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Curkovic M, Rubic F, Jozepovic A, Novak M, Filipovic-Grcic B, Mestrovic J, Lah Tomulic K, Peter B, Spoljar D, Grosek Š, Janković S, Vukovic J, Kujundžić Tiljak M, Štajduhar A, Borovecki A. Navigating the shadows: medical professionals' values and perspectives on end-of-life care within pediatric intensive care units in Croatia. Front Pediatr 2024; 12:1394071. [PMID: 39188642 PMCID: PMC11345198 DOI: 10.3389/fped.2024.1394071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 07/15/2024] [Indexed: 08/28/2024] Open
Abstract
Background and aim This study explores healthcare professionals' perspectives on end-of-life care in pediatric intensive care units (ICUs) in Croatia, aiming to illuminate their experiences with such practices, underlying attitudes, and major decision-making considerations. Amid the high variability, complexity, and emotional intensity of pediatric end-of-life decisions and practices, understanding these perspectives is crucial for improving care and policies. Methods The study utilized a cross-sectional survey intended for physicians and nurses across all pediatric ICUs in Croatia. It included healthcare professionals from six neonatal and four pediatric ICUs in total. As the data from neonatal and pediatric ICUs were examined jointly, the term pediatric ICU was used to denominate both types of ICUs. A statistical analysis was performed using Python and JASP, focusing on professional roles, professional experience, and regional differences. Results The study included a total of 103 participants (with an overall response rate-in relation to the whole target population-of 48% for physicians and 29% for nurses). The survey revealed diverse attitudes toward and experiences with various aspects of end-of-life care, with a significant portion of healthcare professionals indicating infrequent involvement in life-sustaining treatment (LST) limitation discussions and decisions, as well as somewhat ambiguous attitudes regarding such practices. Notably, discrepancies emerged between different professional roles and, in particular, regions, underscoring the high variability of LST limitation-related procedures. Conclusions The findings highlight a pressing need for more straightforward guidelines, legal frameworks, support mechanisms, and communication strategies to navigate the complex terrain of rather burdensome end-of-life pediatric care, which is intrinsically loaded with profound ethical quandaries.
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Affiliation(s)
- Marko Curkovic
- University Psychiatric Hospital Vrapče, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Filip Rubic
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ana Jozepovic
- Department of Anesthesiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Milivoj Novak
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Boris Filipovic-Grcic
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Julije Mestrovic
- Department of Pediatrics, University Hospital Centre Split, Split, Croatia
| | | | - Branimir Peter
- Department of Gynecology and Obstetrics, University Hospital Centre Rijeka, Rijeka, Croatia
| | - Diana Spoljar
- Palliative Care Service, Community Health Center Zagreb, Zagreb, Croatia
| | - Štefan Grosek
- Department of Perinatology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Sunčana Janković
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jurica Vukovic
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mirjana Kujundžić Tiljak
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Andrija Štajduhar
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ana Borovecki
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
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Morillo Palomo A, Esquerda Aresté M, Riverola de Veciana A, Cambra Lasaosa FJ. End-of-life decision-making in the neonatal intensive care unit. Front Pediatr 2024; 11:1352485. [PMID: 38259598 PMCID: PMC10800896 DOI: 10.3389/fped.2023.1352485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Most paediatric deaths occur in the neonatal period, many of them in neonatal intensive care units after withdrawal of life support or the decision not to initiate new treatments. In these circumstances, discussions with families and decision-making are fundamental elements of the care and attention given to newborn babies. In this context, bioethical deliberation can help us to identify the values at stake, the different courses of action to be taken, and the means to ensure that family-shared decision-making is appropriate to the patient's situation and in accordance with the family's values.
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Affiliation(s)
- Ana Morillo Palomo
- Neonatal Intensive Care Unit, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Montse Esquerda Aresté
- Institut Borja de Bioètica, Universitat Ramon Llull, Barcelona, Spain
- School of Medicine, University of Lleida, Lleida, Spain
| | | | - Francisco José Cambra Lasaosa
- Institut Borja de Bioètica, Universitat Ramon Llull, Barcelona, Spain
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, Barcelona, Spain
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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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Poogoda S, Lynch F, Stark Z, Wilkinson D, Savulescu J, Vears D, Gyngell C. Intensive Care Clinicians' Perspectives on Ethical Challenges Raised by Rapid Genomic Testing in Critically Ill Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:970. [PMID: 37371202 DOI: 10.3390/children10060970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/21/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023]
Abstract
Rapid genomic testing (rGT) enables genomic information to be available in a matter of hours, allowing it to be used in time-critical settings, such as intensive care units. Although rGT has been shown to improve diagnostic rates in a cost-effective manner, it raises ethical questions around a range of different areas, including obtaining consent and clinical decision-making. While some research has examined the perspectives of parents and genetics health professionals, the attitudes of intensive care clinicians remain under-explored. To address this gap, we administered an online survey to English-speaking neonatal/paediatric intensivists in Europe, Australasia and North America. We posed two ethical scenarios: one relating to obtaining consent from the parents and the second assessing decision-making regarding the provision of life-sustaining treatments. Descriptive statistics were used to analyse the data. We received 40 responses from 12 countries. About 50-75% of intensivists felt that explicit parental consent was necessary for rGT. About 68-95% felt that a diagnosis from rGT should affect the provision of life-sustaining care. Results were mediated by intensivists' level of experience. Our findings show divergent attitudes toward ethical issues generated by rGT among intensivists and suggest the need for guidance regarding ethical decision-making for rGT.
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Affiliation(s)
- Sachini Poogoda
- Department of Paediatrics, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Fiona Lynch
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC 3052, Australia
| | - Zornitza Stark
- Department of Paediatrics, University of Melbourne, Melbourne, VIC 3010, Australia
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC 3052, Australia
- Australian Genomics, Melbourne, VIC 3052, Australia
| | - Dominic Wilkinson
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford OX1 1PT, UK
| | - Julian Savulescu
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC 3052, Australia
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford OX1 1PT, UK
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119077, Singapore
| | - Danya Vears
- Department of Paediatrics, University of Melbourne, Melbourne, VIC 3010, Australia
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC 3052, Australia
- Centre for Biomedical Ethics and Law, KU Leuven, 3000 Leuven, Belgium
| | - Christopher Gyngell
- Department of Paediatrics, University of Melbourne, Melbourne, VIC 3010, Australia
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC 3052, Australia
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Cambonie G, Desage C, Thaller P, Lemaitre A, de Balanda KB, Combes C, Gavotto A. Context of a neonatal death affects parental perception of end-of-life care, anxiety and depression in the first year of bereavement. BMC Palliat Care 2023; 22:58. [PMID: 37173678 PMCID: PMC10182590 DOI: 10.1186/s12904-023-01183-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Neonatal death is often preceded by end-of-life medical decisions. This study aimed to determine whether the context of death - after a decision of withholding or withdrawing life-sustaining treatment (WWLST) or despite maximum care - was associated with subsequent risk of parental anxiety or depression. The secondary objective was to assess parents' perceptions of end-of-life care according to death context. METHODS Prospective single center observational study of all neonatal deaths in a neonatal intensive care unit over a 5-year period. Data were collected during hospitalization and from face-to-face interviews with parents 3 months after the infant's death. Anxiety and depression were assessed using Hospital Anxiety and Depression Scale (HADS) questionnaires, completed by parents 5 and 15 months after death. RESULTS Of 179 deaths, 115 (64%) occurred after the WWLST decision and 64 (36%) despite maximum care. Parental satisfaction with newborn care and received support by professionals and relatives was higher in the first condition. Sixty-one percent of parents (109/179) attended the 3-month interview, with the distribution between groups very close to that of hospitalization. The completion rates of the HADS questionnaires by the parents who attended the 3-month interview were 75% (82/109) at 5 months and 65% (71/109) at 15 months. HADS scores at 5 months were consistent with anxiety in at least one parent in 73% (60/82) of cases and with depression in 50% (41/82). At 15 months, these rates were, respectively, 63% (45/71) and 28% (20/71). Risk of depression at 5 months was lower after a WWLST decision (OR 0.35 [0.14, 0.88], p = 0.02). Explicit parental agreement with the WWLST decision had an equivocal impact on the risk of anxiety at 5 months, being higher when expressed during hospitalization, but not at the 3-month interview. CONCLUSIONS Context of death has a significant impact on the emotional experience of parents after neonatal loss, which underlines the importance of systematic follow-up conversations with bereaved parents.
