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Schembs L, Racine E, Shevell M, Jox RJ. Physicians' attitudes towards ethical issues and end-of-life decision-making for pediatric patients with unresponsive wakefulness syndrome: An international survey. Dev Med Child Neurol 2023; 65:1646-1655. [PMID: 36758014 DOI: 10.1111/dmcn.15540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023]
Abstract
AIM We examined physicians' perspectives on the mental capabilities of pediatric patients with unresponsive wakefulness syndrome (UWS) and their attitudes towards limiting life-sustaining treatment (LST) in an international context. METHOD A questionnaire survey was conducted among 267 neuropediatricians, practicing in 65 countries. Comparisons were made according to the Human Development Index (HDI) of the countries. The Idler Index of Religiosity was applied to determine religiosity. RESULTS Participants from countries with a very high HDI were generally more favorable to limiting LST (p < 0.001), specifically cardiopulmonary resuscitation (p = 0.021), intubation/ventilation (p = 0.014), hemodialysis/hemofiltration (p < 0.001), and antibiotic therapy (p < 0.001). Treatment costs that were too high had a weaker influence on their decisions (p < 0.001). Participants who found it never ethically justifiable to limit LST had a higher mean Idler Index of private (p = 0.001) and general (p = 0.020) religiosity and were less satisfied with treatment decisions (p < 0.001) and the communication during the process (p = 0.016). INTERPRETATION The perspectives towards limiting LST for pediatric patients with UWS are markedly different between physicians from countries with very high and lower HDIs.
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Affiliation(s)
- Leah Schembs
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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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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Zhong Y, Cavolo A, Labarque V, Gastmans C. Physician decision-making process about withholding/withdrawing life-sustaining treatments in paediatric patients: a systematic review of qualitative evidence. BMC Palliat Care 2022; 21:113. [PMID: 35751075 PMCID: PMC9229823 DOI: 10.1186/s12904-022-01003-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background With paediatric patients, deciding whether to withhold/withdraw life-sustaining treatments (LST) at the end of life is difficult and ethically sensitive. Little is understood about how and why physicians decide on withholding/withdrawing LST at the end of life in paediatric patients. In this study, we aimed to synthesise results from the literature on physicians’ perceptions about decision-making when dealing with withholding/withdrawing life-sustaining treatments in paediatric patients. Methods We conducted a systematic review of empirical qualitative studies. Five electronic databases (Pubmed, Cinahl®, Embase®, Scopus®, Web of Science™) were exhaustively searched in order to identify articles published in English from inception through March 17, 2021. Analysis and synthesis were guided by the Qualitative Analysis Guide of Leuven. Results Thirty publications met our criteria and were included for analysis. Overall, we found that physicians agreed to involve parents, and to a lesser extent, children in the decision-making process about withholding/withdrawing LST. Our analysis to identify conceptual schemes revealed that physicians divided their decision-making into three stages: (1) early preparation via advance care planning, (2) information giving and receiving, and (3) arriving at the final decision. Physicians considered advocating for the best interests of the child and of the parents as their major focus. We also identified moderating factors of decision-making, such as facilitators and barriers, specifically those related to physicians and parents that influenced physicians’ decision-making. Conclusions By focusing on stakeholders, structure of the decision-making process, ethical values, and influencing factors, our analysis showed that physicians generally agreed to share the decision-making with parents and the child, especially for adolescents. Further research is required to better understand how to minimise the negative impact of barriers on the decision-making process (e.g., difficult involvement of children, lack of paediatric palliative care expertise, conflict with parents). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01003-5.
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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, 3000, Leuven, Belgium.
| | - Alice Cavolo
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
| | - Veerle Labarque
- Centre for Molecular and Vascular Biology, Faculty of Medicine, KU Leuven/UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
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Carr K, Hasson F, McIlfatrick S, Downing J. Initiation of paediatric advance care planning: Cross-sectional survey of health professionals reported behaviour. Child Care Health Dev 2022; 48:423-434. [PMID: 34873744 PMCID: PMC9306788 DOI: 10.1111/cch.12943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Globally, initiation of paediatric advance care planning discussions is advocated early in the illness trajectory; however, evidence suggests it occurs at crisis points or close to end of life. Few studies have been undertaken to ascertain the prevalence and determinants of behaviour related to initiation by the healthcare professional. METHOD Underpinned by the Capability, Opportunity, Motivation-Behaviour (COM-B) model for behaviour change, a cross-sectional online survey was conducted in United Kingdom and Ireland using a purposive sample of health professionals. Descriptive and inferential statistics were applied and nonparametric statistical analysis used. Open-ended questions were mapped and correlations between COM-B and demographic profiles identified. RESULTS Responses (n = 140): Paediatric advance care planning was viewed positively; however, initiation practices were found to be influenced by wide ranging diagnoses and disease trajectories. Whilst some tools and protocols exist, they were not used in a systematic manner, and initiation behaviour was often not guided by them. Initiation was unstandardized, individually led, guided by intuition and experience and based on a range of prerequisites. Such behaviour, combined with inconsistencies in professional development, resulted in varying practice when managing clinical deterioration. Professionals who felt adequately trained initiated more conversations (capability). Those working in palliative care specialties, hospice settings and doctors initiated more discussions (opportunity). There was no difference in Motivation between professions, clinical settings or specialisms, although 25% (n = 35) of responses indicated discomfort discussing death and 34% (n = 49) worried about families' emotional reaction. CONCLUSION Although advocated, paediatric advance care planning is a complex process, commonly triggered by the physical deterioration and rarely underpinned by support tools. The COM-B framework was useful in identifying fundamental differences in initiation behaviour; however, further research is required to explore the complexity of initiation behaviour and the system within which the care is being delivered to identify influences on initiation.
