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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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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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Grosek S. Special Issue: Intensive Care for Critically Ill Neonates: Clinical Diagnosis and Treatment. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1203. [PMID: 37508700 PMCID: PMC10377810 DOI: 10.3390/children10071203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
Many physicians and researchers in the recent past have recognized the need to provide care and to study term and preterm infants when sufficient knowledge had not yet been attained, and to research how to approach and care for the most vulnerable children, i [...].
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Affiliation(s)
- Stefan Grosek
- Department of Perinatology, Division of Gynaecology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
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Serrano-Zamago AB, Altamirano-Bustamante MM. Appealing to Tacit Knowledge and Axiology to Enhance Medical Practice in the COVID-19 Pandemic: A Systematic Review and Hermeneutic Bioethical Analysis. Front Public Health 2021; 9:686773. [PMID: 34956997 PMCID: PMC8692268 DOI: 10.3389/fpubh.2021.686773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 11/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The pressure of coronavirus disease 2019 (COVID-19) pandemic, epidemiological and demographic changes, personnel-patient relationship in healthcare, and the development of biotechnologies do not go unnoticed by the healthcare professional. Changes are so wide and at a high rate that guidelines and mere scientific knowledge, which are represented by evidence-based medicine, are not sufficient to lead actions, thus the experiential aspects in the configuration of an ethos present as a fundamental part of the resources to deal with critical scenarios, such as a pandemic. In this regard, the recognition of tacit knowledge as a way of teaching and learning skills related to ethical aspects such as principles, virtues, and values, revealed as a fundamental part of the clinical field. The challenge is to strengthen binomial evidence-based medicine and values-based in order to achieve excellence in the health care of the patients and the well-being of the clinical personnel. Method: A 2-fold analysis was conducted taking pediatric endocrinology as an example. First, a systematic review was carried out in electronic databases BIREME, PubMed, and PhilPapers following PEO and PRISMA approaches. A total of 132 articles were garnered. After reading their title and abstract, 30 articles were obtained. Quantitative information was arranged in an Excel database according to three themes: ethics, axiology, and tacit knowledge. A quality criterion that meets our research question was assigned to each article and those which had a quality criterion of 3 (9) were taken to carry out the hermeneutic bioethical analysis, which consisted of three stages, namely naïve reading, codification, and interpretation. The results were analyzed in Atlas.ti. to elucidate the relations between the three main themes in accordance with the objective. Results: Although there was no difference in the frequency of tacit knowledge skills, including cognitive, social, and technical, for medical practice, there is an intrinsic relationship between epistemic and ethical values with cognitive skills, this means that professionals who practice honesty, authenticity and self-control are capable of seeing patients as persons and thus respect their dignity. This suggested that there is a strong partnership between evidence-based medicine and value-based medicine, which reinforced this binomial as the two feet on which medical practice decisions rested. With regard to tacit knowledge in terms of the context of the COVID-19 pandemic, the challenges refer to (1) adapting and learning a new way of establishing trust with the patient and (2) how to capitalize on the new knowledge that new experiences have posed. Discussion: The analysis of ethical-tacit knowledge in medicine is a recent phenomenon and is in full development. Although no references were found that dealt with any of the main topics in pediatric endocrinology, there is an interest in pediatrics to explore and discuss educational strategies in ethics related to its tacit dimension as a vector of enhancement in the clinical practice. Educational strategies ought to take into consideration the development of skills that promote reflection and discussion of experiences, even more vigorously in the context of the COVID-19 pandemic.
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Affiliation(s)
- Ana-Beatriz Serrano-Zamago
- Grupo Transfuncional en Bioética, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.,Master and Doctorate Program in Medical and Health Sciences, Universidad Nacional Autónoma de México, Mexico City, Mexico.,Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México, México
| | - Myriam M Altamirano-Bustamante
- Grupo Transfuncional en Bioética, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México.,Unidad de Investigación en Enfermedades Metabólicas, Instituto Mexicano del Seguro Social, Ciudad de México, México
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Rener-Primec Z. Can we improve prediction of neurological outcome in children after cardiac arrest? Eur J Paediatr Neurol 2020; 28:4-5. [PMID: 32878719 DOI: 10.1016/j.ejpn.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Zvonka Rener-Primec
- University Children's Hospital Ljubljana, Department of Child, Adolescent & Developmental Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia; Medical Faculty University of Ljubljana, Ljubljana, Slovenia.
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Orzechowski M, Schochow M, Steger F. Clinical Ethics Consultation in the Transition Countries of Central and Eastern Europe. SCIENCE AND ENGINEERING ETHICS 2020; 26:833-850. [PMID: 31587148 DOI: 10.1007/s11948-019-00141-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 09/24/2019] [Indexed: 06/10/2023]
Abstract
Since 1989, clinical ethics consultation in form of hospital ethics committees (HECs) was established in most of the transition countries of Central and Eastern Europe. Up to now, the similarities and differences between HECs in Central and Eastern Europe and their counterparts in the U.S. and Western Europe have not been determined. Through search in literature databases, we have identified studies that document the implementation of clinical ethics consultation in Central and Eastern Europe. These studies have been analyzed under the following aspects: mode of establishment of HECs, character of consultation they provide, and their composition. The results show that HECs in the transition countries of Central and Eastern Europe differ from their western-European or U.S. counterparts with regard to these three aspects. HECs were established because of centrally imposed legal regulations. Little initiatives in this area were taken by medical professionals interested in resolving emerging ethical issues. HECs in the transition countries concentrate mostly on review of research protocols or resolution of administrative conflicts in healthcare institutions. Moreover, integration of non-professional third parties in the workings of HECs is often neglected. We argue that these differences can be attributed to the historical background and the role of medicine in these countries under the communist regime. Political and organizational structures of healthcare as well as education of healthcare staff during this period influenced current functioning of clinical ethics consultation in the transition countries.
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Affiliation(s)
- Marcin Orzechowski
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Parkstraße 11, 89073, Ulm, Germany.
| | - Maximilian Schochow
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Parkstraße 11, 89073, Ulm, Germany
| | - Florian Steger
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Parkstraße 11, 89073, Ulm, Germany
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Notes on the Development of the Slovenian Ethical Recommendations for Decision-Making on Treatment and Palliative Care of Patients at the End of Life in Intensive Care Medicine. Pediatr Crit Care Med 2018; 19:S48-S52. [PMID: 30080807 DOI: 10.1097/pcc.0000000000001606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the process of development of "Slovenian Ethical Recommendations for Decision-Making on Treatment and Palliative Care of Patients at the End of Life in Intensive Care Medicine" and its final outcomes. DATA SOURCES Personal experience and reflection, complemented by published data. STUDY SELECTION Not applicable. DATA EXTRACTION Not applicable. DATA SYNTHESIS Narrative, experiential reflection, literature review. CONCLUSIONS Slovenian ethical recommendations bring a small piece to a long tradition of ethical practice in a small European country. Despite the availability of informative international guiding documents on the issue, there are several specific good reasons for a small country or a region to develop its own unique guidelines (i.e., lack of local directives and legislation, unique cultural and political situation, need for development of professional expertise and terminology, and to educate healthcare providers). The authors strongly believe that our recommendations positively impact practice and will support best possible integrated palliative and end-of-life quality care with the ICU.
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