Withdrawing artificial feeding from children with brain damage

Content Validity and Inter-rater Reliability of the Music Interventions in Pediatric DoC Behavior Observation Record

Aligned with best practice guidelines for patients presenting with a disorder of consciousness (DoC), music therapy interventions with this population aim to increase arousal and awareness to support emergence to consciousness. There is a significant evidence base supporting music therapy for adults with a DoC; however, there are currently no published tools that systematically capture behavioral responses of this population during rehabilitative music therapy interventions. Further, the developmentally specific response to severe brain injury in the pediatric population means pediatric-specific research is required. The Music Interventions in Pediatric DoC Behavior Observation Record (Music Behavior Record [MBR]) was developed to objectively record responses during music therapy interventions for children presenting with a DoC. To establish content validity and inter-rater reliability, a pragmatic pilot study was undertaken. Results established that the MBR has content validity with 100% agreement among participants. Overall fair-substantial inter-rater reliability in >70% of the behavioral responses recorded in the MBR indicate the MBR is an early but promising tool to objectively capture responses during music therapy interventions. The use of the MBR may ultimately support clinical advancement and intervention research to optimize consciousness recovery for the pediatric DoC population.

Reprint of "Ethical issues with artificial nutrition of children with degenerative brain diseases"

This report highlights viewpoints of the authors and comments from the auditory at a workshop, held during the 14th international Congress on neuronal ceroid lipofuscinoses (NCL) in Córdoba, Argentina, on ethical aspects of artificial nutrition in children with degenerative brain diseases. The discussion centers on what constitutes the best interest of a patient whose personality was immature before the onset of the disease, who has become demented during its course and is unable to communicate his/her own positions and desires. There is wide consensus that in a child with advanced disease who cannot be fed naturally, decisions to withhold nutrition or to institute or stop artificial nutrition, should only be made by parents (or their representatives) who are adequately prepared on an intellectual and emotional level. We try to show that such decisions are highly individual but can be made in a rationally and emotionally acceptable way after a careful and prolonged dialogue between families and professionals. A checklist summarizes important considerations. This article is part of a Special Issue entitled: "Current Research on the Neuronal Ceroid Lipofuscinoses (Batten Disease)".

Ethical issues with artificial nutrition of children with degenerative brain diseases

This report highlights viewpoints of the authors and comments from the auditory at a workshop, held during the 14th international Congress on neuronal ceroid lipofuscinoses (NCL) in Córdoba, Argentina, on ethical aspects of artificial nutrition in children with degenerative brain diseases. The discussion centers on what constitutes the best interest of a patient whose personality was immature before the onset of the disease, who has become demented during its course and is unable to communicate his/her own positions and desires. There is wide consensus that in a child with advanced disease who cannot be fed naturally, decisions to withhold nutrition or to institute or stop artificial nutrition, should only be made by parents (or their representatives) who are adequately prepared on an intellectual and emotional level. We try to show that such decisions are highly individual but can be made in a rationally and emotionally acceptable way after a careful and prolonged dialogue between families and professionals. A checklist summarizes important considerations. This article is part of a Special Issue entitled: "Current Research on the Neuronal Ceroid Lipofuscinoses (Batten Disease)".

Clinical report--Forgoing medically provided nutrition and hydration in children

There is broad consensus that withholding or withdrawing medical interventions is morally permissible when requested by competent patients or, in the case of patients without decision-making capacity, when the interventions no longer confer a benefit to the patient or when the burdens associated with the interventions outweigh the benefits received. The withdrawal or withholding of measures such as attempted resuscitation, ventilators, and critical care medications is common in the terminal care of adults and children. In the case of adults, a consensus has emerged in law and ethics that the medical administration of fluid and nutrition is not fundamentally different from other medical interventions such as use of ventilators; therefore, it can be forgone or withdrawn when a competent adult or legally authorized surrogate requests withdrawal or when the intervention no longer provides a net benefit to the patient. In pediatrics, forgoing or withdrawing medically administered fluids and nutrition has been more controversial because of the inability of children to make autonomous decisions and the emotional power of feeding as a basic element of the care of children. This statement reviews the medical, ethical, and legal issues relevant to the withholding or withdrawing of medically provided fluids and nutrition in children. The American Academy of Pediatrics concludes that the withdrawal of medically administered fluids and nutrition for pediatric patients is ethically acceptable in limited circumstances. Ethics consultation is strongly recommended when particularly difficult or controversial decisions are being considered.

Palliative care management of a child with juvenile onset Huntington’s disease

This is a case report of the palliative care management of a 13-year-old girl who died of juvenile onset Huntington's disease in a children's hospice in the southeast of England. It outlines her disease progression and describes the care that she received. In particular, the medications and other measures used to control her symptoms during her last 10 days are discussed. The article also explores some of the ethical difficulties of caring for children dying from degenerative disorders. Although juvenile onset Huntington's disease is an extremely rare condition, the issues around terminal care management are very similar to those for any neuro-degenerative disorder, whether in an adult or child. A number of children's hospices have opened in the last 10-15 years in the UK. They accept children with a wide range of life-limiting conditions and have become experts in offering respite care and symptom control to these children and their families. They are chosen increasingly as the place of death for such children.

Aftercare in severe neurological impairment

Modern neonatal intensive care has major emphasis on the resuscitation and management of infants born at the limits of viability. An additional significant group of infants are those, born at or close to term, who present with major neurological disease. This is a heterogeneous group of infants who have major care needs due to the continuing neurological abnormalities into the postneonatal period. Re-admissions to hospital are frequent and long-term developmental progress is poor. In this group of infants, there is a high early mortality. The recurrent admission of infants in this group for active resuscitation and/or intensive care may not always be the wisest management, and important medical, ethical and legal dilemmas are faced by families and carers of these infants.

The ethics of withholding/withdrawing nutrition in the newborn

The provision of nutrition and hydration to newborn infants is considered fundamental care. For premature and critically ill newborns, similar considerations generally hold true. Nutrition may be provided for these infants using assisted measures such as parenteral nutrition or tube feedings. However, for some newborn infants the provision of medically assisted nutrition may be a more complicated issue. In particular, the goals of nutrition need to be clearly elaborated for newborns with lethal conditions or for whom appropriately administered intensive care is unsuccessful in sustaining life. These infants may benefit from palliative measures of care and a limitation or withdrawal of burdensome or nonbeneficial interventions. This article explores issues pertinent to deciding and communicating the appropriate withdrawal of medically assisted nutrition and implementing palliative comfort measures.