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Affiliation(s)
- Karen Carr
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Felicity Hasson
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Sonja McIlfatrick
- Institute of Nursing and Health ResearchUlster UniversityNewtownabbeyUK
| | - Julia Downing
- International Children's Palliative Care NetworkBristolUK,Department of MedicineMakerere UniversityKampalaUganda
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Daxer M, Monz A, Hein K, Heitkamp N, Knochel K, Borasio GD, Führer M. How to Open the Door: A Qualitative, Observational Study on Initiating Advance Care Discussions with Parents in Pediatric Palliative Care. J Palliat Med 2021; 25:562-569. [PMID: 34807732 DOI: 10.1089/jpm.2021.0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Context: Advance care discussions (ACD) between health care professionals (HCPs) and parents of children with a life-limiting disease are a core element of successful pediatric advance care planning (pACP). Yet, they are perceived as a challenging situation for all participants. Objectives: Our goal was to investigate the first step of ACD and identify its challenges and helpful communication strategies to develop a conversation guide for initiating the pACP process and structure the conversational opening. Methods: We performed a participant observation of 11 initial ACD and 24 interviews with 13 HCPs and 20 parents of 11 children cared for by 3 different palliative care teams in southern Germany. Qualitative data collection was supplemented by a questionnaire. Content analysis and conversation analysis were used for evaluation. Results: Parents and HCPs start the process with different expectations, which can lead to misunderstandings and confusion. HCPs gain parental cooperation when they express the purpose of the meeting clearly and early, provide structure and guidance, and give parents time to talk about their experiences and feelings. Addressing dying and death is hard for both sides and requires a sensitive approach. Conclusions: Initiating ACD is extremely challenging for all participants. HCPs and parents should clarify expectations and aims at the beginning of the conversation. Future research should focus on how HCPs can be trained for this task and how the right timing for introducing ACD to families can be identified. Clinical Trial Registration number 049-12.
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Affiliation(s)
- Marion Daxer
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Anna Monz
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Kerstin Hein
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Nari Heitkamp
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Kathrin Knochel
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University, Munich, Germany
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Carr K, Hasson F, McIlfatrick S, Downing J. Factors associated with health professionals decision to initiate paediatric advance care planning: A systematic integrative review. Palliat Med 2021; 35:503-528. [PMID: 33372582 PMCID: PMC7975890 DOI: 10.1177/0269216320983197] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Advance care planning for children with palliative care needs is an emotionally, legally and complex aspect of care, advocated as beneficial to children, families and health professionals. Evidence suggests healthcare professionals often avoid or delay initiation. An overview of evidence on the factors that influence and impact on the health care professional's initiation of paediatric advance care planning process is lacking. AIM To review and synthesise evidence on the factors associated with health care professional's decision to initiate paediatric advance care planning. DESIGN Systematic integrative review using constant comparison method. DATA SOURCES Electronic databases (CINAHL, PubMed, PsycINFO, Ovid MEDLINE, EMBASE, Web of Science and Cochrane) using MeSH terms and word searches in Oct 2019. No limit set on year of publication or country. Grey literature searches were also completed. RESULTS The search yielded 4153 citations from which 90 full text articles were reviewed. Twenty-one met inclusion criteria consisting of quantitative (n = 8), qualitative (n = 6) and theoretical (n = 7) studies.Findings revealed overarching and interrelated themes 'The timing of initiation', 'What makes an initiator, 'Professionals' perceptions' and 'Prerequisites to initiation'. CONCLUSIONS This review provides insights into the complexities and factors surrounding the initiation of advance care planning in paediatric practice. Uncertainty regarding prognosis, responsibility and unpredictable parental reactions result in inconsistent practice. Future research is required to inform intervention to assist health care professionals when initiating paediatric advance care planning conversations.