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Affiliation(s)
- Gilles Cambonie
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France.
- Pathogenesis and Control of Chronic Infection, UMR 1058, INSERM, University of Montpellier, Montpellier, France.
| | - Chloé Desage
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Pénélope Thaller
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Anne Lemaitre
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Karine Bertran de Balanda
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Clémentine Combes
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Arthur Gavotto
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France
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Arkell K, Gyngell C, Stark Z, Vears DF. Rapid Genomic Testing in Intensive Care: Health Professionals' Perspectives on Ethical Challenges. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050824. [PMID: 37238372 DOI: 10.3390/children10050824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
Ultra-rapid genomic sequencing (urGS) is increasingly used in neonatal and pediatric intensive care settings (NICU/PICU), demonstrating high diagnostic and clinical utility. This study aimed to explore the perspectives of healthcare professionals (HPs) and the challenges raised by urGS, particularly when making treatment decisions. Four focus groups and two interviews were conducted with HPs who had experience using urGS in NICU/PICU. Inductive content analysis was used to analyze the data. Nineteen HPs participated overall (eight clinical geneticists, nine genetic counselors, and two intensivists). One challenging area of practice identified by HPs was setting realistic expectations for outcomes of urGS among HPs and families. HPs reported modifying pre-test counseling to include life-limiting diagnoses as a possible test outcome and felt concerned about the timing of the test and its impact on parent-child bonding. UrGS results of uncertain prognostic significance posed considerable challenges. Moral distress arose when families and HPs were misaligned regarding treatment goals following the urGS diagnosis. We identified areas of practice that remain ethically challenging for HPs using urGS in the NICU/PICU. HPs experiences of using urGS in the NICU/PICU could inform specialized training in withdrawal of treatment decision making for the genomics workforce.
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Affiliation(s)
- Katie Arkell
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Christopher Gyngell
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- Melbourne Law School, The University of Melbourne, Carlton, VIC 3053, Australia
| | - Zornitza Stark
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia
- Australian Genomics, Parkville, VIC 3052, Australia
| | - Danya F Vears
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- Melbourne Law School, The University of Melbourne, Carlton, VIC 3053, Australia
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Pellikka HK, Axelin A, Sankilampi U, Kangasniemi M. Shared responsibility for decision-making in NICU: A scoping review. Nurs Ethics 2023; 30:462-476. [PMID: 36688269 DOI: 10.1177/09697330221134948] [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: 01/24/2023]
Abstract
BACKGROUND Shared responsibility is an essential part of family-centred care and it characterizes the relationship between parents and healthcare professionals. Despite this, little is known about their shared responsibility for decision-making in neonatal intensive care units. AIM The aim of this scoping review was to identify previous studies on the subject and to summarize the knowledge that has been published so far. METHOD The review was conducted using electronic searches in the CINAHL, PubMed, Scopus and PsycINFO databases and manual searches of the reference lists of the selected papers. The searches were limited to peer-reviewed papers that had been published in English from 2010 to September 2021. The data were selected based on inclusion and exclusion criteria and the findings were inductively summarized. We identified eight papers that met the inclusion criteria. ETHICAL CONSIDERATIONS The scoping review was conducted according to good scientific practice by respecting authorship and reporting the study processes accurately, honestly and transparently. RESULTS The results showed that shared responsibility for decision-making was based on the parents' intentions, but the degree to which they were willing to take responsibility varied. The facilitating and inhibiting factors for shared responsibility for decision-making were related to the communication between parents and professionals. The impact was related to the parents' emotions. CONCLUSION It is essential that parents and professionals negotiate how both parties will contribute to their shared responsibility for decision-making. This will enable them to reach a mutual understanding of what is in the infants' best interests and to mitigate the emotional burden of decisions in neonatal intensive care units. More research is needed to clarify the concept of shared responsibility for decision-making in this intensive care context.
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Affiliation(s)
| | | | - Ulla Sankilampi
- 60650Kuopio University Hospital, Finland; University of Eastern Finland, Finland
| | - Mari Kangasniemi
- 60654University of Turku, Finland; Satakunta Hospital District, Finland
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HarnEnz Z, Vermilion P, Foster-Barber A, Treat L. Pediatric neuropalliative care. HANDBOOK OF CLINICAL NEUROLOGY 2023; 191:157-184. [PMID: 36599507 DOI: 10.1016/b978-0-12-824535-4.00015-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.
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Affiliation(s)
- Zoe HarnEnz
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Paul Vermilion
- Department of Medicine, University of Rochester, Rochester, NY, United States
| | - Audrey Foster-Barber
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - Lauren Treat
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States.
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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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Knochel K, Zaimovic V, Gatzweiler B, Hein KK, Heitkamp N, Monz A, Reimann D, Borasio GD, Führer M. Participatory Development of a Modular Advance Care Planning Program in Pediatric Palliative Care (MAPPS). J Pain Symptom Manage 2022; 63:189-198. [PMID: 34597758 DOI: 10.1016/j.jpainsymman.2021.09.013] [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: 03/31/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
CONTEXT Decision-making in pediatric palliative care concerns mainly children without decision-making capacity. It has to balance the child's best interests, parental responsibility and the impact on the family system. OBJECTIVES Advance care planning (ACP) supports decision making about future medical care. A consistent pediatric approach is still missing. This study aimed at developing a pediatric ACP program (pedACP) meeting specific needs of children, parents and professionals. METHODS Bereaved parents of children with life-limiting conditions and professionals involved in pedACP participated. Employing the technique of constellation analysis, they collaboratively assigned content, actors, tools and warning notes about pedACP along a timeline. The researchers analyzed, systematized and translated these results into a pedACP program draft, which was revised by the participants. RESULTS The participants' overall focus was on the children's quality of life and an individualized interdisciplinary communication process along the disease trajectory. The program was conceptualized in modular design with fixed modules at the beginning (to build a trustful relationship and frame the process) and at the end (to summarize results and prepare implementation). The main discussions are structured in flexible modules (About the child, Emergencies, Disease-specific scenarios and End of life care). General themes cover timing, communication, engaging children and structural issues. The participants appreciated the program's comprehensiveness and flexibility. CONCLUSION Parents and professionals combined their perspectives on reflecting goals of care and the complexity of pedACP. They perceived the resulting modular program as suitable for meeting the individual needs of patients, families and professional stakeholders.
