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Zhong Y, Cavolo A, Labarque V, Gastmans C. Physicians' attitudes and experiences about withholding/withdrawing life-sustaining treatments in pediatrics: a systematic review of quantitative evidence. BMC Palliat Care 2023; 22:145. [PMID: 37773128 PMCID: PMC10540364 DOI: 10.1186/s12904-023-01260-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND One of the most important and ethically challenging decisions made for children with life-limiting conditions is withholding/withdrawing life-sustaining treatments (LST). As important (co-)decision-makers in this process, physicians are expected to have deeply and broadly developed views. However, their attitudes and experiences in this area remain difficult to understand because of the diversity of the studies. Hence, the aim of this paper is to describe physicians' attitudes and experiences about withholding/withdrawing LST in pediatrics and to identify the influencing factors. METHODS We systematically searched Pubmed, Cinahl®, Embase®, Scopus®, and Web of Science™ in early 2021 and updated the search results in late 2021. Eligible articles were published in English, reported on investigations of physicians' attitudes and experiences about withholding/withdrawing LST for children, and were quantitative. RESULTS In 23 included articles, overall, physicians stated that withholding/withdrawing LST can be ethically legitimate for children with life-limiting conditions. Physicians tended to follow parents' and parents-patient's wishes about withholding/withdrawing or continuing LST when they specified treatment preferences. Although most physicians agreed to share decision-making with parents and/or children, they nonetheless reported experiencing both negative and positive feelings during the decision-making process. Moderating factors were identified, including barriers to and facilitators of withholding/withdrawing LST. In general, there was only a limited number of quantitative studies to support the hypothesis that some factors can influence physicians' attitudes and experiences toward LST. CONCLUSION Overall, physicians agreed to withhold/withdraw LST in dying patients, followed parent-patients' wishes, and involved them in decision-making. Barriers and facilitators relevant to the decision-making regarding withholding/withdrawing LST were identified. Future studies should explore children's involvement in decision-making and consider barriers that hinder implementation of decisions about withholding/withdrawing LST.
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Affiliation(s)
- Yajing Zhong
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, Block D, box 7001, Leuven, 3000, Belgium.
| | - Alice Cavolo
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, Block D, box 7001, Leuven, 3000, Belgium
| | - Veerle Labarque
- Centre for Molecular and Vascular Biology, Faculty of Medicine, KU Leuven/UZ Leuven, Herestraat 49, Leuven, 3000, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, Block D, box 7001, Leuven, 3000, Belgium
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Sousa ITE, Cruz CT, Soares LCDC, van Leeuwen G, Garros D. End-of-life care in Brazilian Pediatric Intensive Care Units. J Pediatr (Rio J) 2023; 99:341-347. [PMID: 36963435 PMCID: PMC10373144 DOI: 10.1016/j.jped.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/19/2023] [Accepted: 02/23/2023] [Indexed: 03/26/2023] Open
Abstract
OBJECTIVE Most deaths in Pediatric Intensive Care Units involve forgoing life-sustaining treatment. Such deaths required carefully planned end-of-life care built on compassion and focused on palliative care measures. This study aims to assess topics related to the end of life care in Brazilian pediatric intensive care units from the perspective of a multidisciplinary team. METHOD The authors used a tested questionnaire, utilizing Likert-style and open-ended questions. After ethics committee approval, it was sent by email from September to November/2019 to three Pediatric Intensive Care Units in the South and Southeast of Brazil. One unit was exclusively dedicated to oncology patients; the others were mixed units. RESULTS From 144 surveys collected (23% response rate) 136 were analyzed, with 35% physicians, 30% nurses, 21% nurse technicians, and 14% physiotherapists responding. Overall, only 12% reported enough end-of-life care training and 40% reported never having had any, albeit this was not associated with the physician's confidence in forgoing life-sustaining treatment. Furthermore, 60% of physicians and 46% of other professionals were more comfortable with non-escalation than withdrawing therapies, even if this could prolong suffering. All physicians were uncomfortable with palliative extubation; 15% of all professionals have witnessed it. The oncologic team uniquely felt that "resistance from the teams of specialists" was the main barrier to end-of-life care implementation. CONCLUSION Most professionals felt unprepared to forego life-sustaining treatment. Even for terminally ill patients, withholding is preferred over the withdrawal of treatment. Socio-cultural barriers and the lack of adequate training may be contributing to insecurity in the care of terminally ill patients, diverging from practices in other countries.
