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Atsaidis Z, Robitaille S, Guadagno E, Wiseman J, Emil S, Poenaru D. "Your child needs surgery": A survey-based evaluation of simulated expert consent conversations by key stakeholders. J Pediatr Surg 2023; 58:902-907. [PMID: 36828674 DOI: 10.1016/j.jpedsurg.2023.01.024] [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: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Consent conversations in pediatric surgery are essential components of pre-operative care which, when inadequate, can lead to significant adverse consequences for the child, parents, surgeon, and others in the healthcare system. The aim of this study is to explore expert consenting practice from the key stakeholders' perspective. METHODS Four senior attending pediatric surgeons obtained consent from a standardized mother of a child requiring surgery in two scenarios: a low-risk elective surgery (inguinal hernia repair - Video 1), and a high-risk emergency surgery (intestinal atresia - Video 2). All sessions were recorded. Families of children who had undergone minor or major surgery, families without medical or surgical background, and healthcare professionals were invited to view and evaluate the videos using a semi-structured questionnaire. RESULTS Out of 251 distributed surveys, 56 complete responses were received. Thirty two participants (57.1%) evaluated video 1 and 24 (42.9%) evaluated. Overall, 22 (69%) respondents to video 1 and 20 (84%) respondents to video 2 were "very satisfied" with the recorded consent conversation. Qualitative responses shared common themes of valuing surgeon empathy, good surgeon communication, patient engagement, and adequate time and information. Suggestions for improvement included additional resources and visual aids, improved patient engagement, and discussion of post-operative expectations. CONCLUSION Our data identifies strengths and gaps in the current consent process from the perspective of patient families and providers. Identified areas for improvement in the informed consent process based on multi-stakeholder input will guide the planned development of a consenting educational video resource. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Zoe Atsaidis
- McGill University Faculty of Medicine & Health Sciences, Montreal, Quebec, Canada.
| | - Stephan Robitaille
- Department of Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Jeffrey Wiseman
- Division of Internal Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Sherif Emil
- McGill University Faculty of Medicine & Health Sciences, Montreal, Quebec, Canada; Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Dan Poenaru
- McGill University Faculty of Medicine & Health Sciences, Montreal, Quebec, Canada; Harvey E. Beardmore Division of Pediatric Surgery, The Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Understanding the effectiveness of consent processes and conversations in pediatric surgery: A systematic-scoping review. J Pediatr Surg 2022; 57:834-844. [PMID: 36031429 DOI: 10.1016/j.jpedsurg.2022.08.004] [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: 02/09/2022] [Revised: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The consent conversation in pediatric surgery is an essential part of pre-operative care which, when inadequate, can lead to significant adverse consequences for the child, parents, surgeon, other healthcare workers and the healthcare system. We reviewed the published literature on what key stakeholders perceive are the components of effective and ineffective consenting processes in pediatric surgery. METHODS A medical librarian searched seven databases to retrieve articles looking at the informed consenting process in surgical care for the pediatric population. Two independent reviewers screened all publications and categorized them by stakeholder perspectives (patient/family, surgical team, other healthcare team, and hospital administration or policy maker). General study characteristics, interventions to improve consent and features of effective and ineffective consent conversations were extracted. RESULTS 5079 titles and abstracts were screened, resulting in 88 full-text studies and 43 articles included in the final review. Most publications (51%) discussed informed consent only from the patient/family perspective, while 21% added surgeon's perspective. No study approached the consenting process from the perspective of all stakeholder groups. Effective consent components identified included use of multimedia, presence of multiple conversations prior to surgery, and individualized communication catered to unique family knowledge and needs. In contrast, ineffective conversations did not include a clear assessment of parental understanding, delivered too much information, and did not address parental anxiety. CONCLUSIONS The literature on the consenting process in pediatric surgery is narrow in stakeholder perspectives. Our findings highlight gaps in the literature and opportunities to improve the informed consent processes prior to pediatric surgery.