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Affiliation(s)
- Kathrin Knochel
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Vedrana Zaimovic
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Birga Gatzweiler
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Kerstin K Hein
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Nari Heitkamp
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Anna Monz
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Daniel Reimann
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service (G.D.B.), Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care (K.K., V.Z., B.G., K.K.H., N.H., A.M., D.R., M.F.), Dr von Hauner Children's Hospital, University of Munich, Munich, Germany.
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Klee K, Wilfond B, Thomas K, Ridling D. Conflicts between parents and clinicians: Tracheotomy decisions and clinical bioethics consultation. Nurs Ethics 2022; 29:685-695. [DOI: 10.1177/09697330211023986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The parent of a child with profound cognitive disability will have complex decisions to consider throughout the life of their child. An especially complex decision is whether to place a tracheotomy to support the child’s airway. The decision may involve the parent wanting a tracheotomy and the clinician advising against this intervention or the clinician recommending a tracheotomy while the parent is opposed to the intervention. This conflict over what is best for the child may lead to a bioethics consult. Objective: The study explores the conflicts that may arise around tracheotomy placements. Research design: This study is a retrospective cohort study of pediatric patients for whom a tracheotomy decision required a bioethics consult. Participants and research context: Pediatric patients aged birth to 18 years old with a bioethics consult for a tracheotomy decision conflict between April 2010 and December 2016. A standardized data collection tool was used to review notes entered by the palliative care team, social workers, primary clinical team interim summaries, and the bioethics consult service. Ethical considerations: The study was reviewed and approved by the medical center’s institutional review board. Results: There were 248 clinical bioethics consults during the identified study period. There were 31 consults involving 21 children where the word tracheotomy was mentioned in the consult, and 13 of the 21 consults were for children with profound cognitive disability. Discussion and conclusion: Clinicians need to be aware of their own biases when discussing a child’s prognosis and treatment options while also understanding the parents’ values and what the parent might consider to be burdensome in the care of their child and the acceptable burden for the child to experience.
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12
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März JW. What does the best interests principle of the convention on the rights of the child mean for paediatric healthcare? Eur J Pediatr 2022; 181:3805-3816. [PMID: 36083315 PMCID: PMC9546983 DOI: 10.1007/s00431-022-04609-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 08/24/2022] [Accepted: 09/01/2022] [Indexed: 12/01/2022]
Abstract
The present review analyses the implications of the best interests of the child principle, which is one of the most widely discussed principles of medical ethics and human rights, for paediatric healthcare. As a starting point, it presents the interpretation of the best interests principle by the United Nations Committee on the Rights of the Child. On this basis, it points out possible fields of application of the best interests principle with regard to paediatric healthcare and discusses the potential difficulties in the application of the best interests principle. Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing. Conclusion: The best interests principle requires action, inter alia, by health policymakers, professional associations, hospital managers and medical teams to ensure children receive the best possible healthcare. Whilst the best interests principle does not provide a conclusive solution to all ethical dilemmas in paediatric healthcare (as illustrated by the case studies), it provides children, medical teams, parents and families, and clinical ethicists with an indispensable framework for health care centred on the rights of the child. What is Known: • The best interests principle is one of the most widely discussed principles of medical ethics and human rights and one of the four general principles of the Convention on the Rights of the Child. What is New: • The present review discusses possible fields of application and potential difficulties of the best interests principle with regard to paediatric healthcare. • Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing.
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Affiliation(s)
- Julian W. März
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
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13
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Vadakkencherry Ramaswamy V, Abiramalatha T, Weiner GM, Trevisanuto D. A comparative evaluation and appraisal of 2020 American Heart Association and 2021 European Resuscitation Council neonatal resuscitation guidelines. Resuscitation 2021; 167:151-159. [PMID: 34464679 DOI: 10.1016/j.resuscitation.2021.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 01/08/2023]
Abstract
AIM The International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support forms the basis for guidelines developed by regional councils such as the American Heart Association (AHA) and the European Resuscitation Council (ERC). We aimed to determine if the updated guidelines are congruent, identify the source of variation, and score their quality. METHODS We compared the approach to developing recommendations, final recommendations, and cited evidence in the AHA 2020 and ERC 2021 neonatal resuscitation guidelines. Two investigators scored guideline quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. RESULTS Differences in the recommendations were found between AHA 2020 and ERC 2021 neonatal resuscitation guidelines. The councils gave differing recommendations for practices that had sparse evidence and made recommendations based on expert consensus or observational studies. AGREE II assessment revealed that AHA scored better for the domain 'rigour of development', but ERC had a higher score for 'stakeholder involvement'. Both AHA and ERC scored relatively less for 'applicability'. CONCLUSION AHA and ERC guidelines are predominantly based on the ILCOR CoSTR. Differences in recommendations between the two were largely related to the evidence gathering process for questions not reviewed by ILCOR, paucity of evidence for some recommendations based on existing regional practices and supported by expert opinion, and different interpretation or application of same evidence. Overall, both guidelines scored well on the AGREE II assessment, but each had domains that could be improved in future editions.
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Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Gary M Weiner
- Department of Pediatrics - Neonatology, University of Michigan, Ann Arbor, MI, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
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14
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Banazadeh M, Khanjari S, Naddaf A, Oskouie F. Healthcare professionals-related factors affecting parents' participation in decision making for neonates with life-threatening conditions: A qualitative study. J Eval Clin Pract 2021; 27:885-897. [PMID: 33103330 DOI: 10.1111/jep.13492] [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] [Received: 05/12/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Neonates with life-threatening conditions face complex clinical circumstances that confront parents and professionals with ethical decisions. Parents' participation in decision making has not gained sufficient attention in practice. Understanding factors affecting parents' participation is required. This study is part of a comprehensive project that explored the process of parents' participation in decision making for neonates with life-threatening conditions. The current study aimed to explore healthcare professionals-related factors affecting parents' participation in decision-making for neonates with life-threatening conditions. METHODS A grounded theory methodology was used in the comprehensive project. Twenty-two interviews/68 hours of observation were conducted. Data were concurrently analysed throughout data generation and constant comparative analysis. Data collected until theoretical saturation was reached, the extracted categories were coherent and the emerging theory made sense. After coding stages, the core category and the relationships with other main categories involved in the process of parents' participation in decision-making were developed. For this study, the category reflecting healthcare professionals-related factors affecting parents' participation in decision-making was reported. RESULTS Four themes were found: risk aversion including fear of litigation, fear of being accountable to the parents, and fear of bearing emotional distress; unprofessionalism including poor adherence to professional ethics, inadequate skill/knowledge, poor communication, and nurses' negligence in playing their professional role; information deficiencies including insufficient information, conflicting information, and complex and technical information, and clashes of attitudes including conflict about parents' participation in decision-making and conflict about the best interest of neonates. CONCLUSION Professionals should be aware of their role in involving parents in decision making. Training professionals on family centred care principle and communication skills contribute to support parents emotionally and respond empathically to their negative expressions. Training on ethics, development, and dissemination of guidelines and rules of conduct can make professionals more sensitive to ethical aspects of their work and may reduce their fear of litigation.
