, treatment aims and poor communication are recognised warning signs. Conflict management strategies can be used to prevent escalation, but are not a routine component of clinical training.

OBJECTIVE

To report the findings from a novel training intervention, aimed at enabling paediatric staff to identify and understand the warning signs of conflict, and to implement conflict resolution strategies.

DESIGN AND SETTING

Self-report measures were taken at baseline, immediately after the training and at 6 months. Questionnaires recorded quantitative and qualitative feedback on the experience of training, and the ability to recognise and de-escalate conflict. The training was provided in a tertiary teaching paediatric hospital in England over 18 months, commencing in June 2013.

INTERVENTION

A 4-h training course on identifying, understanding and managing conflict was provided to staff.

RESULTS

Baseline data were collected from all 711 staff trained, and 6-month follow-up data were collected for 313 of those staff (44%). The training was successful in equipping staff to recognise and de-escalate conflict. Six months after the training, 57% of respondents had experienced conflict, of whom 91% reported that the training had enabled them to de-escalate the conflict. Learning was retained at 6 months with staff more able than at baseline recognising conflict triggers (Fischer's exact test, p=0.001) and managing conflict situations (Pearson's χ² test, p=0.001).

CONCLUSIONS

This training has the potential to reduce substantially the human and economic costs of conflicts for healthcare providers, healthcare staff, patients and relatives.

Conflict in a paediatric hospital: a prospective mixed-method study

BACKGROUND

Conflict in healthcare is a well-recognised but under-examined phenomenon. Little is known about the prevalence and causes of conflict across paediatric specialties.

OBJECTIVE

To report the frequency and characteristics of conflict in a paediatric hospital.

DESIGN AND SETTING

An explanatory sequential mixed-method approach was adopted. A bespoke questionnaire recorded frequency, severity, cause and staff involved in conflict prospectively. Data were recorded for the same two 12-week periods in 2013 and 2014, in one UK children's teaching hospital. Data were analysed using descriptive statistics and correlation, the findings of which informed the construction of a semistructured interview schedule. Qualitative interviews were conducted with six key informant healthcare professionals to aid data interpretation; interviews were analysed thematically.

RESULTS

136 individual episodes of conflict were reported. The three most common causes were 'communication breakdown', 'disagreements about treatment' and 'unrealistic expectations'. Over 448 h of healthcare professional time was taken up by these conflicts; most often staff nurses, consultants, doctors in training and matrons. The mean severity rating was 4.9 out of 10. Qualitative interviews revealed consensus regarding whether conflicts were ranked as low, medium or high severity, and explanations regarding why neurology recorded the highest number of conflicts in the observed period.

CONCLUSIONS

Conflict is prevalent across paediatric specialties, and particularly in neurology, general paediatrics and neonatology. Considerable staff time is taken in managing conflict, indicating a need to focus resources on supporting staff to resolve conflict, notably managing communication breakdown.

The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective

Premature infants at the limits of viability raise difficult ethical, legal, social and economic questions. Neonatologists attending an international Collegium were surveyed about delivery room behaviour, and the approach taken by selected countries practicing 'modern' medicine was explored.

CONCLUSION

There were strong preferences for comfort care at 22 weeks and full resuscitation at 24 weeks. Resuscitation was a grey area at 23 weeks. Cultural, social and legal factors also had a considerable impact on decision-making.

Challenges in reconciling best interest and parental exercise of autonomy in pediatric life-or-death situations

OBJECTIVE

To study attitudes regarding life-saving interventions.

STUDY DESIGN

An Internet questionnaire describing 6 patients of different ages needing resuscitation was sent to members of the Norwegian Pediatric Association (n = 676): a 24-week gestational age infant, a term infant, a 2-month-old infant, a 7-year, a 50-year, and an 80-year-old individual. Neonates had similar or better described outcomes than older patients.

RESULTS

A total of 266 people responded (39.4%). The majority would resuscitate all the patients except the 80-year-old. The majority thought that resuscitation was in the best interest of the younger 5 patients, but fewer thought so for neonates (P < .05). Although the majority of the respondents thought that resuscitation was in the neonates' best interest (71% for 24-week-old and 75% for term infant), significantly more would accept comfort care at parental demand (62% for 24-week-old and 72% for term infant), unlike for other scenarios. Quality of life was used to justify decision making; 25% used the length of the life for neonates to motivate their answers. Patients were prioritized for resuscitation in the following order: 2-month-old infant, 7-year-old child with multiple disabilities, 50-year-old adult, the neonates, and lastly the 80-year-old individual.

CONCLUSION

There are challenges in reconciling best interest and parental exercise of autonomy in pediatric life-or-death situations. Neonates seem to be devalued.

Advanced clinical medicine requires advanced clinical ethics

Many advances have occurred in clinical medicine in the last decades. Solid organ transplants, corrective surgery for congenital malformations, improved cytostatic regimes for children with cancer, and respiratory care for premature infants are but a few examples of the changing face of medical practice. Such changes have added years to life. But along the way many patients have paid a price, both in terms of loss of life and of added suffering. Even today, some survivors are faced with a life of impairment and suffering. Follow-up studies of extremely low-birth-weight infants show that the smallest infants have a high rate of severe sequelae. Some argue that such suffering should be sufficient reason to make us desist from further attempts to advance the frontiers of therapy. This paper seeks to reflect on the character of advanced medicine and on how we relate to patients and their kin in our quest for further improvements in therapy. The price for continued advances will inevitably be paid by some patients who will not profit from them. Therefore, patients who are asked to participate in such a quest must receive honest and transparent information, including a discussion about where and how they would draw the limits. Clinical competency is a core concept in advanced medicine, but a caring comportment also demands that our relationship to the patient be characterized by honesty, integrity, and decency. In dialogue with parents, finding the right balance between parental exercise of autonomy and safe-guarding the best interest of the child remains a challenge.

A life worth giving? The threshold for permissible withdrawal of life support from disabled newborn infants

When is it permissible to allow a newborn infant to die on the basis of their future quality of life? The prevailing official view is that treatment may be withdrawn only if the burdens in an infant's future life outweigh the benefits. In this paper I outline and defend an alternative view. On the Threshold View, treatment may be withdrawn from infants if their future well-being is below a threshold that is close to, but above the zero-point of well-being. I present four arguments in favor of the Threshold View, and identify and respond to several counter-arguments. I conclude that it is justifiable in some circumstances for parents and doctors to decide to allow an infant to die even though the infant's life would be worth living. The Threshold View provides a justification for treatment decisions that is more consistent, more robust, and potentially more practical than the standard view.

Birthing ethics: what mothers, families, childbirth educators, nurses, and physicians should know about the ethics of childbirth

This article discusses current ethical issues associated with childbirth in the United States. It provides a review of moral problems and ethical choices made by parents and health-care professionals during the prenatal, intrapartum, and postpartum periods. Ethical issues are identified and framed through a "naturalized bioethics" approach, as recommended by Margaret Walker and her colleagues, Hilde Lindemann and Marian Verkerk. This approach critiques traditional bioethics and gives attention to everyday ethics and the social, economic, and political context within which ethical problems exist. This approach provides the reader with the tools needed to critically assess the way ethical problems are defined and resolved.