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Affiliation(s)
- Ian Teixeira E Sousa
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Unidade de Terapia Intensiva Pediátrica do Hospital Criança Conceição, Porto Alegre, RS, Brazil.
| | | | - Leonardo Cavadas da Costa Soares
- Universidade Federal do Paraná, Curitiba, PR, Brazil; Hospital Pequeno Príncipe, Unidade de Cuidados Intensivos Cardiovasculares Pediátrica, Curitiba, PR, Brazil
| | - Grace van Leeuwen
- Weill Cornell Medicine - Qatar, Critical Care Division, Pediatric Critical Care Unit - Sidra Medicine, Doha, Qatar
| | - Daniel Garros
- Stollery Children's Hospital Pediatric Intensive Care Unit, Edmonton, AB, Canada; University of Alberta, Faculty of Medicine, Division of Critical Care, Dept of Pediatrics, Edmonton, Canada
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End-of-Life Decision-Making in Pediatric and Neonatal Intensive Care Units in Croatia—A Focus Group Study among Nurses and Physicians. Medicina (B Aires) 2022; 58:medicina58020250. [PMID: 35208575 PMCID: PMC8879945 DOI: 10.3390/medicina58020250] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives: Working in pediatric and neonatal intensive care units (ICUs) can be challenging and differs from work in adult ICUs. This study investigated for the first time the perceptions, experiences and challenges that healthcare professionals face when dealing with end-of-life decisions in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) in Croatia. Materials and Methods: This qualitative study with focus groups was conducted among physicians and nurses working in NICUs and PICUs in five healthcare institutions (three pediatric intensive care units (PICUs) and five neonatal intensive care units (NICUs)) at the tertiary level of healthcare in the Republic of Croatia, in Zagreb, Rijeka and Split. A total of 20 physicians and 21 nurses participated in eight focus groups. The questions concerned everyday practices in end-of-life decision-making and their connection with interpersonal relationships between physicians, nurses, patients and their families. The constant comparative analysis method was used in the analysis of the data. Results: The analysis revealed two main themes that were the same among the professional groups as well as in both NICU and PICU units. The theme “critical illness” consisted of the following subthemes: the child, the family, myself and other professionals. The theme “end-of-life procedures” consisted of the following subthemes: breaking point, decision-making, end-of-life procedures, “spill-over” and the four walls of the ICU. The perceptions and experiences of end-of-life issues among nurses and physicians working in NICUs and PICUs share multiple common characteristics. The high variability in end-of-life procedures applied and various difficulties experienced during shared decision-making processes were observed. Conclusions: There is a need for further research in order to develop clinical and professional guidelines that will inform end-of-life decision-making, including the specific perspectives of everyone involved, and the need to influence policymakers.
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Akkermans AA, Lamerichs JMWJJ, Schultz MJM, Cherpanath TGVT, van Woensel JBMJ, van Heerde MM, van Kaam AHLCA, van de Loo MDM, Stiggelbout AMA, Smets EMAE, de Vos MAM. How doctors actually (do not) involve families in decisions to continue or discontinue life-sustaining treatment in neonatal, pediatric, and adult intensive care: A qualitative study. Palliat Med 2021; 35:1865-1877. [PMID: 34176357 PMCID: PMC8637379 DOI: 10.1177/02692163211028079] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Intensive care doctors have to find the right balance between sharing crucial decisions with families of patients on the one hand and not overburdening them on the other hand. This requires a tailored approach instead of a model based approach. AIM To explore how doctors involve families in the decision-making process regarding life-sustaining treatment on the neonatal, pediatric, and adult intensive care. DESIGN Exploratory inductive thematic analysis of 101 audio-recorded conversations. SETTING/PARTICIPANTS One hundred four family members (61% female, 39% male) and 71 doctors (60% female, 40% male) of 36 patients (53% female, 47% male) from the neonatal, pediatric, and adult intensive care of a large university medical center participated. RESULTS We identified eight relevant and distinct communicative behaviors. Doctors' sequential communicative behaviors either reflected consistent approaches-a shared approach or a physician-driven approach-or reflected vacillating between both approaches. Doctors more often displayed a physician-driven or a vacillating approach than a shared approach, especially in the adult intensive care. Doctors did not verify whether their chosen approach matched the families' decision-making preferences. CONCLUSIONS Even though tailoring doctors' communication to families' preferences is advocated, it does not seem to be integrated into actual practice. To allow for true tailoring, doctors' awareness regarding the impact of their communicative behaviors is key. Educational initiatives should focus especially on improving doctors' skills in tactfully exploring families' decision-making preferences and in mutually sharing knowledge, values, and treatment preferences.