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Affiliation(s)
- Karen Carr
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Felicity Hasson
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, Ulster University, Newtownabbey, UK
| | - Julia Downing
- International Children's Palliative Care Network, UK & Makerere University, Kampala, Uganda
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Fawcett K, Gerber N, Iyer S, De Angulo G, Pusic M, Mojica M. Common Conditions Requiring Emergency Life Support. Pediatr Rev 2019; 40:291-301. [PMID: 31152101 DOI: 10.1542/pir.2017-0331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Kelsey Fawcett
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY
| | - Nicole Gerber
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY
| | - Shweta Iyer
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY
| | - Guillermo De Angulo
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY
| | | | - Michael Mojica
- Department of Emergency Medicine and.,Department of Pediatrics, New York University School of Medicine, New York, NY.,Department of Emergency Medicine, Bellevue Hospital Center, New York, NY
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Schneider K, Metze B, Bührer C, Cuttini M, Garten L. End-of-Life Decisions 20 Years after EURONIC: Neonatologists' Self-Reported Practices, Attitudes, and Treatment Choices in Germany, Switzerland, and Austria. J Pediatr 2019; 207:154-160. [PMID: 30772016 DOI: 10.1016/j.jpeds.2018.12.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/07/2018] [Accepted: 12/31/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess changes in attitudes of neonatologists regarding the care of extremely preterm infants and parental involvement over the last 20 years. STUDY DESIGN Internet-based survey (2016) involving 170 tertiary neonatal intensive care units in Austria, Switzerland, and Germany using the European Project on Parents' Information and Ethical Decision Making in Neonatal Intensive Care Units questionnaire (German edition) with minor modifications to the original survey from 1996 to 1997. RESULTS The 2016 survey included 104 respondents (52.5% response rate). In 2016, significantly more neonatologists reported having ever withheld intensive care treatment (99% vs 69%) and withdrawn mechanical ventilation (96% vs 61%) or life-saving drugs (99% vs 79%), compared with neonatologists surveyed in 1996-1997. Fewer considered limiting intensive care as a slippery slope possibly leading to abuse (18% vs 48%). In the situation of a deteriorating clinical condition despite all treatment, significantly more neonatologists would ask parental opinion about continuation of intensive care (49% vs 18%). In 2016, 21% of German neonatologists would resuscitate a hypothetical infant at the limits of viability, even against parental wishes. CONCLUSIONS Withholding or withdrawing intensive care for extremely preterm infants at the limits of viability with parental involvement has become more acceptable than it was 20 years ago. However, resuscitating extremely preterm infants against parental wishes remains an option for up to one-fifth of the responding neonatologists in this survey.
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Affiliation(s)
- Katja Schneider
- Department of Neonatology, GFO Kliniken Bonn, Bonn, Germany.
| | - Boris Metze
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Lars Garten
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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9
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Edwards JD, Kun SS, Graham RJ, Keens TG. End-Of-Life Discussions and Advance Care Planning for Children on Long-Term Assisted Ventilation with Life-Limiting Conditions. J Palliat Care 2018. [DOI: 10.1177/082585971202800104] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Families of children with life-limiting conditions who are on long-term assisted ventilation need to undertake end-of-life advance care planning (ACP) in order to align their goals and values with the inevitability of their child's condition and the risks it entails. To discuss how best to conduct ACP in this population, we performed a retrospective analysis of end-of-life discussions involving our deceased ventilator-assisted patients between 1987 and 2009. A total of 34 (72 percent) of 47 study patients were the subject of these discussions; many discussions occurred after acute deterioration. They resulted in directives to forgo or limit interventions for 21 children (45 percent). We surmise that many families were hesitant to discuss end-of-life issues during periods of relative stability. By offering anticipatory guidance and encouraging contemplation of patients’ goals both in times of stability and during worsening illness, health care providers can better engage patients’ families in ACP. As the child's condition progresses, the emphasis can be recalibrated. How families respond to such encouragement can also serve as a gauge of their willingness to pursue ACP.
