What is known about parents' treatment decisions? A narrative review of pediatric decision making

Plasma-derived product recipients' views on the acceptability of implementing a programme of plasma donation for fractionation from men who have sex with men

BACKGROUND AND OBJECTIVES

Over the past few years in Québec, Canada, exclusion criteria for blood donation and plasma donation for fractionation have been modified. Héma-Québec, the institution responsible for blood products, has made changes to allow more inclusive access to blood and plasma donation, in accordance with evolving scientific data concerning donation safety. The study, conducted before those changes were implemented, aimed to assess acceptability of recipients and parents of recipients of plasma-derived products for men who have sex with men (MSM) to become eligible to donate plasma for fractionation.

MATERIALS AND METHODS

Eight qualitative interviews (4 focus groups, 4 individual) were conducted with a total of 17 plasma product recipients and parents of children needing plasma-derived products. Data were analysed using thematic analysis.

RESULTS

Participants were rather favourable regarding acceptability of MSM as potential donors. Participants viewed this change as necessary and beneficial. They also felt they must rely on trust in Héma-Québec, conferred automatically or by default. However, some participants raised concerns about donation safety and reported feeling helpless regarding inclusion of MSM. The importance of being informed and that recipients' safety be prioritized first and foremost were also mentioned.

CONCLUSION

Despite their nuanced attitudes, recipients showed high levels of acceptability of including MSM in plasma donation for fractionation. Actions can be taken to reduce concerns regarding the safety of products received.

"As a parent, I want to do more for my child": A phenomenological approach to understanding the experiences of parents involved in surgical decision-making for children with congenital hand anomalies

BACKGROUND

A congenital anomaly of the hand can affect both function and appearance, and places a stressful psychological burden on the family, especially parents. Surgery during infancy may prevent later disabilities, but little is known of the importance of parents' involvement in these decisions in terms of psychological adjustment or treatment satisfaction.

OBJECTIVE

To understand parents' perceptions of involvement in their child's surgery for limb anomaly, and their preferences for the support of healthcare professionals. Results should lead to recommended interventions to improve familial adjustment to the child's condition.

METHODS

Qualitative data was collected from semi-structured confidential self-reported interviews of 35 parents (65.7 % mothers) of children who had received reconstructive surgery for congenital hand anomaly (at age 24.89 ± 9.26 months); interviews were coincident with the 1-month postoperative follow-up. The parents ranged in age, gender, educational background, economic status, and type of anomaly. Data analysis referenced Colaizzi's phenomenological approach.

RESULTS

The concerns of the parents were consolidated into three themes: attitudes toward Parental involvement in surgical decision-making; status of parental involvement in Surgical decision-making; and need for help and support.

CONCLUSION

Some parents were comfortable leaving surgical decisions entirely to the medical staff, but most preferred active participation and were disappointed at their lack of inclusion. The maximum benefit from surgery for congenital abnormalities in infancy is achieved when the parents and extended families have access to the expertise, skills, encouragement, and psychological support of healthcare providers.

Developing a care bundle for children who are eating and drinking with acknowledged risk: A Delphi study with speech and language therapists

BACKGROUND

There is minimal research and no formal written guidance for speech and language therapists (SLTs) managing children eating and drinking with acknowledged risks (EDAR). Many SLTs lack confidence due to the complexity of these cases medically, ethically and emotionally. Guidance is recommended to aid paediatric EDAR management.

AIMS

To establish consensus amongst expert paediatric SLTs regarding core components of a care bundle guiding the management of children who are EDAR.

METHODS & PROCEDURES

A two-round online modified Delphi technique was used. An expert panel of UK SLTs working across paediatric settings (education, hospital, community) were recruited using snowball sampling. Both rounds comprised 36 statements related to potential components of a care bundle, which participants rated on a 7-point scale (strongly agree to strongly disagree), and one open-box question. Consensus was calculated using predetermined criteria (percentage, median and interquartile range) and the final list was ranked by level of importance (mean).

OUTCOMES & RESULTS

A total of 35 participants completed round 1, with 31 completing round 2 (88.6% response rate). Thirty out of 36 statements achieved high to very high consensus. The nine statements reaching very high consensus covered topics such as documentation, capacity, safeguarding and person-centred care.