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Affiliation(s)
- Marjan Banazadeh
- Nursing Care Research Centre, Iran University of Medical Sciences, Tehran, Iran.,School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Sedigheh Khanjari
- Nursing Care Research Centre, Iran University of Medical Sciences, Tehran, Iran.,School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Naddaf
- Pediatric Department, Vali-Asr Hospital, Imam Khomeini Hospital Complex, Maternal-Fetal & Neonatal Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Oskouie
- Nursing Care Research Centre, Iran University of Medical Sciences, Tehran, Iran.,School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
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15
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Akdeniz M, Yardımcı B, Kavukcu E. Ethical considerations at the end-of-life care. SAGE Open Med 2021; 9:20503121211000918. [PMID: 33786182 PMCID: PMC7958189 DOI: 10.1177/20503121211000918] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/12/2021] [Indexed: 11/16/2022] Open
Abstract
The goal of end-of-life care for dying patients is to prevent or relieve
suffering as much as possible while respecting the patients’ desires.
However, physicians face many ethical challenges in end-of-life care.
Since the decisions to be made may concern patients’ family members
and society as well as the patients, it is important to protect the
rights, dignity, and vigor of all parties involved in the clinical
ethical decision-making process. Understanding the principles
underlying biomedical ethics is important for physicians to solve the
problems they face in end-of-life care. The main situations that
create ethical difficulties for healthcare professionals are the
decisions regarding resuscitation, mechanical ventilation, artificial
nutrition and hydration, terminal sedation, withholding and
withdrawing treatments, euthanasia, and physician-assisted suicide.
Five ethical principles guide healthcare professionals in the
management of these situations.
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Affiliation(s)
- Melahat Akdeniz
- Department of Family Medicine, Faculty of Medicine, Akdeniz University Hospital, Akdeniz University, Antalya, Turkey
| | | | - Ethem Kavukcu
- Department of Sports Medicine, Faculty of Medicine, Akdeniz University Hospital, Akdeniz University, Antalya, Turkey
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16
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European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation 2021; 161:291-326. [PMID: 33773829 DOI: 10.1016/j.resuscitation.2021.02.014] [Citation(s) in RCA: 223] [Impact Index Per Article: 74.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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17
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Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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18
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Shaw C, Connabeer K, Drew P, Gallagher K, Aladangady N, Marlow N. Initiating end-of-life decisions with parents of infants receiving neonatal intensive care. PATIENT EDUCATION AND COUNSELING 2020; 103:1351-1357. [PMID: 32111382 DOI: 10.1016/j.pec.2020.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 02/06/2020] [Accepted: 02/08/2020] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To investigate whether parent-initiated or doctor-initiated decisions about limiting life-sustaining treatment (LST) in neonatal care has consequences for how possible courses of action are presented. METHOD Formal conversations (n = 27) between doctors and parents of critically ill babies from two level 3 neonatal intensive care units were audio or video recorded. Sequences of talk where decisions about limiting LST were presented were analysed using Conversation Analysis and coded using a Conversation Analytic informed coding framework. Relationships between codes were analysed using Fisher's exact test. RESULTS When parents initiated the decision point, doctors subsequently tended to refer to or list available options. When doctors initiated, they tended to use 'recommendations' or 'single-option' choice (conditional) formats (p=0.017) that did not include multiple treatment options. Parent initiations overwhelmingly concerned withdrawal, as opposed to withholding of LST (p=0.030). CONCLUSION Aligning parents to the trajectory of the news about their baby's poor condition may influence how the doctor subsequently presents the decision to limit LST, and thereby the extent to which parents are invited to participate in shared decision-making. PRACTICE IMPLICATIONS Explicitly proposing treatment options may provide parents with opportunities to be involved in decisions for their critically ill babies, thereby fostering shared decision-making.
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Affiliation(s)
- Chloe Shaw
- UCL EGA Institute for Women's Health, University College London, London, UK.
| | | | - Paul Drew
- Department of Language & Linguistic Science, University of York, York, UK.
| | - Katie Gallagher
- UCL EGA Institute for Women's Health, University College London, London, UK.
| | - Narendra Aladangady
- Department of Neonatology, Homerton University Hospital, London, UK; Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, QMUL, London, UK.
| | - Neil Marlow
- UCL EGA Institute for Women's Health, University College London, London, UK.
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19
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Wosinski B, Newman CJ. Physicians' attitudes when faced with life-threatening events in children with severe neurological disabilities. Dev Neurorehabil 2019; 22:61-66. [PMID: 29648486 DOI: 10.1080/17518423.2018.1461946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Children with severe neurological disabilities are at an increased risk of acute, life-threatening events. We assessed physicians' attitudes when making decisions in these situations. METHODS We surveyed physicians in pediatric intensive care, neurology, and rehabilitation units in Swiss hospitals. The questionnaire explored participants' attitudes toward life-threatening situations in two scenarios: a child with profound intellectual and multiple disabilities (PIMD) and an infant with spinal muscular atrophy (SMA) type I. RESULTS The participation rate was 55% (52/95). There was a consensus favoring non-invasive ventilation and comfort care as well as avoiding tracheostomy and invasive ventilation. For the child with PIMD, 61% of participants opposed cardiopulmonary resuscitation (CPR), 51% for the child with SMA. Physicians with over 20 years of experience were significantly more opposed to providing CPR than less experienced colleagues. CONCLUSIONS Physicians held different views, influenced by personal factors. This highlights the importance of standardizing multidisciplinary processes toward approaching these complex situations.
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Affiliation(s)
- Benjy Wosinski
- a Paediatrics department , Lausanne University Hospital , Lausanne , Switzerland
| | - Christopher J Newman
- b Paediatric Neurology and Neurorehabilitation Unit , Lausanne University Hospital , Lausanne , Switzerland
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20
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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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21
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The role of the neuropediatrician in pediatric intensive care unit: Diagnosis, therapeutics and major participation in collaborative multidisciplinary deliberations about life-sustaining treatments' withdrawal. Eur J Paediatr Neurol 2019; 23:171-180. [PMID: 30262235 DOI: 10.1016/j.ejpn.2018.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 07/03/2018] [Accepted: 09/04/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND In Pediatric Intensive Care Unit (PICU) two types of population require the intervention of neuropediatricians (NP): chronic brain diseases' patients who face repetitive and prolonged hospitalizations, and patients with acute brain failure facing the risk of potential neurologic sequelae, and both conditions may result in a limitation of life-sustaining treatments (LLST) decision. OBJECTIVE To assess NP's involvement in LLST decisions within the PICU of a tertiary hospital. METHOD Retrospective study of medical reports of patients hospitalized during 2014 in the Necker-Hospital PICU. Patients were selected using keywords ("cardiorespiratory arrest", "death", "withdrawal of treatment", "palliative care", "acute brain failure", or "chronic neurological disease"), and/or if they were assessed by a NP during the hospitalization. Demographic and medical data were analysed, including the NP's assessment and data about Collaborative Multidisciplinary Deliberation (CMD) to discuss potential LLST. RESULTS Among 1160 children, 274 patients were included and 142 (56%) were assessed by a NP during their hospitalization for diagnosis (n = 55) and/or treatment (n = 95) management. NP was required for 59%-100% of patients with neurological acute failure, and for 14-44% of patients with extra neurological failure. A LLST decision was taken after a CMD for 27 (9.8%) of them, and a NP was involved in 19/27 (70%) of these decisions that occurred during the hospitalization (n = 19) or before (n = 8).12 patients died thereafter the LLST decision (40% of the 30 dead patients). CONCLUSION NP are clearly involved in the decision-process of LLST for patients admitted in PICU, claiming for close collaboration to improve current practices and the quality of the care provided to children.