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Affiliation(s)
- Jeffrey D. Edwards
- JD Edwards (corresponding author): Division of Pediatric Critical Care, University of California, San Francisco, and Moffitt Hospital, Box 0106, 505 Parnassus Avenue, San Francisco, California, USA 94143–0106
| | - Sheila S. Kun
- SS Kun: Division of Pediatric Pulmonology, Children's Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert J. Graham
- RJ Graham: Critical Care, Anesthesia, Perioperative Extension (CAPE) and Home Ventilation Program, and Division of Critical Care Medicine, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas G. Keens
- TG Keens: Division of Pediatric Pulmonology, Children's Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Plymire CJ, Miller EG, Frizzola M. Retrospective Review of Limitations of Care for Inpatients at a Free-Standing, Tertiary Care Children's Hospital. CHILDREN (BASEL, SWITZERLAND) 2018; 5:E164. [PMID: 30544741 PMCID: PMC6306927 DOI: 10.3390/children5120164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/02/2018] [Accepted: 12/03/2018] [Indexed: 11/16/2022]
Abstract
Limited studies exist regarding the timing, location, or physicians involved in do-not-resuscitate (DNR) order placement in pediatrics. Prior pediatric studies have noted great variations in practice during end-of-life (EOL) care. This study aims to analyze the timing, location, physician specialties, and demographic factors influencing EOL care in pediatrics. We examined the time preceding and following the implementation of a pediatric palliative care team (PCT) via a 5-year, retrospective chart review of all deceased patients previously admitted to inpatient services. Thirty-five percent (167/471) of the patients in our study died with a DNR order in place. Sixty-two percent of patients died in an ICU following DNR order placement. A difference was noted in DNR order timing between patients on general inpatient units and those discharged to home compared with those in the ICUs (p = 0.02). The overall DNR order rate increased following the initiation of the PCT from 30.8% to 39.2% (p = 0.05), but no change was noted in the rate of death in the ICUs. Our study demonstrates a variation in the timing of death following DNR order placement when comparing ICUs and general pediatric floors. Following the initiation of the PCT, we saw increased DNR frequency but no change in the interval between a DNR order and death.
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Affiliation(s)
- Christopher J Plymire
- Division of Pediatric Critical Care, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.
| | - Elissa G Miller
- Division of Palliative Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.
| | - Meg Frizzola
- Division of Pediatric Critical Care, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.
- Division of Palliative Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19899, USA.
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Kim MS, Lee J, Sim JA, Kwon JH, Kang EJ, Kim YJ, Lee J, Song EK, Kang JH, Nam EM, Kim SY, Yun HJ, Jung KH, Park JD, Yun YH. Discordance between Physician and the General Public Perceptions of Prognostic Disclosure to Children with Serious Illness: a Korean Nationwide Study. J Korean Med Sci 2018; 33:e327. [PMID: 30505258 PMCID: PMC6262186 DOI: 10.3346/jkms.2018.33.e327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/10/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND It is difficult to decide whether to inform the child of the incurable illness. We investigated attitudes of the general population and physicians toward prognosis disclosure to children and associated factors in Korea. METHODS Physicians working in one of 13 university hospitals or the National Cancer Center and members of the general public responded to the questionnaire. The questionnaire consisted of the age appropriate for informing children about the prognosis and the reason why children should not be informed. This survey was conducted as part of research to identify perceptions of physicians and general public on the end-of-life care in Korea. RESULTS A total of 928 physicians and 1,241 members of the general public in Korea completed the questionnaire. Whereas 92.7% of physicians said that children should be informed of their incurable illness, only 50.7% of the general population agreed. Physicians were also more likely to think that younger children should know about their poor prognosis compared with the general population. Physicians who opposed incurable illness disclosure suggested that children might not understand the situation, whereas the general public was primarily concerned that disclosure would exacerbate the disease. Physicians who were women or religious were more likely to want to inform children of their poor prognosis. In the general population, gender, education, comorbidity, and caregiver experience were related to attitude toward poor prognosis disclosure to children. CONCLUSION Our findings indicate that physicians and the general public in Korea differ in their perceptions about informing children of poor prognosis.
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Affiliation(s)
- Min Sun Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Jihye Lee
- Department of Biomedical Informatics, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Ah Sim
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hye Kwon
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Eun Joo Kang
- Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yu Jung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Junglim Lee
- Department of Hemato-Oncology, Daegu Fatima Hospital, Daegu, Korea
| | - Eun-Kee Song
- Division of Hematology and Oncology, Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Jung Hun Kang
- Department of Internal Medicine, Gyeongsang National University, Jinju, Korea
| | - Eun Mi Nam
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Si-Young Kim
- Department of Medical Oncology and Hematology, Kyung Hee University Hospital, Seoul, Korea
| | - Hwan-Jung Yun
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Kyung Hae Jung
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ho Yun
- Department of Biomedical Informatics, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University College of Medicine, Seoul, Korea
- Department of Family Medicine, Seoul National University College of Medicine, Seoul, Korea
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12
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Marsac ML, Kindler C, Weiss D, Ragsdale L. Let's Talk About It: Supporting Family Communication during End-of-Life Care of Pediatric Patients. J Palliat Med 2018; 21:862-878. [PMID: 29775556 DOI: 10.1089/jpm.2017.0307] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Communication is key in optimizing medical care when a child is approaching end of life (EOL). Research is yet to establish best practices for how medical teams can guide intrafamily communication (including surviving siblings) when EOL care is underway or anticipated for a pediatric patient. While recommendations regarding how medical teams can facilitate communication between the medical team and the family exist, various barriers may prevent the implementation of these recommendations. OBJECTIVE This review aims to provide a summary of research-to-date on family and medical provider perceptions of communication during pediatric EOL care. DESIGN Systematic review. RESULTS Findings from a review of 65 studies suggest that when a child enters EOL care, many parents try to protect their child and/or themselves by avoiding discussions about death. Despite current recommendations, medical teams often refrain from discussing EOL care with pediatric patients until death is imminent for a variety of reasons (e.g., family factors and discomfort with EOL conversations). Parents consistently report a need for honest complete information, delivered with sensitivity. Pediatric patients often report a preference to be informed of their prognosis, and siblings express a desire to be involved in EOL discussions. CONCLUSIONS Families may benefit from enhanced communication around EOL planning, both within the family and between the family and medical team. Future research should investigate a potential role for medical teams in supporting intrafamily communication about EOL challenges and should examine how communication between medical teams and families can be facilitated as EOL approaches.