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Affiliation(s)
- A Aranka Akkermans
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J M W J Joyce Lamerichs
- Faculty of Humanities, Department of Language, Literature and Communication, VU Amsterdam, Amsterdam, The Netherlands
| | - M J Marcus Schultz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - T G V Thomas Cherpanath
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J B M Job van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Marc van Heerde
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A H L C Anton van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M D Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A M Anne Stiggelbout
- Medical Decision Making, Department of Biomedical Data Science, Leiden University Medical Center, Leiden, the Netherlands
| | - E M A Ellen Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M A Mirjam de Vos
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
OBJECTIVES The purpose of this scoping review was to identify the extent, range, and nature of information currently available on family presence during pediatric resuscitation on resuscitation team members and their performance. DATA SOURCES A comprehensive search strategy was created and executed by identifying primary keywords in central articles, pretesting key words and combinations of them in databases to confirm articles returned fell within the search parameters, and checking that key articles were returned which confirmed the search strategy was not too narrow. STUDY SELECTION Two members of the research team independently conducted relevance screening using predetermined inclusion and exclusion parameters. Titles and abstracts of retrieved articles were reviewed using the set criteria involving. From the refined list of selected articles, full texts of each article were considered for final determination of inclusion. DATA EXTRACTION Key items of information were gathered from each article selected using a predefined extraction list. The extracted information was then sorted into themes and relevant issues. DATA SYNTHESIS Of the 3,012 studies initially identified, 48 met the inclusion criteria. Themes identified included as follows: 1) attitudes and opinions on family presence during pediatric resuscitation; 2) reasons in support of or against family presence during pediatric resuscitation; 3) education, training, and support; and 4) resuscitation performance and outcomes. Our review of the available information highlighted that the majority of work done to this point has focused heavily on healthcare provider opinions and relied mainly on survey method. CONCLUSIONS We propose that future research employ more rigorous research techniques, such as randomized control trials, place greater emphasis on healthcare provider behaviors and clinical outcomes during family presence during pediatric resuscitation, and increase exploration into the education and training needs of healthcare providers who already currently manage family presence during pediatric resuscitation.
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Groenewoud AS, Sasaki N, Westert GP, Imanaka Y. Preferences in end of life care substantially differ between the Netherlands and Japan: Results from a cross-sectional survey study. Medicine (Baltimore) 2020; 99:e22743. [PMID: 33126312 PMCID: PMC7598825 DOI: 10.1097/md.0000000000022743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Strategies to increase appropriateness of EoL care, such as shared decision making (SDM), and advance care planning (ACP) are internationally embraced, especially since the COVID-19 pandemic. However, individuals preferences regarding EoL care may differ internationally. Current literature lacks insight in how preferences in EoL care differ between countries and continents. This study's aim is to compare Dutch and Japanese general publics attitudes and preferences toward EoL care, and EoL decisions. Methods: a cross-sectional survey design was chosen. The survey was held among samples of the Dutch and Japanese general public, using a Nationwide social research panel of 220.000 registrants in the Netherlands and 1.200.000 in Japan. A quota sampling was done (age, gender, and living area). N = 1.040 in each country.More Japanese than Dutch citizens tend to avoid thinking in advance about future situations of dependence (26.0% vs 9.4%; P = .000); say they would feel themselves a burden for relatives if they would become dependent in their last phase of life (79.3% vs 47.8%; P = .000); and choose the hospital as their preferred place of death (19.4% vs 3.6% P = .000). More Dutch than Japanese people say they would be happy with a proactive approach of their doctor regarding EoL issues (78.0% vs 65.1% JPN; P = .000).Preferences in EoL care substantially differ between the Netherlands and Japan. These differences should be taken into account a) when interpreting geographical variation in EoL care, and b) if strategies such as SDM or ACP - are considered. Such strategies will fail if an international "one size fits all" approach would be followed.
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Affiliation(s)
- A Stef Groenewoud
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Noriko Sasaki
- Department of Healthcare Economics and Quality Management, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Gert P Westert
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Kyoto University, Graduate School of Medicine, Kyoto, Japan
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Sprung CL, Ricou B, Hartog CS, Maia P, Mentzelopoulos SD, Weiss M, Levin PD, Galarza L, de la Guardia V, Schefold JC, Baras M, Joynt GM, Bülow HH, Nakos G, Cerny V, Marsch S, Girbes AR, Ingels C, Miskolci O, Ledoux D, Mullick S, Bocci MG, Gjedsted J, Estébanez B, Nates JL, Lesieur O, Sreedharan R, Giannini AM, Fuciños LC, Danbury CM, Michalsen A, Soliman IW, Estella A, Avidan A. Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016. JAMA 2019; 322:1692-1704. [PMID: 31577037 PMCID: PMC6777263 DOI: 10.1001/jama.2019.14608] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. OBJECTIVE To determine the changes in end-of-life practices in European ICUs after 16 years. DESIGN, SETTING, AND PARTICIPANTS Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision. EXPOSURES Comparison between the 1999-2000 cohort vs 2015-2016 cohort. MAIN OUTCOMES AND MEASURES End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists. RESULTS Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.