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22
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Winters JP. When Parents Refuse: Resolving Entrenched Disagreements Between Parents and Clinicians in Situations of Uncertainty and Complexity. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:20-31. [PMID: 30133394 DOI: 10.1080/15265161.2018.1485758] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
When shared decision making breaks down and parents and medical providers have developed entrenched and conflicting views, ethical frameworks are needed to find a way forward. This article reviews the evolution of thought about the best interest standard and then discusses the advantages of the harm principle (HP) and the zone of parental discretion (ZPD). Applying these frameworks to parental refusals in situations of complexity and uncertainty presents challenges that necessitate concrete substeps to analyze the big picture and identify key questions. I outline and defend a new decision-making tool that includes three parts: identifying the nature of the disagreement, checklists for key elements of the HP and ZPD, and a "think list" of specific questions designed to enhance use of the HP and ZPD in clinical decision making. These tools together will assist those embroiled in complex disagreements to disentangle the issues to find a path to resolution.
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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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Abstract
The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process.
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25
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Richards CA, Starks H, O’Connor MR, Bourget E, Hays RM, Doorenbos AZ. Physicians Perceptions of Shared Decision-Making in Neonatal and Pediatric Critical Care. Am J Hosp Palliat Care 2018; 35:669-676. [PMID: 28990396 PMCID: PMC5673589 DOI: 10.1177/1049909117734843] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Most children die in neonatal and pediatric intensive care units after decisions are made to withhold or withdraw life-sustaining treatments. These decisions can be challenging when there are different views about the child's best interest and when there is a lack of clarity about how best to also consider the interests of the family. OBJECTIVE To understand how neonatal and pediatric critical care physicians balance and integrate the interests of the child and family in decisions about life-sustaining treatments. METHODS Semistructured interviews were conducted with 22 physicians from neonatal, pediatric, and cardiothoracic intensive care units in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analysis. RESULTS We identified 3 main themes: (1) beliefs about child and family interests; (2) disagreement about the child's best interest; and (3) decision-making strategies, including limiting options, being directive, staying neutral, and allowing parents to come to their own conclusions. Physicians described challenges to implementing shared decision-making including unequal power and authority, clinical uncertainty, and complexity of balancing child and family interests. They acknowledged determining the level of engagement in shared decision-making with parents (vs routine engagement) based on their perceptions of the best interests of the child and parent. CONCLUSIONS Due to power imbalances, families' values and preferences may not be integrated in decisions or families may be excluded from discussions about goals of care. We suggest that a systematic approach to identify parental preferences and needs for decisional roles and information may reduce variability in parental involvement.
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Affiliation(s)
- Claire A. Richards
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Helene Starks
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - M. Rebecca O’Connor
- Department of Family and Child Nursing, School of Nursing, University of Washington, Seattle, WA, USA
| | - Erica Bourget
- Department of Immunology, Fred Hutchinson’s Cancer Research Center, Seattle, WA, USA
| | - Ross M. Hays
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Rehabilitative Medicine, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
- Palliative Care Program, Seattle Children’s Hospital, Seattle, WA, USA
- The Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA
| | - Ardith Z. Doorenbos
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Unusual long survival despite severe lung disease of a child with biallelic loss of function mutations in ABCA-3. Respir Med Case Rep 2018; 23:173-175. [PMID: 29719811 PMCID: PMC5926270 DOI: 10.1016/j.rmcr.2018.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/02/2018] [Accepted: 03/04/2018] [Indexed: 12/19/2022] Open
Abstract
Homozygous or compound heterozygous for frameshift or nonsense mutations in the ATP–binding cassette transporter A3 (ABCA3) is associated with neonatal respiratory failure and death within the first year of life without lung transplantation. We report the case of a newborn baby girl who developed severe respiratory distress soon after birth. She was diagnosed with compound heterozygous frameshift mutation of the ABCA3 gene. Despite extensive treatment (intravenous corticosteroids pulse therapy, oral corticosteroids, azithromycin, and hydroxychloroquine), she developed chronic respiratory failure. As the parents refused cardio-pulmonary transplantation and couldn't resolve to an accompaniment of end of life, a tracheostomy was performed resulting in continuous mechanical ventilation. A neurodevelopmental delay and an overall muscular dystrophy were noted. At the age of 5 years, after 2 episodes of pneumothorax, the patient died from severe respiratory failure. To our knowledge, this was the first case of a child with compound heterozygous frameshift mutation who posed such an ethical dilemma with a patient surviving till the age of five years.
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Abstract
OBJECTIVES Typically pediatric end-of-life decision-making studies have examined the decision-making process, factors, and doctors' and parents' roles. Less attention has focussed on what happens after an end-of-life decision is made; that is, decision enactment and its outcome. This study explored the views and experiences of bereaved parents in end-of-life decision-making for their child. Findings reported relate to parents' experiences of acting on their decision. It is argued that this is one significant stage of the decision-making process. METHODS A qualitative methodology was used. Semi-structured interviews were conducted with bereaved parents, who had discussed end-of-life decisions for their child who had a life-limiting condition and who had died. Data were thematically analysed. RESULTS Twenty-five bereaved parents participated. Findings indicate that, despite differences in context, including the child's condition and age, end-of-life decision-making did not end when an end-of-life decision was made. Enacting the decision was the next stage in a process. Time intervals between stages and enactment pathways varied, but the enactment was always distinguishable as a separate stage. Decision enactment involved making further decisions - parents needed to discern the appropriate time to implement their decision to withdraw or withhold life-sustaining medical treatment. Unexpected events, including other people's actions, impacted on parents enacting their decision in the way they had planned. Several parents had to re-implement decisions when their child recovered from serious health issues without medical intervention. Significance of results A novel, critical finding was that parents experienced end-of-life decision-making as a sequence of interconnected stages, the final stage being enactment. The enactment stage involved further decision-making. End-of-life decision-making is better understood as a process rather than a discrete once-off event. The enactment stage has particular emotional and practical implications for parents. Greater understanding of this stage can improve clinician's support for parents as they care for their child.