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Affiliation(s)
- Meghan L Marsac
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.,2 College of Medicine, University of Kentucky , Lexington, Kentucky
| | - Christine Kindler
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky
| | - Danielle Weiss
- 3 Department of Pediatrics, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Lindsay Ragsdale
- 1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.,2 College of Medicine, University of Kentucky , Lexington, Kentucky
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Archambault-Grenier MA, Roy-Gagnon MH, Gauvin F, Doucet H, Humbert N, Stojanovic S, Payot A, Fortin S, Janvier A, Duval M. Survey highlights the need for specific interventions to reduce frequent conflicts between healthcare professionals providing paediatric end-of-life care. Acta Paediatr 2018; 107:262-269. [PMID: 28793184 DOI: 10.1111/apa.14013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/28/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
AIMS This study explored how paediatric healthcare professionals experienced and coped with end-of-life conflicts and identified how to improve coping strategies. METHODS A questionnaire was distributed to all 2300 professionals at a paediatric university hospital, covering the frequency of end-of-life conflicts, participants, contributing factors, resolution strategies, outcomes and the usefulness of specific institutional coping strategies. RESULTS Of the 946 professionals (41%) who responded, 466 had witnessed or participated in paediatric end-of-life discussions: 73% said these had led to conflict, more frequently between professionals (58%) than between professionals and parents (33%). Frequent factors included professionals' rotations, unprepared parents, emotional load, unrealistic parental expectations, differences in values and beliefs, parents' fear of hastening death, precipitated situations and uncertain prognosis. Discussions with patients and parents and between professionals were the most frequently used coping strategies. Conflicts were frequently resolved by the time of death. Professionals mainly supported designating one principal physician and nurse for each patient, two-step interdisciplinary meetings - between professionals then with parents - postdeath ethics meetings, bereavement follow-up protocols and early consultations with paediatric palliative care and clinical ethics services. CONCLUSION End-of-life conflicts were frequent and predominantly occurred between healthcare professionals. Specific interventions could target most of the contributing factors.
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Affiliation(s)
| | - Marie-Hélène Roy-Gagnon
- Centre de Recherche; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON Canada
| | - France Gauvin
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Soins Palliatifs Pédiatriques; CHU Sainte-Justine; Montréal QC Canada
| | - Hubert Doucet
- Comité de Bioéthique; CHU Sainte-Justine; Montréal QC Canada
| | - Nago Humbert
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Soins Palliatifs Pédiatriques; CHU Sainte-Justine; Montréal QC Canada
| | - Sanja Stojanovic
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Centre de Réadaptation Marie-Enfant; CHU Sainte-Justine; Montréal QC Canada
| | - Antoine Payot
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Soins Palliatifs Pédiatriques; CHU Sainte-Justine; Montréal QC Canada
- Comité de Bioéthique; CHU Sainte-Justine; Montréal QC Canada
- Unité de Consultation en Éthique Clinique; CHU Sainte-Justine; Montréal QC Canada
| | - Sylvie Fortin
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Comité de Bioéthique; CHU Sainte-Justine; Montréal QC Canada
- Unité de Consultation en Éthique Clinique; CHU Sainte-Justine; Montréal QC Canada
| | - Annie Janvier
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Éthique Clinique; CHU Sainte-Justine; Montréal QC Canada
- Soins Intensifs Néonataux; CHU Sainte-Justine; Montréal QC Canada
| | - Michel Duval
- Service d'Hématologie-Oncologie; Centre de Cancérologie Charles-Bruneau; Montréal QC Canada
- Département de Pédiatrie; CHU Sainte-Justine; Université de Montréal; Montréal QC Canada
- Unité de Consultation en Soins Palliatifs Pédiatriques; CHU Sainte-Justine; Montréal QC Canada
- Unité de Consultation en Éthique Clinique; CHU Sainte-Justine; Montréal QC Canada
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A Retrospective Review of Resuscitation Planning at a Children's Hospital. CHILDREN-BASEL 2018; 5:children5010009. [PMID: 29300339 PMCID: PMC5789291 DOI: 10.3390/children5010009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 12/18/2017] [Accepted: 12/20/2017] [Indexed: 11/25/2022]
Abstract
Resuscitation plans (RP) are an important clinical indicator relating to care at the end of life in paediatrics. A retrospective review of the medical records of children who had been referred to the Royal Children’s Hospital, Brisbane, Australia who died in the calendar year 2011 was performed. Of 62 records available, 40 patients (65%) had a life limiting condition and 43 medical records (69%) contained a documented RP. This study demonstrated that both the underlying condition (life-limiting or life-threatening) and the setting of care (Pediatric Intensive Care Unit or home) influenced the development of resuscitation plans. Patients referred to the paediatric palliative care (PPC) service had a significantly longer time interval from documentation of a resuscitation plan to death and were more likely to die at home. All of the patients who died in the paediatric intensive care unit (PICU) had a RP that was documented within the last 48 h of life. Most RPs were not easy to locate. Documentation of discussions related to resuscitation planning should accommodate patient and family centered care based on individual needs. With varied diagnoses and settings of care, it is important that there is inter-professional collaboration, particularly involving PICU and PPC services, in developing protocols of how to manage this difficult but inevitable clinical scenario.