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Affiliation(s)
- Charles L. Sprung
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Bara Ricou
- Department of Anesthesiology, Pharmacology, and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Christiane S. Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin and Klinik Bavaria, Kreischa, Germany
| | - Paulo Maia
- Intensive Care Department, Hospital S. Antonio, Centro Hospitalar do Porto, Porto, Portugal
| | - Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
| | - Manfred Weiss
- Clinic of Anaesthesiology, University Hospital Medical School, Ulm, Germany
| | - Phillip D. Levin
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Laura Galarza
- Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Veronica de la Guardia
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joerg C. Schefold
- Inselspital, Department of Intensive Care Medicine, University of Bern, Switzerland
| | - Mario Baras
- The Hebrew University—Hadassah School of Public Health, Jerusalem, Israel
| | - Gavin M. Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Hans-Henrik Bülow
- Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark
| | - Georgios Nakos
- Department of Intensive Care Medicine, University of Ioannina, Ioannina, Greece
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine, and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Czech Republic
| | - Stephan Marsch
- Medical Intensive Care, University of Basel Hospital, Basel, Switzerland
| | - Armand R. Girbes
- Department of Intensive Care Medicine, VU Medical Center, Amsterdam, the Netherlands
| | - Catherine Ingels
- Intensive Care Medicine, University Hospitals K.U. Leuven, Leuven Belgium
| | - Orsolya Miskolci
- Mater Misericordiae University Hospital, Intensive Care Unit, Dublin, Ireland
| | - Didier Ledoux
- Department of Anesthesiology and Intensive Care Medicine, University of Liege, Liege, Belgium
| | | | - Maria G. Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jakob Gjedsted
- Department of Anesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Belén Estébanez
- Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Joseph L. Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston
| | - Olivier Lesieur
- Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - Roshni Sreedharan
- Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Alberto M. Giannini
- Division of Pediatric Anesthesia and Intensive Care, ASST Spedali Civili, Brescia, Italy
| | | | | | - Andrej Michalsen
- Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany
| | - Ivo W. Soliman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Angel Estella
- Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Di Nardo M, Dalle Ore A, Testa G, Annich G, Piervincenzi E, Zampini G, Bottari G, Cecchetti C, Amodeo A, Lorusso R, Del Sorbo L, Kirsch R. Principlism and Personalism. Comparing Two Ethical Models Applied Clinically in Neonates Undergoing Extracorporeal Membrane Oxygenation Support. Front Pediatr 2019; 7:312. [PMID: 31417882 PMCID: PMC6682695 DOI: 10.3389/fped.2019.00312] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/11/2019] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technology used to temporarily assist critically ill patients with acute and reversible life-threatening cardiac and/or respiratory failure. This technology can often be lifesaving but is also associated with several complications that may contribute to reduced survival. Currently, neonates supported with ECMO are complex and bear an increased risk of mortality. This means that clinicians must be particularly prepared not only to deal with complex clinical scenarios, but also ethical issues associated with ECMO. In particular, clinicians should be trained to handle unsuccessful ECMO runs with attention to high quality end of life care. Within this manuscript we will compare and contrast the application of two ethical frameworks, used in the authors' institutions (Toronto and Rome). This is intended to enhance a broader understanding of cultural differences in applied ethics which is useful to the clinician in an increasingly multicultural and diverse patient mix.