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Psychosocial Care Models for Families of Critically Ill Children in Pediatric Emergency Department Settings: A Scoping Review. J Pediatr Nurs 2018; 38:46-52. [PMID: 29167080 DOI: 10.1016/j.pedn.2017.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 10/21/2017] [Accepted: 10/22/2017] [Indexed: 11/23/2022]
Abstract
PROBLEM Critical illness in children is a significant and stressful life event for families. Within pediatric emergency department (ED) settings it is acknowledged that these crises are challenging for both the families of these children, and for the clinical staff treating the child. Literature recommends routine care should include an offer to the family to be present with their critically ill child, however there is a lack of clarity regarding specific family care models or evidence-based interventions to guide clinical practice. ELIGIBILITY CRITERIA Peer reviewed articles written in English, published between 2006 and 2016, proposing or testing psychosocial care models in pediatric (or mixed) emergency settings. SAMPLE Nine articles met inclusion criteria. RESULTS Search results showed limited evidence available in the literature at this time. Thematic analysis of article content and proposed model showed strong support for the benefit of family presence, including shifting the family role from passive to active, needing to be inclusive of the psychological impact of critical health events, importance of multidisciplinary education, and the need for additional exploratory and empirical research to evaluate and refine proposed care models. CONCLUSIONS Pediatric emergency health events are challenging for both families and staff, and care models provide staff with a consistent, evidence-informed approach to caring for families in challenging situations. IMPLICATIONS There is a need to find common ground from specific discipline guidelines into a multidisciplinary team approach for the care of families within emergency care.
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Kirsch RE, Coronado J, Roeleveld PP, Tweddell J, Mott AM, Roth SJ. The Burdens of Offering: Ethical and Practical Considerations. World J Pediatr Congenit Heart Surg 2017; 8:715-720. [PMID: 29187107 DOI: 10.1177/2150135117733940] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We reflect upon highlights of a facilitated panel discussion from the 2016 Pediatric Cardiac Intensive Care Society Meeting. The session was designed to explore challenges, share practical clinical experiences, and review ethical underpinnings surrounding decisions to offer intensive, invasive therapies to patients who have a poor prognosis for survival or are likely to be burdened with multiple residual comorbidities if survival is achieved. The discussion panel was representative of a variety of disciplines including pediatric cardiology, cardiac intensive care, nursing, and cardiovascular surgery as well as different health-care delivery systems. Key issues discussed included patient's best interests, physician obligations, moral distress, and communication in the context of decisions about providing therapy for patients with a poor prognosis.
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Affiliation(s)
- Roxanne E Kirsch
- 1 Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,2 Department of Bioethics, The Hospital for Sick Children, Toronto, Ontario, Canada.,3 Cardiac Critical Care, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jillian Coronado
- 3 Cardiac Critical Care, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter P Roeleveld
- 4 Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, the Netherlands
| | - James Tweddell
- 5 Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, The Heart Institute, Cincinnati, OH, USA
| | - Antonio M Mott
- 6 Division of Pediatric Cardiology, Texas Children's Hospital Heart Center, Houston, TX, USA
| | - Stephen J Roth
- 7 Division of Pediatric Cardiology, Betty Irene Moore Children's Heart Center, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, USA
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Birchley G, Gooberman-Hill R, Deans Z, Fraser J, Huxtable R. 'Best interests' in paediatric intensive care: an empirical ethics study. Arch Dis Child 2017; 102:930-935. [PMID: 28408466 PMCID: PMC5739819 DOI: 10.1136/archdischild-2016-312076] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/30/2017] [Accepted: 03/08/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In English paediatric practice, English law requires that parents and clinicians agree the 'best interests' of children and, if this is not possible, that the courts decide. Court intervention is rare and the concept of best interests is ambiguous. We report qualitative research exploring how the best interests standard operates in practice, particularly with decisions related to planned non-treatment. We discuss results in the light of accounts of best interests in the medical ethics literature. DESIGN We conducted 39 qualitative interviews, exploring decision making in the paediatric intensive care unit, with doctors, nurses, clinical ethics committee members and parents whose children had a range of health outcomes. Interviews were audio-recorded and analysed thematically. RESULTS Parents and clinicians indicated differences in their approaches to deciding the child's best interests. These were reconciled when parents responded positively to clinicians' efforts to help parents agree with the clinicians' view of the child's best interests. Notably, protracted disagreements about a child's best interests in non-treatment decisions were resolved when parents' views were affected by witnessing their child's physical deterioration. Negotiation was the norm and clinicians believed avoiding the courts was desirable. CONCLUSIONS Sensitivity to the long-term interests of parents of children with life-limiting conditions is defensible but must be exercised proportionately. Current approaches emphasise negotiation but offer few alternatives when decisions are at an impasse. In such situations, the instrumental role played by a child's deterioration and avoidance of the courts risks giving insufficient weight to the child's interests. New approaches to decision making are needed.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | | | - Zuzana Deans
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - James Fraser
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
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Delany C, Xafis V, Gillam L, Hughson JA, Hynson J, Wilkinson D. A good resource for parents, but will clinicians use it?: Evaluation of a resource for paediatric end-of-life decision making. BMC Palliat Care 2017; 16:12. [PMID: 28122549 PMCID: PMC5264290 DOI: 10.1186/s12904-016-0177-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 12/20/2016] [Indexed: 11/10/2022] Open
Abstract
Background Communication with parents about end-of-life care and decisions is a difficult and sensitive process. The objective of the present study was to ascertain clinicians’ views on the acceptability and usefulness of a handbook and web-based resource (Caring Decisions) that was designed as an aid for parents facing end-of-life decisions for their child. Methods Qualitative interviews were conducted with a range of health professionals who provide care to children facing life-limiting conditions. Results Data analysis confirmed the acceptability and usefulness of the resource. Two major themes were revealed: 1. Family empowerment, with sub-themes Giving words and clarity, Conversation starter, ‘I’m not alone in this’, and A resource to take away, highlighted how the resource filled a gap by supporting and enabling families in a multitude of ways; 2. Not just for families, with sub-themes A guide for staff, When to give the resource?, How to give the resource and Who should give the resource?, explored the significant finding that participants viewed the resource as a valuable tool for themselves, but its presence also brought into relief potential gaps in communication processes around end-of-life care. Conclusion The interview data indicated the positive reception and clear value and need for this type of resource. However, it is likely that successful resource uptake will be contingent on discussion and planning around dissemination and use within the health care team.