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Lotz JD, Daxer M, Jox RJ, Borasio GD, Führer M. "Hope for the best, prepare for the worst": A qualitative interview study on parents' needs and fears in pediatric advance care planning. Palliat Med 2017; 31:764-771. [PMID: 27881828 PMCID: PMC5557107 DOI: 10.1177/0269216316679913] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pediatric advance care planning is advocated by healthcare providers because it may increase the chance that patient and/or parent wishes are respected and thus improve end-of-life care. However, since end-of-life decisions for children are particularly difficult and charged with emotions, physicians are often afraid of addressing pediatric advance care planning. AIM We aimed to investigate parents' views and needs regarding pediatric advance care planning. DESIGN We performed a qualitative interview study with parents of children who had died from a severe illness. The interviews were analyzed by descriptive and evaluation coding according to Saldaña. SETTING/PARTICIPANTS We conducted semi-structured interviews with 11 parents of 9 children. Maximum variation was sought regarding the child's illness, age at death, care setting, and parent gender. RESULTS Parents find it difficult to engage in pediatric advance care planning but consider it important. They argue for a sensitive, individualized, and gradual approach. Hope and quality of life issues are primary. Parents have many non-medical concerns that they want to discuss. Written advance directives are considered less important, but medical emergency plans are viewed as necessary in particular cases. Continuity of care and information should be improved through regular pediatric advance care planning meetings with the various care providers. Parents emphasize the importance of a continuous contact person to facilitate pediatric advance care planning. CONCLUSION Despite a need for pediatric advance care planning, it is perceived as challenging. Needs-adjusted content and process and continuity of communication should be a main focus in pediatric advance care planning. Future research should focus on strategies that facilitate parent engagement in pediatric advance care planning to increase the benefit for the families.
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Affiliation(s)
- Julia Desiree Lotz
- 1 Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Marion Daxer
- 1 Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Ralf J Jox
- 2 Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany.,3 Geriatric Palliative Care, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Gian Domenico Borasio
- 4 Palliative Care Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- 1 Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
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Yotani N, Kizawa Y, Shintaku H. Differences between Pediatricians and Internists in Advance Care Planning for Adolescents with Cancer. J Pediatr 2017; 182:356-362. [PMID: 28040231 DOI: 10.1016/j.jpeds.2016.11.079] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/24/2016] [Accepted: 11/30/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate differences between pediatricians and internists in the practice of and barriers to advance care planning (ACP) for adolescent patients with cancer. STUDY DESIGN A self-reported questionnaire was administered to assess the practice of ACP, advance directives, and barriers to ACP for adolescent patients with cancer. All 3392 Japanese board-certified hematologists were surveyed, and 600 hematologists (227 pediatricians, 373 internists) who take care of adolescent patients with cancer with decision-making capacity were analyzed. RESULTS If a patient's prognosis for survival was <3 months, pediatricians were significantly less likely to discuss ACP with their patients than internists, including discussions regarding the patient's medical condition (59% vs 70%), the patient's understanding of his/her medical condition (55% vs 66%), do not attempt resuscitation orders (17% vs 24%), and ventilator treatment if the patient's condition worsened (19% vs 25%). More than 75% of hematologists (both pediatricians and internists) discussed all ACP topics with patients' families. Similarly, with regard to advance directives, pediatricians were less likely than internists to discuss cardiopulmonary resuscitation (24% vs 47%) and the use of ventilators (31% vs 51%), vasopressors (24% vs 42%), and antibiotics (21% vs 31%) with their patients. Both pediatricians and internists discussed these issues more often with patients' families than with patients, especially cardiopulmonary resuscitation (98%) as well as the use of ventilators (98%) and vasopressors (91%). CONCLUSIONS Pediatricians were less likely than internists to discuss ACP and advance directives with patients, and both pediatricians and internists tended to discuss ACP and advance directives more often with patients' families.