CONCLUSION & IMPLICATIONS

There is a high level of consensus amongst SLTs about core components for a paediatric EDAR care bundle. This study provides a useful starting point for the future development of a care bundle to manage children who are EDAR.

WHAT THIS PAPER ADDS

What is already known on the subject There is limited research and guidance for SLTs managing children who are EDAR. In adult populations, care bundles have been introduced with positive effects (e.g., better patient outcomes, increased standardisation of care and clinician confidence) and are seen as a promising avenue for paediatrics. What this study adds to the existing knowledge To the research team's knowledge, this is the first published Delphi study on SLT opinion around a care bundle for paediatric EDAR. There were high levels of consensus amongst UK SLTs and the results highlighted documentation, capacity, safeguarding and person-centred care as key areas in practice. Finally, the results provide a ranked list of components UK SLTs felt are important for developing a care bundle. What are the practical and clinical implications of this work? This study could be a useful starting point for creating a care bundle to support the management of children who are EDAR.

Exploring communication preferences and risk thresholds of clinicians and parents of febrile infants under 90 days presenting to the emergency department: a qualitative study

BACKGROUND

Febrile infants under 3 months of age are at higher risk of invasive bacterial illness (IBI) when compared with older children. Increasingly sequential assessment based on age, clinical appearance and biomarkers is used to determine the risk of IBI, and appropriateness of invasive procedures such as lumbar puncture. The purpose of this qualitative study is to report parents and clinicians' opinions on communication of risks and benefits of sequential assessment and tailored treatment.

METHODS

18 parents enrolled in the Febrile Infant Diagnostic Assessment and Outcomes study and seven clinicians from England, Wales and Northern Ireland were purposively selected to participate in virtual qualitative interviews. Data were analysed thematically.

RESULTS

Tailored treatment plans were widely supported. Confidence in the clinician was central to parents' attitude towards management recommendations. Parents' decision-making preferences change throughout their child's clinical journey, with an initial preference for clinician-led decisions evolving towards collaborative decision-making as their stress and anxiety reduce. There were widespread differences in preferences for how risk was discussed. Parents self-reported poor retention of information and felt communication adjuncts helped their understanding. Clinicians were generally positive about the use of clinical decision aids as a communication tool, rather than relying on them for decision-making.

DISCUSSION

Parents want to feel informed, but their desire to be involved in shared decision-making evolves over time.Clinicians appear to use their clinical judgement to provide individualised information, evolving their communication in response to perceived parental needs.Poor information retention highlights the need for repetition of information and use of communication adjuncts.

TRIAL REGISTRATION NUMBER

NCT05259683.

Understanding family-level decision-making when seeking access to acute surgical care for children: Protocol for a cross-sectional mixed methods study

BACKGROUND

There is limited understanding of how social determinants of health (SDOH) impact family decision-making when seeking surgical care for children. Our objectives of this study are to identify key family experiences that contribute to decision-making when accessing surgical care for children, to confirm if family experiences impact delays in care, and to describe differences in family experiences across populations (race, ethnicity, socioeconomic status, rurality).

METHODS

We will use a prospective, cross-sectional, mixed methods design to examine family experiences during access to care for children with appendicitis. Participants will include 242 parents of consecutive children (0-17 years) with acute appendicitis over a 15-month period at two academic health systems in North Carolina and Virginia. We will collect demographic and clinical data. Parents will be administered the Adult Responses to Children's Symptoms survey (ARCS), the child and parental forms of the Adverse Childhood Experiences (ACE) survey, the Accountable Health Communities Health-Related Social Needs Screening Tool, and Single Item Literacy Screener. Parallel ARCS data will be collected from child participants (8-17 years). We will use nested concurrent, purposive sampling to select a subset of families for semi-structured interviews. Qualitative data will be analyzed using thematic analysis and integrated with quantitative data to identify emerging themes that inform a conceptual model of family-level decision-making during access to surgical care. Multivariate linear regression will be used to determine association between the appendicitis perforation rate and ARCS responses (primary outcome). Secondary outcomes include comparison of health literacy, ACEs, and SDOH, clinical outcomes, and family experiences across populations.