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Affiliation(s)
- Clare Delany
- Children's Bioethics Centre, Royal Children's Hospital Melbourne, 50 Flemington Rd, Parkville, VIC, 3052, Australia. .,University of Melbourne, Parkville, VIC, 3010, Australia.
| | - Vicki Xafis
- Sydney Children's Hospitals Network, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, 2145, Australia.,Centre for Values Ethics and the Law in Medicine, University of Sydney, Medical Foundation Building K25, Camperdown, NSW, 2006, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, Royal Children's Hospital Melbourne, 50 Flemington Rd, Parkville, VIC, 3052, Australia
| | | | - Jenny Hynson
- Children's Bioethics Centre, Royal Children's Hospital Melbourne, 50 Flemington Rd, Parkville, VIC, 3052, Australia
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, St Ebbes Street, Oxford, OX1 1PT, UK
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Shaw C, Stokoe E, Gallagher K, Aladangady N, Marlow N. Parental involvement in neonatal critical care decision-making. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:1217-1242. [PMID: 27666147 DOI: 10.1111/1467-9566.12455] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The article analyses the decision-making process between doctors and parents of babies in neonatal intensive care. In particular, it focuses on cases in which the decision concerns the redirection of care from full intensive care to palliative care at the end of life. Thirty one families were recruited from a neonatal intensive care unit in England and their formal interactions with the doctor recorded. The conversations were transcribed and analysed using conversation analysis. Analysis focused on sequences in which decisions about the redirection of care were initiated and progressed. Two distinct communicative approaches to decision-making were used by doctors: 'making recommendations' and 'providing options'. Different trajectories for parental involvement in decision-making were afforded by each design, as well as differences in terms of the alignments, or conflicts, between doctors and parents. 'Making recommendations' led to misalignment and reduced opportunities for questions and collaboration; 'providing options' led to an aligned approach with opportunities for questions and fuller participation in the decision-making process. The findings are discussed in the context of clinical uncertainty, moral responsibility and the implications for medical communication training and guidance. A Virtual Abstract of this paper can be accessed at: https://www.youtube.com/watch?v=MyuymxDNupk&feature=youtu.be.
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Affiliation(s)
- Chloe Shaw
- Department of Neonatology, University College London, UK.
| | | | | | - Narendra Aladangady
- Department of Neonatology, Homerton University Hospital, London, UK
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, QMUL
| | - Neil Marlow
- Department of Neonatology, University College London, UK
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Christiansen SB, Kristensen AT, Lassen J, Sandøe P. Veterinarians' role in clients' decision-making regarding seriously ill companion animal patients. Acta Vet Scand 2016; 58:30. [PMID: 27221809 PMCID: PMC4879734 DOI: 10.1186/s13028-016-0211-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 04/28/2016] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND When companion animals become seriously ill clients may have doubts about treatment choices, if any, and turn to veterinarians for help. But how should veterinarians reply? Influence on clients' decision-making may or may not be acceptable-depending on one's attitude to principles such as 'paternalism', 'respect for autonomy' and 'shared decision-making'. This study takes as a starting point a situation where the animal is chronically ill, or aged, with potentially reduced animal welfare and client quality of life, and thus where clients need to consider treatment options or euthanasia. It is assumed throughout that both veterinarians and clients have the animals' best interest at heart. The purpose of the study was to explore the challenges these situations hold and to investigate how clients experience veterinary influence. A second aim was to reflect on the ethical implications of the role of veterinarians in these situations. Qualitative interviews were conducted with 12 dog owners considering treatment or euthanasia of their chronically ill or aged dogs. RESULTS Challenges relating to the dog and to the client were identified. Some situations left the interviewees hesitant, e.g. if lacking a clear cut-off point, the dog appeared normal, the interviewee felt uncertain about treatments or animal welfare, or experienced conflicting concerns. Some interviewees found that veterinarians could influence their decisions. Such influence was received in different ways by the interviewees. Some interviewees wanted active involvement of the veterinarian in the decision-making process, and this may challenge a veterinarian's wish to respect client autonomy. CONCLUSIONS Different preferences are likely to exist amongst both veterinarians and clients about veterinary involvement in clients' decision-making, and such preferences may vary according to the situation. It is suggested, that one way to handle this challenge is to include respect for client preference on veterinary involvement under a wider understanding of respect for autonomy, and to apply models of shared decision-making to veterinary practice. In any case there is a need to further explore the challenges these situations raise, and for the veterinary profession to engage in more formal and structured deliberation over the role of veterinarians in relation to clients' decision-making.
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Affiliation(s)
- Stine Billeschou Christiansen
- Department of Large Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Grønnegårdsvej 8, 1870 Frederiksberg C, Denmark
| | - Annemarie Thuri Kristensen
- Department of Veterinary Clinical and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Dyrlægevej 16, 1870 Frederiksberg C, Denmark
| | - Jesper Lassen
- Department of Food and Resource Economics, Faculty of Science, University of Copenhagen, Rolighedsvej 25, 1958 Frederiksberg C, Denmark
| | - Peter Sandøe
- Department of Large Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Grønnegårdsvej 8, 1870 Frederiksberg C, Denmark
- Department of Food and Resource Economics, Faculty of Science, University of Copenhagen, Rolighedsvej 25, 1958 Frederiksberg C, Denmark
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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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Xafis V, Wilkinson D, Sullivan J. What information do parents need when facing end-of-life decisions for their child? A meta-synthesis of parental feedback. BMC Palliat Care 2015; 14:19. [PMID: 25924893 PMCID: PMC4424961 DOI: 10.1186/s12904-015-0024-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 04/23/2015] [Indexed: 11/17/2022] Open
Abstract
Background The information needs of parents facing end-of-life decisions for their child are complex due to the wide-ranging dimensions within which such significant events unfold. While parents acknowledge that healthcare professionals are their main source of information, they also turn to a variety of additional sources of written information in an attempt to source facts, discover solutions, and find hope. Much has been written about the needs of parents faced with end-of-life decisions for their child but little is known about the written information needs such parents have. Research in the adult intensive care context has shown that written resources impact positively on the understanding of medical facts, including diagnoses and prognoses, communication between families and healthcare professionals, and the emotional wellbeing of families after their relative’s death. Methods A meta-synthesis of predominantly empirical research pertaining to features which assist or impede parental end-of-life decisions was undertaken to provide insight and guidance in our development of written resources (short print and online comprehensive version) for parents. Results The most prominently cited needs in the literature related to numerous aspects of information provision; the quantity, quality, delivery, and timing of information and its provision impacted not only on parents’ ability to make end-of-life decisions but also on their emotional wellbeing. The meta-synthesis supports the value of written materials, as these provide guidance for both parents and healthcare professionals in pertinent content areas. Conclusions Further research is required to determine the impact that written resources have on parental end-of-life decision-making and on parents’ wellbeing during and after their experience and time in the hospital environment. Electronic supplementary material The online version of this article (doi:10.1186/s12904-015-0024-0) contains supplementary material, which is available to authorized users.
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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, The University of Adelaide, Adelaide, Australia. .,John Radcliffe Hospital Oxford, Director of Medical Ethics, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.
| | - Jane Sullivan
- Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Australia. .,The Centre for Health Equity, The University of Melbourne, Melbourne, Australia.