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Affiliation(s)
- Nobuyuki Yotani
- Kobe University Graduate School of Medicine, Kobe, Japan; Osaka City University Graduate School of Medicine, Osaka, Japan.
| | | | - Haruo Shintaku
- Osaka City University Graduate School of Medicine, Osaka, Japan
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Lotz JD, Jox RJ, Meurer C, Borasio GD, Führer M. Medical indication regarding life-sustaining treatment for children: Focus groups with clinicians. Palliat Med 2016; 30:960-970. [PMID: 26847523 PMCID: PMC5117124 DOI: 10.1177/0269216316628422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Decisions about medical indication are a relevant problem in pediatrics. Difficulties arise from the high prognostic uncertainty, the decisional incapacity of many children, the importance of the family, and conflicts with parents. The objectivity of judgments about medical indication has been questioned. Yet, little is known about the factors pediatricians actually include in their decisions. AIM Our aims were to investigate which factors pediatricians apply in deciding about medical indication, and how they manage conflicts with parents. DESIGN We performed a qualitative focus group study with experienced pediatricians. The transcripts were subjected to qualitative content analysis. SETTING/PARTICIPANTS We conducted three focus groups with pediatricians from different specialties caring for severely ill children/adolescents. They discussed life-sustaining treatment in two case scenarios that varied according to diagnosis, age, and gender. RESULTS The decisions about medical indication were based on considerations relating to the individual patient, to the family, and to other patients. Individual patient factors included clinical aspects and benefit-burden considerations. Physicians' individual views and feelings influenced their decision-making. Different factors were applied or weighed differently in the two cases. In case of conflict with parents, physicians preferred solutions aimed at establishing consensus. CONCLUSION The pediatricians defined medical indication on a case-by-case basis and were influenced by emotional reasoning. In contrast to prevailing ethico-legal principles, they included the interests of other persons in their decisions. Decision-making strategies should incorporate explicit discussions of social aspects and physicians' feelings to improve the transparency of the decision-making process and reduce bias.
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Affiliation(s)
- Julia Desiree Lotz
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Christine Meurer
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Gian Domenico Borasio
- Palliative Care Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
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Xafis V, Watkins A, Wilkinson D. Death talk: Basic linguistic rules and communication in perinatal and paediatric end-of-life discussions. PATIENT EDUCATION AND COUNSELING 2016; 99:555-561. [PMID: 26561310 DOI: 10.1016/j.pec.2015.10.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 10/22/2015] [Accepted: 10/28/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE This paper considers clinician/parent communication difficulties noted by parents involved in end-of-life decision-making in the light of linguistic theory. METHODS Grice's Cooperative Principle and associated maxims, which enable effective communication, are examined in relation to communication deficiencies that parents have identified when making end-of-life decisions for the child. Examples from the literature are provided to clarify the impact of failing to observe the maxims on parents and on clinician/parent communication. RESULTS Linguistic theory applied to the literature on parental concerns about clinician/parent communication shows that the violation of the maxims of quantity, quality, relation, and manner as well as the stance that some clinicians adopt during discussions with parents impact on clinician/parent communication and lead to distrust, anger, sadness, and long-term difficulties coping with the experience of losing one's child. CONCLUSION Parents have identified communication deficiencies in end-of-life discussions. Relating these communication deficiencies to linguistic theory provides insight into communication difficulties but also solutions. PRACTICE IMPLICATIONS Gaining an understanding of basic linguistic theory that underlies human interactions, gaining insight into the communication deficiencies that parents have identified, and modifying some communication behaviours in light of these with the suggestions made in this article may lead to improved clinician/parent communication.
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Affiliation(s)
- Vicki Xafis
- Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia.
| | | | - Dominic Wilkinson
- Discipline of Obstetrics and Gynaecology, Women's and Children's Hospital, The University of Adelaide, Adelaide, Australia; Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.
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Abstract
In 1965, when the first issue of Journal of Paediatrics and Child Health appeared, medical ethics was just becoming established as a discipline. The sub-speciality of paediatric ethics did not make an appearance until the late 1980s, with the first key texts appearing in the 1990s. Professional concern to practice ethically in paediatrics obviously goes much further back than that, even if not named as such. In clinical areas of paediatrics, the story of the last 50 years is essentially a story of progress - better understanding of disease, better diagnosis, more effective treatment, better outcomes. In paediatric ethics, the story of the last 50 years is a bit more complicated. In ethics, the idea of progress, rather than just change, is not so straightforward and is sometimes hotly contested. There has certainly been change, including some quite radical shifts in attitudes and practices, but on some issues, the ethical debate now looks remarkably similar to that of 40-50 years ago. This is the story of some things that have changed in paediatric ethics, some things that have stayed the same and the key ethical ideas lying beneath the surface.