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Jones AE, McCarty MM, Brito JP, Noseworthy PA, Cavanaugh KL, Cameron KA, Barnes GD, Steinberg BA, Witt DM, Crossley GH, Passman R, Kansal P, Hargraves I, Schmidt M, Jackson E, Guzman A, Ariotti A, Pershing ML, Herrick J, Montori VM, Fagerlin A, Ozanne EM. Randomized evaluation of decision support interventions for atrial fibrillation: Rationale and design of the RED-AF study. Am Heart J 2022; 248:42-52. [PMID: 35218727 PMCID: PMC11348720 DOI: 10.1016/j.ahj.2022.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Shared decision making (SDM) improves the likelihood that patients will receive care in a manner consistent with their priorities. To facilitate SDM, decision aids (DA) are commonly used, both to prepare a patient before their clinician visit, as well as to facilitate discussion during the visit. However, the relative efficacy of patient-focused or encounter-based DAs on SDM and patient outcomes remains largely unknown. We aim to directly estimate the comparative effectiveness of two DA's on SDM observed in encounters to discuss stroke prevention strategies in patients with atrial fibrillation (AF). METHODS The study aims to recruit 1200 adult patients with non-valvular AF who qualify for anticoagulation therapy, and their clinicians who manage stroke prevention strategies, in a 2x2 cluster randomized multi-center trial at six sites. Two DA's were developed as interactive, online, non-linear tools: a patient decision aid (PDA) to be used by patients before the encounter, and an encounter decision aid (EDA) to be used by clinicians with their patients during the encounter. Patients will be randomized to PDA or usual care; clinicians will be randomized to EDA or usual care. RESULTS Primary outcomes are quality of SDM, patient decision making, and patient knowledge. Secondary outcomes include anticoagulation choice, adherence, and clinical events. CONCLUSION This trial is the first randomized, head-to-head comparison of the effects of an EDA versus a PDA on SDM. Our results will help to inform future SDM interventions to improve patients' AF outcomes and experiences with stroke prevention strategies.
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Affiliation(s)
- Aubrey E Jones
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT
| | - Madeleine M McCarty
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Peter A Noseworthy
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Kerri L Cavanaugh
- Department of Medicine, Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Kenzie A Cameron
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah School of Medicine, SLC, UT
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT
| | - George H Crossley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | - Rod Passman
- Department of Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Preeti Kansal
- Department of Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Ian Hargraves
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Monika Schmidt
- Department of Medicine, US Department of Veterans Affairs, Nashville, TN
| | - Elizabeth Jackson
- Division of Cardiovascular Disease, University of Alabama Birmingham, Birmingham, AL
| | - Adriana Guzman
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Anthony Ariotti
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT
| | - Mandy L Pershing
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT
| | - Jennifer Herrick
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, SLC, UT
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT; VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT.
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Delaney RK, Pinto NM, Ozanne EM, Stark LA, Pershing ML, Thorpe A, Witteman HO, Thokala P, Lambert LM, Hansen LM, Greene TH, Fagerlin A. Study protocol for a randomised clinical trial of a decision aid and values clarification method for parents of a fetus or neonate diagnosed with a life-threatening congenital heart defect. BMJ Open 2021; 11:e055455. [PMID: 34893487 PMCID: PMC8666895 DOI: 10.1136/bmjopen-2021-055455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Parents who receive the diagnosis of a life-threatening, complex heart defect in their fetus or neonate face a difficult choice between pursuing termination (for fetal diagnoses), palliative care or complex surgical interventions. Shared decision making (SDM) is recommended in clinical contexts where there is clinical equipoise. SDM can be facilitated by decision aids. The International Patient Decision Aids Standards collaboration recommends the inclusion of values clarification methods (VCMs), yet little evidence exists concerning the incremental impact of VCMs on patient or surrogate decision making. This protocol describes a randomised clinical trial to evaluate the effect of a decision aid (with and without a VCM) on parental mental health and decision making within a clinical encounter. METHODS AND ANALYSIS Parents who have a fetus or neonate diagnosed with one of six complex congenital heart defects at a single tertiary centre will be recruited. Data collection for the prospective observational control group was conducted September 2018 to December 2020 (N=35) and data collection for two intervention groups is ongoing (began October 2020). At least 100 participants will be randomised 1:1 to two intervention groups (decision aid only vs decision aid with VCM). For the intervention groups, data will be collected at four time points: (1) at diagnosis, (2) postreceipt of decision aid, (3) postdecision and (4) 3 months postdecision. Data collection for the control group was the same, except they did not receive a survey at time 2. Linear mixed effects models will assess differences between study arms in distress (primary outcome), grief and decision quality (secondary outcomes) at 3-month post-treatment decision. ETHICS AND DISSEMINATION This study was approved by the University of Utah Institutional Review Board. Study findings have and will continue to be presented at national conferences and within scientific research journals. TRIAL REGISTRATION NUMBER NCT04437069 (Pre-results).