DISCUSSION

We expect to identify key family experiences when accessing care for appendicitis which may impact outcomes and differ across populations. Increased understanding of how SDOH and family experiences influence family decision-making may inform novel strategies to mitigate surgical disparities in children.

Guess Who's Coming to Clinic? Companions in a Pediatric Urology Clinic

INTRODUCTION

Understanding who accompanies children to clinic visits is necessary to engage stakeholders and tailor communication and educational materials. We undertook this study to describe the clinical companions for new patients in a general pediatric urology clinic.

METHODS

This retrospective cross-sectional study included all new urology patients aged less than 18 y at a single freestanding quaternary care children's hospital in selected months of 2019 and 2022. Data were collected on patient demographics, diagnosis, level of community disadvantage, and companion present. The number and identities of companions of patients living in more and less disadvantaged neighborhoods were compared.

RESULTS

Of 1940 patients, 1014 (52%) were accompanied by mothers alone, 266 (14%) by fathers alone, and 580 (30%) by both mother and father. Mothers were at 85% of clinical visits and fathers at 45% of visits. The likelihood of having one versus two parents present was similar in more and less disadvantaged areas (odds ratio [OR] = 1.11, 95% confidence interval: 0.80-1.55, P = 0.53). When one parent was present, the odds of being accompanied by the mother was lower for patients living in Area Deprivation Index 1-2 (less disadvantaged areas; OR = 0.38, 95% confidence interval: 0.23-0.62, P = 0.0001), and for the father to accompany children aged 12 y and more than infants (OR = 2.16, P = 0.0005) if there was only one parent present.

CONCLUSIONS

Our findings highlight opportunities to engage nonmaternal caregivers in pediatric urologic care, to further explore parental decisions around appointment attendance, and to optimize how clinical information is delivered to caregivers who are and are not present during appointments.

Shared decision-making and its influencing factors among parents of children with cancer in China: A cross-sectional study

PURPOSE

This study aimed at exploring SDM implementation and its influencing factors, and preferences towards SDM among parents of children with cancer in China.

DESIGN AND METHODS

This cross-sectional study recruited 204 participants from 2 grade-A tertiary hospitals in Guangzhou, China. The preferences towards decision-making, the status of SDM were measured by CPS-P and SDM-Q-9. The nurse support were measure by NPST, the needs of parents were measured by Questionnaire for Needs of Parents Whose Children are in PICU, and sociodemographic and disease-related questionnaires were used to investigate general information of children and parents. Descriptive statistics, univariate analysis, and multivariable linear regression were used for data analysis.

RESULTS

Of 204 participants, about half of parents (55.4 %) tended to choose SDM, however, 40.2 % of them still show passive attitudes. The mean SDM-Q-9 score was 31.07 ± 8.74, and the result showed that age (β = 2.480, P＜0.05), relapse (β = 4.407, P＜0.01), course of disease (β = -5.213, P＜0.01), relationships with doctors (β = -4.05, P＜0.05), trust in doctors (β = -2.796, P＜0.05), and communication and information support from nurses (β = 0.651, P＜0.01) were the main factors influencing SDM for parents.

CONCLUSIONS

Over half of Chinese parents tended to choose SDM, but their real participation in SDM is unsatisfactory. Parents who were older, had good relationships with doctors, trusted in doctors, received more communication and information support from nurses, and whose children had shorter course of disease, suffered relapses, participated in SDM better.

Incorporating parental values in complex paediatric and perinatal decisions

Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.

Decisional conflict in parents of children with congenital heart defect: Towards development of a model

AIM

This study aimed to develop a model to help parents cope with decisional conflict.

BACKGROUND

Parents of children with congenital heart defect experience decisional conflict when they are uncertain about treatment decisions for their child, which may lead to delay in seeking care or distress over the decision made.

DESIGN

Correlational design with model building and data triangulation was used.

METHODS

Data were collected through surveys and interviews with a consecutive sample of 221 parent respondents from June to December 2018. Structural equation modelling and qualitative data analysis were used.