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Affiliation(s)
| | - Anna Dalle Ore
- Clinical Bioethics, Children's Hospital Bambino Gesù, Rome, Italy
| | | | - Gail Annich
- Department of Critical Care, The Hospital for Sick Children, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | - Antonio Amodeo
- Mechanical Assist Device and ECMO Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Roberto Lorusso
- Department of Adult Cardiac Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,MSICU, Toronto General Hospital, Toronto, ON, Canada
| | - Roxanne Kirsch
- Department of Critical Care, The Hospital for Sick Children, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Bioethics, The Hospital for Sick Children, Toronto, ON, Canada
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9
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Ethical, Cultural, Social, and Individual Considerations Prior to Transition to Limitation or Withdrawal of Life-Sustaining Therapies. Pediatr Crit Care Med 2018; 19:S10-S18. [PMID: 30080802 DOI: 10.1097/pcc.0000000000001488] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
As part of the invited supplement on Death and Dying in the PICU, we reviewed ethical, cultural, and social considerations for the bedside healthcare practitioner prior to engaging with children and families in decisions about limiting therapies, withholding, or withdrawing therapies in a PICU. Clarifying beliefs and values is a necessary prerequisite to approaching these conversations. Striving for medical consensus is important. Discussion, reflection, and ethical analysis may determine a range of views that may reasonably be respected if professional disagreements persist. Parental decisional support is recommended and should incorporate their information needs, perceptions of medical uncertainty, child's condition, and their role as a parent. Child's involvement in decision making should be considered, but may not be possible. Culturally attuned care requires early examination of cultural perspectives before misunderstandings or disagreements occur. Societal influences may affect expectations and exploration of such may help frame discussions. Hospital readiness for support of social media campaigns is recommended. Consensus with family on goals of care is ideal as it addresses all parties' moral stance and diminishes the risk for superseding one group's value judgments over another. Engaging additional supportive services early can aid with understanding or resolving disagreement. There is wide variation globally in ethical permissibility, cultural, and societal influences that impact the clinician, child, and parents. Thoughtful consideration to these issues when approaching decisions about limitation or withdrawal of life-sustaining therapies will help to reduce emotional, spiritual, and ethical burdens, minimize misunderstanding for all involved, and maximize high-quality care delivery.
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Pastura PSVC, Land MGP. CRIANÇAS COM MÚLTIPLAS MALFORMAÇÕES CONGÊNITAS: QUAIS SÃO OS LIMITES ENTRE OBSTINAÇÃO TERAPÊUTICA E TRATAMENTO DE BENEFÍCIO DUVIDOSO? REVISTA PAULISTA DE PEDIATRIA 2017; 35:110-114. [PMID: 28977304 PMCID: PMC5417797 DOI: 10.1590/1984-0462/;2017;35;1;00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/07/2016] [Indexed: 11/29/2022]
Abstract
Objective: Therapeutic approach of children with multiple malformations poses many dilemmas, making it difficult to build a line between the treatment of uncertain benefit and therapeutic obstinacy. The aim of this paper was to highlight possible sources of uncertainty in the decision-making process, for this group of children. Case description: An 11-month-old boy, born with multiple birth defects and abandoned by his parents, has never been discharged home. He has complex congenital heart disease, main left bronchus stenosis and imperforate anus. He is under technological support and has gone through many surgical procedures. The complete correction of the cardiac defect seems unlikely, and every attempt to wean the ventilator has failed. Comments: The first two main sources of uncertainty in the management of children with multiple birth defects are related to an uncertain prognosis. There is a lack of empirical data, due to the multiple possibilities of anatomic or functional organ involvement, with few similar cases described. Prognosis is also unpredictable for neuro-developmental evolution, as well as the capacity for the development and regeneration of other organs. Another source of uncertainty is how to qualify the present and future life as worth living, by weighing the costs and benefits. The fourth source of uncertainty is who has the decision: physicians or parents? Finally, if a treatment is defined futile then, how to limit support? No single framework exists to help these delicate decision-making processes. We propose, then, that physicians should be committed to develop their own perception skills in order to understand patient’s manifestations of needs and family values.
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Abstract
Pediatric intensive care is a relatively new medical specialty, which has experienced significant technological advances in recent years. These developments have led to a prolongation of the dying process, with additional suffering for patients and their families, creating complex situations, and often causing a painful life extension. The term, limitation of the therapeutic effort refers to the adequacy and/or proportionality of the treatment, trying to avoid obstinacy and futility. The English literature does not talk about limitation of treatments, but instead the terms, withholding or withdrawal of life-sustaining treatment, are used. The removal or the non-installation of certain life support measures and the absence of CPR are the types of limitation most used. Also, there is evidence of insufficient medical training in bioethics, which is essential, as most doctors in the PICU discuss and make decisions regarding the end of life without the opinion of bioethicists. This article attempts to review the current status of knowledge concerning the limitation of therapeutic efforts to support pediatric clinical work.
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Affiliation(s)
- V Gonzalo Morales
- Pediatra, Unidad de Cuidados Intensivos Pediátricos y Programa de Magíster en Bioética, Clínica Alemana-Universidad del Desarrollo y Unidad de Cuidados Intensivos Pediátricos, Hospital Roberto del Río, Universidad de Chile.