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Affiliation(s)
- Rebecca K Delaney
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nelangi M Pinto
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Elissa M Ozanne
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Louisa A Stark
- Human Genetics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Mandy L Pershing
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alistair Thorpe
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Holly O Witteman
- Family and Emergency Medicine, Laval University, Quebec City, Quebec, Canada
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Linda M Lambert
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Lisa M Hansen
- Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Tom H Greene
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Angela Fagerlin
- Population Health Sciences, The University of Utah School of Medicine, Salt Lake City, Utah, USA
- VA HSR&D Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, UT, USA
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Einerson BD, Watt MH, Sartori B, Silver R, Rothwell E. Lived experiences of patients with placenta accreta spectrum in Utah: a qualitative study of semi-structured interviews. BMJ Open 2021; 11:e052766. [PMID: 34732490 PMCID: PMC8572396 DOI: 10.1136/bmjopen-2021-052766] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To describe the lived experience of patients undergoing diagnosis and treatment of placenta accreta spectrum (PAS). DESIGN Qualitative study of semi-structured interviews. A content analysis was used to analyse interview data using a consistent set of codes to designate data segments that contain similar material. Codes were analysed and grouped based on thematic similarities. Thematic results were systematically reviewed, verified and audited to address trustworthiness and rigour of the data and analysis. SETTING A single PAS programme in Utah, USA, from 2017 to 2020. PARTICIPANTS Patients with PAS during the study period were eligible. Those experiencing fetal demise or termination were excluded. Of 25 patients contacted at random, 17 agreed to participate in interviews. Those included were predominantly non-Hispanic white, highly parous, with average age of 34.7 years. RESULTS The lived experiences of patients with PAS emerged across the time continuum from diagnosis, pregnancy, birth, to postpartum care and recovery. Themes common across the care continuum were: the emotional burden of diagnosis and management; fear and uncertainty related to health outcomes; and lack of autonomy and medical helplessness related to medical decision-making. Many patients experienced birth-related trauma, mourned the loss of future fertility and were dissatisfied with the lack of options for treatment for this serious pregnancy complication. CONCLUSIONS Patients undergoing diagnosis and treatment for PAS often experienced care that conflicted with their goals for pregnancy and birth. Clinical care for PAS would benefit from interventions aiming to engage patients and providers in shared decision-making and systems designed to address the social, psychological and emotional needs of patients with PAS.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Melissa H Watt
- Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Brittney Sartori
- College of Nursing, University of Utah Health, Salt Lake City, Utah, USA
| | - Robert Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Erin Rothwell
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
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Parental decision making regarding treatment of hypoplastic left heart syndrome. Adv Neonatal Care 2010; 10:316-22; quiz 323-4. [PMID: 21102175 DOI: 10.1097/anc.0b013e3181fc7c5d] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Parents of children diagnosed with a complex congenital heart anomaly such as hypoplastic left heart syndrome (HLHS) are faced with the challenge of choosing the best treatment option for their children. Parents must decide among options of compassionate care, palliative reconstructive surgery, or neonatal cardiac transplantation, and additionally with antenatal diagnosis must decide regarding continuation of pregnancy. With improved survival rates yet persistent morbidities following the Norwood surgical approach for HLHS, controversy remains whether parents should be counseled on all treatment options as evidenced by research that articulates the varied opinions of health care providers. The parents' perspective is less well researched. In this study, interview data from parents who chose the Norwood-Sano surgical option were analyzed to provide insight into the various treatment options they were given following diagnosis of HLHS in their children and how they came to choose the surgical palliation option.
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Mercurio MR, Peterec SM, Weeks B. Hypoplastic left heart syndrome, extreme prematurity, comfort care only, and the principle of justice. Pediatrics 2008; 122:186-9. [PMID: 18596004 DOI: 10.1542/peds.2008-0143] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Mark R Mercurio
- Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064, USA.
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Mekechuk J. Moral distress in the pediatric intensive care unit: the impact on pediatric nurses. Leadersh Health Serv (Bradf Engl) 2006; 19:i-vi. [PMID: 16961105 DOI: 10.1108/13660750610683215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to explore the concept of moral distress in particular as it impacts on the pediatric intensive care nurse caught between caring for infants and children who would not otherwise be alive were it not for the advances of modern medical technology, and their personal beliefs concerning the societal value of life at any cost. DESIGN/METHODOLOGY/APPROACH Describes cases and real incidents to illustrate the moral distress experienced by-these nurses caught between caring for the children and at the same time interacting with the families. Such families are too often living on hope, with a profound faith in the ever advancing world of medical technology to keep loved ones alive with little thought to the consequences. FINDINGS Suggests that the impact of moral distress on pediatric nurses, particularly as it relates to burnout, may well jeoparidize their ability to deliver effective care and is another unrecognized cost in the medical world. PRACTICAL IMPLICATIONS Suggests that an ethical approach to care is necessary through hard to answer questions. Due to the fact that such questions are not often addressed, the author suggests consideration be given to medical ethicists to mediate and assist those caught in this dilemma. ORIGINALITY/VALUE This paper will be of value to those concerned with how medical and life-saving technologies are outstripping our human abilities to comprehend and live with the consequences, and some of the ethical issues that arise.
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Affiliation(s)
- Joy Mekechuk
- Pediatric Intensive Care Unit, University of Alberta, Edmonton, Canada.
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