RESULTS

Lower decisional conflict was seen in parents with higher income, more nurse support and physician risk communication. Time delay for surgery was correlated with the child's age, social service coverage, and social support. Decisional conflict mediated the influence of income, nurse support and physician risk communication on satisfaction with decision. Based on model fit parameters, the emerging model is a good and parsimonious model of decisional conflict. The overall theme, 'Deciding for Surgery: What Matters Most', described the processes parents went through in making treatment decisions.

CONCLUSION

Nurses may help parents feel more certain, less conflicted, and more satisfied with their decision by addressing factors including knowledge gaps, personal values, available support, and resource access.

Shared decision making in the treatment of pediatric strabismus

PURPOSE

To quantify the results of shared decision making in pediatric strabismus surgery from the parent perspective using the nine-item Shared Decision Making (SDM) Questionnaire and the associations of SDM score with parental education level; secondarily, to evaluate postoperative parental satisfaction as a function of child age, parental education level, SDM scores, and motor outcomes.

METHODS

Consecutive parents of children 2-14 years of age with concomitant manifest strabismus that consented to strabismus surgery were surveyed using the SDM Questionnaire. A four-point Likert scale was used to gauge the level of postoperative satisfaction (POS). Potential predictors were estimated in multivariable regression analysis, with results adjusted for education level, children's age, and motor outcomes.

RESULTS

A total of 100 parents (86 women) completed the survey and were included. Significant differences for SDM score were found between individuals with university-level versus the other three educational levels (P < 0.001 for primary and secondary levels; P = 0.017 for college or lyceum level). Categorical regression analysis showed that POS level was inversely correlated with education level and positively correlated with SDM score. Children's age at time of surgery and postoperative motor outcome were not significantly associated with POS.

CONCLUSIONS

In our study cohort, SDM score was correlated with educational level. Satisfaction was greater among responders with higher SDM scores, indicating that SDM may help improve parent-reported satisfaction with treatment results.

Establishing Goals of Care in Serious and Complex Pediatric Illness

An increasing number of children are living for months and years with serious/complex illness characterized by long-term prognostic uncertainty, intensive interactions with medical systems, functional limitations, and often home medical technologies that shape the child's and family's quality of life. These families face many medical decision points that require intentional and iterative discussions about goals of care. Threats to cohesive goals of care include prognostic uncertainty, diffusion of medical responsibility, individual family context, and blended goals of care. This article offers strategies for addressing each of these challenges.

Parents' experiences of being involved in medical decision-making for their child with a life-limiting condition: A systematic review with narrative synthesis

BACKGROUND

Parental involvement in the decision-making processes about medical treatment for children with life-limiting conditions is recognised as good practice. Previous research highlighted factors affecting the decision-making process, but little is known about how parents experience their participation.

AIM

To explore how parents experience their participation in the process of decision-making about treatment and future care for their children with life-limiting conditions.

DESIGN

A systematically constructed review using narrative synthesis. The PRISMA guidelines were followed to report the findings. Databases Medline, EMBASE, SCOPUS, CINAHL and PsycINFO were searched up to December 2023. The study protocol was registered at PROSPERO (RN CRD42021215863).

RESULTS

From the initial 2512 citations identified, 28 papers met the inclusion criteria and were included in the review. A wide range of medical decisions was identified; stopping general or life-sustaining treatment was most frequent. Narrative synthesis revealed six themes: (1) Temporal aspects affecting the experience with decision-making; (2) Losing control of the situation; (3) Transferring the power to decide to doctors; (4) To be a 'good' parent and protect the child; (5) The emotional state of parents and (6) Sources of support to alleviate the parental experience.

CONCLUSIONS

Parental experiences with decision-making are complex and multifactorial. Parents' ability to effectively participate in the process is limited, as they are not empowered to do so and the circumstances in which the decisions are taking place are challenging. Healthcare professionals need to support parental involvement in an effective way instead of just formally asking them to participate.

Treat-to-Target in Pediatric Rheumatic Diseases

PURPOSE OF REVIEW

To summarize the current evidence on the adoption of the treat-to-target (T2T) strategy in pediatric rheumatic diseases (PRD).