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Zaal-Schuller IH, de Vos MA, Ewals FVPM, van Goudoever JB, Willems DL. End-of-life decision-making for children with severe developmental disabilities: The parental perspective. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 49-50:235-246. [PMID: 26741261 DOI: 10.1016/j.ridd.2015.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 11/28/2015] [Accepted: 12/08/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND AIMS The objectives of this integrative review were to understand how parents of children with severe developmental disorders experience their involvement in end-of-life decision-making, how they prefer to be involved and what factors influence their decisions. METHODS AND PROCEDURES We searched MEDLINE, EMBASE, CINAHL and PsycINFO. The search was limited to articles in English or Dutch published between January 2004 and August 2014. We included qualitative and quantitative original studies that directly investigated the experiences of parents of children aged 0-18 years with severe developmental disorders for whom an end-of-life decision had been considered or made. OUTCOMES AND RESULTS We identified nine studies that met all inclusion criteria. Reportedly, parental involvement in end-of-life decision-making varied widely, ranging from having no involvement to being the sole decision-maker. Most parents preferred to actively share in the decision-making process regardless of their child's specific diagnosis or comorbidity. The main factors that influenced parents in their decision-making were: their strong urge to advocate for their child's best interests and to make the best (possible) decision. In addition, parents felt influenced by their child's visible suffering, remaining quality of life and the will they perceived in their child to survive. CONCLUSIONS AND IMPLICATIONS Most parents of children with severe developmental disorders wish to actively share in the end-of-life decision-making process. An important emerging factor in this process is the parents' feeling that they have to stand up for their child's interests in conversations with the medical team.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital-Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Morita T, Oyama Y, Cheng SY, Suh SY, Koh SJ, Kim HS, Chiu TY, Hwang SJ, Shirado A, Tsuneto S. Palliative Care Physicians' Attitudes Toward Patient Autonomy and a Good Death in East Asian Countries. J Pain Symptom Manage 2015; 50:190-9.e1. [PMID: 25827851 DOI: 10.1016/j.jpainsymman.2015.02.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 01/30/2015] [Accepted: 02/14/2015] [Indexed: 11/20/2022]
Abstract
CONTEXT Clarification of the potential differences in end-of-life care among East Asian countries is necessary to provide palliative care that is individualized for each patient. OBJECTIVES The aim was to explore the differences in attitude toward patient autonomy and a good death among East Asian palliative care physicians. METHODS A cross-sectional survey was performed involving palliative care physicians in Japan, Taiwan, and Korea. Physicians' attitudes toward patient autonomy and physician-perceived good death were assessed. RESULTS A total of 505, 207, and 211 responses were obtained from Japanese, Taiwanese, and Korean physicians, respectively. Japanese (82%) and Taiwanese (93%) physicians were significantly more likely to agree that the patient should be informed first of a serious medical condition than Korean physicians (74%). Moreover, 41% and 49% of Korean and Taiwanese physicians agreed that the family should be told first, respectively; whereas 7.4% of Japanese physicians agreed. Physicians' attitudes with respect to patient autonomy were significantly correlated with the country (Japan), male sex, physician specialties of surgery and oncology, longer clinical experience, and physicians having no religion but a specific philosophy. In all 12 components of a good death, there were significant differences by country. Japanese physicians regarded physical comfort and autonomy as significantly more important and regarded preparation, religion, not being a burden to others, receiving maximum treatment, and dying at home as less important. Taiwanese physicians regarded life completion and being free from tubes and machines as significantly more important. Korean physicians regarded being cognitively intact as significantly more important. CONCLUSION There are considerable intercountry differences in physicians' attitudes toward autonomy and physician-perceived good death. East Asia is not culturally the same; thus, palliative care should be provided in a culturally acceptable manner for each country.
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Affiliation(s)
- Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, and Seirei Hospice, Seirei Mikatahara General Hospital, Shizuoka, Japan.