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Affiliation(s)
- Lynn Gillam
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Durall A, Zurakowski D, Wolfe J. Barriers to conducting advance care discussions for children with life-threatening conditions. Pediatrics 2012; 129:e975-82. [PMID: 22392177 DOI: 10.1542/peds.2011-2695] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Advance care discussions (ACD) occur infrequently or are initiated late in the course of illness. Although data exist regarding barriers to ACD among the care of adult patients, few pediatric data exist. The goal of this study was to identify barriers to conducting ACD for children with life-threatening conditions. METHODS Physicians and nurses from practice settings where advance care planning typically takes place were surveyed to collect data regarding their attitudes and behaviors regarding ACD. RESULTS A total of 266 providers responded to the survey: 107 physicians and 159 nurses (54% response rate). The top 3 barriers were: unrealistic parent expectations, differences between clinician and patient/parent understanding of prognosis, and lack of parent readiness to have the discussion. Nurses identified lack of importance to clinicians (P = .006) and ethical considerations (P < .001) as impediments more often than physicians. Conversely, physicians believed that not knowing the right thing to say (P = .006) was more often a barrier. There are also perceived differences among specialties. Cardiac ICU providers were more likely to report unrealistic clinician expectations (P < .001) and differences between clinician and patient/parent understanding of prognosis (P = .014) as common barriers to conducting ACD. Finally, 71% of all clinicians believed that ACD happen too late in the patient's clinical course. CONCLUSIONS Clinicians perceive parent prognostic understanding and attitudes as the most common barriers to conducting ACD. Educational interventions aimed at improving clinician knowledge, attitudes, and skills in addressing these barriers may help health care providers overcome perceived barriers.
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Affiliation(s)
- Amy Durall
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, Massachusetts 02115, USA.
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Kilham HA. Expressing ethical principles of treatment and care in a charter: what value? J Paediatr Child Health 2011; 47:590-3. [PMID: 21951438 DOI: 10.1111/j.1440-1754.2011.02158.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
More than ever before, public institutions are expected to have accessible guidelines on what they do, both for their staff and for those served by them. With this in mind, some principles of treatment and care of sick children were drafted for the Children's Hospital at Westmead. These were centred on ethics, primarily of what was best for the child. They were neither all-inclusive nor specific. They were labelled as a charter. They were rejected by a parent committee and met with unenthusiastic responses at meetings of hospital and ethics professionals. Reasons for this are unclear, but it is speculated that fear of the unknown and distrust of institutions may be factors. To date, the charter has not proved useful, except in provoking further discussion on how general guidelines are written, used and valued and on end-of-life decision-making more generally.
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Affiliation(s)
- Henry A Kilham
- General Medicine and Clinical Ethics, The Children's Hospital at Westmead, New South Wales, Australia.
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Current World Literature. Curr Opin Support Palliat Care 2009; 3:79-82. [DOI: 10.1097/spc.0b013e3283277013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Stark Z, Hynson J, Forrester M. Discussing withholding and withdrawing of life-sustaining medical treatment in paediatric inpatients: audit of current practice. J Paediatr Child Health 2008; 44:399-403. [PMID: 18638331 DOI: 10.1111/j.1440-1754.2008.01352.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM To understand the circumstances of inpatient deaths at a tertiary paediatric hospital and current practices regarding the timing and documentation of discussions concerning the withholding and withdrawing of life-sustaining medical treatment (WWLSMT). METHODS Retrospective review of the medical records of 50 consecutive inpatient deaths. RESULTS In total, 84% of inpatient deaths occurred in an intensive care setting. In all, 74% of patients had an underlying life-limiting or life-threatening condition and death was documented as having been expected in the short term in 88% of patients. Life-sustaining treatment was either withdrawn or limited prior to death in 84% of cases. There was documented family involvement in the decision-making process in 98% of cases. A total of 83% of discussions first took place on the day of death itself or in the week leading up to the child's death. Although medical staff frequently documented the outcome of these discussions, the content, clarity and accessibility of documentation varied widely. CONCLUSIONS The majority of inpatient deaths at The Royal Children's Hospital occur in acute circumstances and involve patients with chronic conditions. In most cases, death follows WWLSMT. Discussions with families are documented as first occurring relatively late in the course of the final admission although opportunities for earlier discussions may exist. Further research is needed to understand more about how and when discussions actually take place, what the barriers to communication are and to what extent opportunities exist for discussions to be initiated earlier in the illness course.
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Affiliation(s)
- Zornitza Stark
- Department of Clinical Quality and Safety, Royal Children's Hospital, Melbourne, Victoria, Australia
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