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AlFaleh K, Alluwaimi E, AlOsaimi A, Alrajebah S, AlOtaibi B, AlRasheed F, AlKharfi T, Paes B. A prospective study of maternal preference for indomethacin prophylaxis versus symptomatic treatment of a patent ductus arteriosus in preterm infants. BMC Pediatr 2015; 15:47. [PMID: 25895495 PMCID: PMC4414008 DOI: 10.1186/s12887-015-0353-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 03/20/2015] [Indexed: 12/04/2022] Open
Abstract
Background The management of a patent ductus arteriosus in preterm infants continues to be debated among neonatologists due to the absence of concrete evidence that precisely weighs the long term outcomes of active, early intervention against a conservative approach. In the majority of institutions, parents are encouraged to play an active role in the complex, decision –making processes with regard to the care of their infants. The objective of this study is to elicit maternal preferences for indomethacin prophylaxis versus treatment of a patent ductus arteriosus (PDA) in extremely low birth weight (ELBW) infants, utilizing a decision aid instrument (DAI). Methods Healthy and high risk pregnant women at 23–28 weeks gestation, and mothers of admitted ELBW infants were enrolled. A computer based, validated DAI was utilized during interviews. The DAI first provides information about prematurity and concurrent morbidities with comprehensive facts of the pros and cons about prophylactic versus treatment options. It subsequently coaches participants how to select values and preferences based on their decisions. A 17-item questionnaire assessed and valued each short and long term morbidity of extreme prematurity and preferred choice for PDA management. Results Two hundred ninety nine subjects were enrolled; 75% were healthy women at 23–28 weeks gestation, 19% were high risk and 6% recently delivered an ELBW infant. Eighty-two percent preferred a prophylactic indomethacin strategy versus symptomatic treatment for the management of PDA. Across a spectrum of potential morbidities, the occurrence of severe intraventricular hemorrhage was viewed by mothers as the most un-wanted outcome irrespective of the two proposed options. Conclusions In contrast to neonatal practitioners, mothers who used this particular DAI strongly endorsed prophylactic indomethacin versus a treatment intervention for the management of PDA in preterm infants. Electronic supplementary material The online version of this article (doi:10.1186/s12887-015-0353-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Khalid AlFaleh
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Eman Alluwaimi
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Ahlam AlOsaimi
- Department of Pediatrics, King Fahad Medical City, Riyadh, Saudi Arabia.
| | - Sheikha Alrajebah
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Bashayer AlOtaibi
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Fatima AlRasheed
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Turki AlKharfi
- Department of Pediatrics (Division of Neonatology), College of Medicine, King Saud University, Riyadh, Saudi Arabia.
| | - Bosco Paes
- Department of Pediatrics (Neonatal Division), McMaster University, Hamilton, ON, Canada.
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Xafis V, Wilkinson D, Gillam L, Sullivan J. Balancing obligations: should written information about life-sustaining treatment be neutral? JOURNAL OF MEDICAL ETHICS 2015; 41:234-239. [PMID: 24763219 PMCID: PMC4345516 DOI: 10.1136/medethics-2013-101965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 03/04/2014] [Accepted: 04/02/2014] [Indexed: 06/03/2023]
Abstract
Parents who are facing decisions about life-sustaining treatment for their seriously ill or dying child are supported by their child's doctors and nurses. They also frequently seek other information sources to help them deal with the medical and ethical questions that arise. This might include written or web-based information. As part of a project involving the development of such a resource to support parents facing difficult decisions, some ethical questions emerged. Should this information be presented in a strictly neutral fashion? Is it problematic if narratives, arguments or perspectives appear to favour stopping over continuing life-sustaining treatment? Similar questions might arise with written materials about decisions for adults, or for other ethically contentious decisions. This paper explores the meaning of 'balance' in information provision, focusing particularly on written information about life-sustaining treatment for children. We contrast the norm of non-directiveness in genetic counselling with the shared decision-making model often endorsed in end-of-life care. We review evidence that parents do not find neutrality from medical professionals helpful in discussions. We argue that balance in written information must be understood in the light of the aim of the document, the most common situation in which it will be used, and any existing biases. We conclude with four important strategies for ensuring that non-neutral information is nevertheless ethically appropriate.
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Affiliation(s)
- Vicki Xafis
- Perinatal Ethics Unit, Discipline of Obstetrics and Gynaecology, Robinson Institute, The University of Adelaide, North Adelaide, South Australia, Australia
| | - Dominic Wilkinson
- Department of Neonatal Medicine, Robinson Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jane Sullivan
- Centre for Health and Society, University of Melbourne, Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
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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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Disability, discrimination and death: is it justified to ration life saving treatment for disabled newborn infants? Monash Bioeth Rev 2015; 32:43-62. [PMID: 25434064 PMCID: PMC4210721 DOI: 10.1007/s40592-014-0002-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Disability might be relevant to decisions about life support in intensive care in several ways. It might affect the chance of treatment being successful, or a patient’s life expectancy with treatment. It may affect whether treatment is in a patient’s best interests. However, even if treatment would be of overall benefit it may be unaffordable and consequently unable to be provided. In this paper we will draw on the example of neonatal intensive care, and ask whether or when it is justified to ration life-saving treatment on the basis of disability. We argue that predicted disability is relevant both indirectly and directly to rationing decisions.
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Abstract
Active ending of the life of a newborn baby is a crime. Yet its clandestine practise is a reality in several European countries. In this paper, we defend the necessity to institute a proper legal frame for what we define as active neonatal euthanasia. The only legal attempt so far, the Dutch Groningen protocol, is not satisfactory. We critically analyse this protocol, as well as several other clinical practises and philosophical stances. Furthermore, we have tried to integrate our opinions as clinicians into a law project, with the purpose of pinpointing several issues, specific of perinatality that should be addressed by such a law. In conclusion, we argue that the legalisation of neonatal euthanasia under exceptional circumstances is the only way to avoid all the "well-intentioned" malpractices associated with ending life at the very dawn of it.
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Affiliation(s)
- Serge Vanden Eijnden
- Neonatal Intensive Care Unit, CHU Charleroi, Belgium ; Fetal Medicine Department, CHU Charleroi, Belgium
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Understanding how cancer patients actualise, relinquish, and reject advance care planning: implications for practice. Support Care Cancer 2013; 21:2195-205. [PMID: 23494583 DOI: 10.1007/s00520-013-1779-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 02/25/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Although advance care planning (ACP) is recognised as integral to quality cancer care, it remains poorly integrated in many settings. Given cancer patients' unpredictable disease trajectories and equivocal treatment options, a disease-specific ACP model may be necessary. This study examines how Australian cancer patients consider ACP. Responses will inform the development of an Australian Cancer Centre's ACP programme. METHODS A constructivist research approach with grounded theory design was applied. Eighteen adults from lung and gastro-intestinal tumour streams participated. Participants first described their initial understanding of ACP, received ACP information, and finally completed a semi-structured interview assisted by the vignette technique. Qualitative inter-rater reliability was integrated. RESULTS Participants initially had scant knowledge of ACP. On obtaining further information, their responses indicated that: For cancer patients, ACP is an individualised, dynamic, and shared process characterised by myriad variations in choices to actualise, relinquish, and/or reject its individual components (medical enduring power of attorney, statement of choices, refusal of treatment certificate, and advanced directive). Actualisation of each component involves considering, possibly conversing about, planning, and communicating a decision, usually iteratively. Reactions can change over time and are informed by values, memories, personalities, health perceptions, appreciation of prognoses, and trust or doubts in their substitute decision makers. CONCLUSION Findings endorse the value of routinely, though sensitively, discussing ACP with cancer patients at various time points across their disease trajectory. Nonetheless, ACP may also be relinquished or rejected and ongoing offers for ACP in some patients may be offensive to their value system.
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