| | - Yasuhiro Oyama
- Division of Clinical Psychology, Kyoto University, Kyoto, Japan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Sang-Yeon Suh
- Department of Family Medicine, Dongguk University Ilsan Hospital, Dongguk University School of Medicine, Seoul, South Korea
| | - Su Jin Koh
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Hyun Sook Kim
- Department of Social Welfare, Korea National University of Transportation, Chungju City, South Korea
| | - Tai-Yuan Chiu
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Shinn-Jang Hwang
- Department of Family Medicine, Taipei Veterans General Hospital and National Yang Ming University, School of Medicine, Taipei, Taiwan
| | - Akemi Shirado
- Palliative Care Team, Seirei Mikatahara General Hospital, Shizuoka, Japan
| | - Satoru Tsuneto
- Department of Multidisciplinary Cancer Treatment, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Abstract
OBJECTIVE To identify and prioritize research questions of concern to the practice of pediatric critical care nursing practice. DESIGN One-day consensus conference. By using a conceptual framework by Benner et al describing domains of practice in critical care nursing, nine international nurse researchers presented state-of-the-art lectures. Each identified knowledge gaps in their assigned practice domain and then poised three research questions to fill that gap. Then, meeting participants prioritized the proposed research questions using an interactive multivoting process. SETTING Seventh World Congress on Pediatric Intensive and Critical Care in Istanbul, Turkey. PARTICIPANTS Pediatric critical care nurses and nurse scientists attending the open consensus meeting. INTERVENTIONS Systematic review, gap analysis, and interactive multivoting. MEASUREMENTS AND MAIN RESULTS The participants prioritized 27 nursing research questions in nine content domains. The top four research questions were 1) identifying nursing interventions that directly impact the child and family's experience during the withdrawal of life support, 2) evaluating the long-term psychosocial impact of a child's critical illness on family outcomes, 3) articulating core nursing competencies that prevent unstable situations from deteriorating into crises, and 4) describing the level of nursing education and experience in pediatric critical care that has a protective effect on the mortality and morbidity of critically ill children. CONCLUSIONS The consensus meeting was effective in organizing pediatric critical care nursing knowledge, identifying knowledge gaps and in prioritizing nursing research initiatives that could be used to advance nursing science across world regions.
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Al-Mendalawi MD. Mortality patterns among critically ill children in a pediatric intensive care unit of a developing country. Indian J Crit Care Med 2015; 19:293-4. [PMID: 25983443 PMCID: PMC4430755 DOI: 10.4103/0972-5229.156499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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de Vos MA, Seeber AA, Gevers SKM, Bos AP, Gevers F, Willems DL. Parents who wish no further treatment for their child. JOURNAL OF MEDICAL ETHICS 2015; 41:195-200. [PMID: 24917616 DOI: 10.1136/medethics-2013-101395] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In the ethical and clinical literature, cases of parents who want treatment for their child to be withdrawn against the views of the medical team have not received much attention. Yet resolution of such conflicts demands much effort of both the medical team and parents. OBJECTIVE To discuss who can best protect a child's interests, which often becomes a central issue, putting considerable pressure on mutual trust and partnership. METHODS We describe the case of a 3-year-old boy with acquired brain damage due to autoimmune-mediated encephalitis whose parents wanted to stop treatment. By comparing this case with relevant literature, we systematically explored the pros and cons of sharing end-of-life decisions with parents in cases where treatment is considered futile by parents and not (yet) by physicians. CONCLUSIONS Sharing end-of-life decisions with parents is a more important duty for physicians than protecting parents from guilt or doubt. Moreover, a request from parents on behalf of their child to discontinue treatment is, and should be, hard to over-rule in cases with significant prognostic uncertainty and/or in cases with divergent opinions within the medical team.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Division of Public Health and Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Antje A Seeber
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjef K M Gevers
- Department of Health Law, Division of Public Health & Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital/Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Dick L Willems
- Section of Medical Ethics, Division of Public Health and Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Pachys G, Kaufman N, Bdolah-Abram T, Kark JD, Einav S. Predictors of long-term survival after out-of-hospital cardiac arrest: the impact of Activities of Daily Living and Cerebral Performance Category scores. Resuscitation 2014; 85:1052-8. [PMID: 24727137 DOI: 10.1016/j.resuscitation.2014.03.312] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 03/18/2014] [Accepted: 03/21/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Current focus on immediate survival from out-of-hospital cardiac arrest (OHCA) has diverted attention away from the variables potentially affecting long-term survival. AIM To determine the relationship between neurological and functional status at hospital discharge and long-term survival after OHCA. METHODS Prospective data collection for all OHCA patients aged >18 years in the Jerusalem district (n=1043, 2008-2009). PRIMARY OUTCOME MEASURE Length of survival after OHCA. Potential predictors: Activities of Daily Living (ADL) and Cerebral Performance Category (CPC) scores at hospital discharge, age and sex. RESULTS There were 52/279 (18.6%) survivors to hospital discharge. Fourteen were discharged on mechanical ventilation (27%). Interviews with survivors and/or their legal guardians were sought 2.8±0.6 years post-arrest. Eighteen died before long-term follow-up (median survival 126 days, IQR 94-740). Six improved their ADL and CPC scores between discharge and follow-up. Long-term survival was positively related with lower CPC scores (p=0.002) and less deterioration in ADL from before the arrest to hospital discharge (p=0.001). For each point increment in ADL at hospital discharge, the hazard ratio of death was 1.31 (95%CI 1.12, 1.53, p=0.001); this remained unchanged after adjustment for age and sex (HR 1.26, 95%CI 0.07, 1.48, p=0.005). CONCLUSIONS One-third of the patients discharged from hospital after OHCA died within 30 months of the event. Long-term survival was associated both with better neurological and functional level at hospital discharge and a smaller decrease in functional limitation from before to after the arrest, yet some patients with a poor neurological outcome survived prolonged periods after hospital discharge.
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Affiliation(s)
- Gal Pachys
- Hebrew University-Hadassah Faculty of Medicine, Ein Kerem, Jerusalem, Israel; Paramedic, Magen David Adom, Jerusalem, Israel
| | - Nechama Kaufman
- Intensive Care Unit, Department of Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Tali Bdolah-Abram
- Hebrew University-Hadassah Faculty of Medicine, Ein Kerem, Jerusalem, Israel
| | - Jeremy D Kark
- Epidemiology Unit, Hebrew University-Hadassah Braun School of Public Health and Community Medicine, Ein Kerem, Jerusalem, Israel
| | - Sharon Einav
- Hebrew University-Hadassah Faculty of Medicine, Ein Kerem, Jerusalem, Israel; Surgical Intensive Care, Shaare Zedek Medical Center, Israel.
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Affiliation(s)
- Dominic Wilkinson
- Department of Neonatal Medicine, Women's and Children's Hospital, 72 King William Rd, North Adelaide 5006, South Australia, Australia.
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Litak D. Parental presence during child resuscitation: a critical review of a research article. J Perioper Pract 2012; 22:63-6. [PMID: 22724305 DOI: 10.1177/175045891202200204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The article reviewed is: Parental presence during resuscitation in the PICU: the parents' experience. Sharing and surviving the resuscitation: a phenomenological study (Maxton 2008). The article provides an insight into parents' experiences of being present or absent during successful or unsuccessful resuscitation attempts on their child. It can help healthcare practitioners to understand what parents' perspectives and needs may be during this difficult time. Lack of such understanding could potentially lead healthcare practitioners to neglect or misjudge the parents' needs and apply inappropriate interventions which may result in long-lasting and detrimental effects on parental welfare (Dingeman et al 2007). Patient care on this particular occasion extends to a family and therefore it becomes a professional duty of the healthcare practitioners to ensure best practice through provision of a well informed support (HPC 2008).
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Affiliation(s)
- Dominika Litak
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH.
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Forgoing life support: how the decision is made in European pediatric intensive care units. Intensive Care Med 2011; 37:1881-7. [DOI: 10.1007/s00134-011-2357-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 05/08/2011] [Indexed: 10/17/2022]
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Pitak-Arnnop P, Hemprich A, Pausch NC. In reply. J Oral Maxillofac Surg 2011. [DOI: 10.1016/j.joms.2011.02.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Principlism: The simplicity of complexity, or the complexity of simplicity? J Plast Reconstr Aesthet Surg 2011; 64:978-9. [DOI: 10.1016/j.bjps.2011.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 01/11/2011] [Indexed: 11/23/2022]
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Lago PM, Nilson C, Piva JP, Halal MG, Carvalho Abib GMD, Garcia PCR, Vieira AC. Nurses’ participation in the end-of-life — process in two paediatric intensive care units in Brazil. Int J Palliat Nurs 2011; 17:264, 267-70. [DOI: 10.12968/ijpn.2011.17.6.264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Patrícia M Lago
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Cristine Nilson
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Jefferson Pedro Piva
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Michel Georges Halal
- Fellow, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | | | - Pedro Celiny R Garcia
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Ana Cláudia Vieira
- Hospital São Lucas, Pontificia Universidade Catolica do Rio Grande do Sul, Brazil
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Wilkinson DJ. A life worth giving? The threshold for permissible withdrawal of life support from disabled newborn infants. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2011; 11:20-32. [PMID: 21337273 PMCID: PMC3082774 DOI: 10.1080/15265161.2010.540060] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
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.
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Affiliation(s)
- Dominic James Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Littlegate House, St Ebbes St., Oxford, United Kingdom.
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Gresiuk C, Joffe A. Variability in the Pediatric Intensivists’ Threshold for Withdrawal/Limitation of Life Support as Perceived by Bedside Nurses. THE JOURNAL OF CLINICAL ETHICS 2009. [DOI: 10.1086/jce200920404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Yes, our approaches are different, but in similar ways. Pediatr Crit Care Med 2008; 9:651-2. [PMID: 18997595 DOI: 10.1097/pcc.0b013e31818c8656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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