RECENT FINDINGS

The recent advances in the management of PRD have markedly increased the ability to achieve disease remission. Complete disease quiescence is regarded as the ideal therapeutic goal because its attainment leads to lesser long-term damage and physical disability, and to optimization of quality of life. Studies in adult rheumatic diseases have shown that patient outcomes are improved if complete suppression of the inflammatory process is aimed for by frequent adjustments of therapy according to quantitative indices. This approach, which underlies the T2T concept, has been applied in strategic trials in rheumatoid arthritis (RA). Furthermore, recommendations for the T2T have been issued for RA and other adult rheumatic diseases. There is currently a growing interest for the introduction of T2T in PRD, and recommendations for treating juvenile idiopathic arthritis (JIA) to target were promulgated. A similar initiative has been undertaken for childhood-onset systemic lupus erythematosus. Preliminary therapeutic studies have explored the T2T design in JIA. The T2T strategy is a modern therapeutic approach that holds the promise of improving the outcomes in patients with PRD.

Validation of a Process for Shared Decision-Making in Pediatrics

OBJECTIVE

We sought to confirm, refute, or modify a 4-step process for implementing shared decision-making (SDM) in pediatrics that involves determining 1) if the decision includes >1 medically reasonable option; 2) if one option has a favorable medical benefit-burden ratio compared to other options; and 3) parents' preferences regarding the options; then 4) calibrating the SDM approach based on other relevant decision characteristics.

METHODS

We videotaped a purposive sample of pediatric inpatient and outpatient encounters at a single US children's hospital. Clinicians from 7 clinical services (craniofacial, neonatology, oncology, pulmonary, pediatric intensive care, hospital medicine, and sports medicine) were eligible. English-speaking parents of children who participated in inpatient family care conferences or outpatient problem-oriented encounters with participating clinicians were eligible. We conducted individual postencounter interviews with clinician and parent participants utilizing video-stimulated recall to facilitate reflection of decision-making that occurred during the encounter. We utilized direct content analysis with open coding of interview transcripts to determine the salience of the 4-step SDM process and identify themes that confirmed, refuted, or modified this process.

RESULTS

We videotaped 30 encounters and conducted 53 interviews. We found that clinicians' and parents' experiences of decision-making confirmed each SDM step. However, there was variation in the interpretation of each step and a need for flexibility in implementing the process depending on specific decisional contexts.

CONCLUSIONS

The 4-step SDM process for pediatrics appears to be salient and may benefit from further guidance about the interpretation of each step and contextual factors that support a modified approach.

Fertility Preservation in Children and Adolescents during Oncological Treatment-A Review of Healthcare System Factors and Attitudes of Patients and Their Caregivers

Oncofertility is any therapeutic intervention to safeguard the fertility of cancer patients. Anti-cancer therapies (chemotherapy, radiation therapy, etc.) entail the risk of reproductive disorders through cytotoxic effects on gamete-building cells, especially those not yet fully developed. This literature review analyzes the available data on securing fertility in pediatric and adolescent populations to identify the methods used and describe aspects related to financing, ethics, and the perspective of patients and their parents. Topics related to oncofertility in this age group are relatively niche, with few peer-reviewed articles available and published studies mostly on adults. Compared to pubertal individuals, a limited number of fertility preservation methods are used for prepubertal patients. Funding for the procedures described varies from country to country, but only a few governments choose to reimburse them. Oncofertility of pediatric and adolescent patients raises many controversies related to the decision, parents' beliefs, having a partner, ethics, as well as the knowledge and experience of healthcare professionals. As the fertility of young cancer patients is at risk, healthcare professionals should make every effort to provide them with an opportunity to fulfill their future reproductive plans and to have a family and offspring. Systemic solutions should form the basis for the development of oncofertility in pediatric and adolescent populations.

A Systematic Review of the Audiological Efficacy of Cartilage Conduction Hearing Aids and the Factors Influencing Their Clinical Application

This systematic review evaluates the efficacy and benefit of cartilage conduction hearing aids (CC-HAs) and that factors that influence purchasing decisions. The hearing thresholds and functional gain following CC-HA wear were synthesised. A one-way analysis of variance compared the differences in the hearing thresholds and functional gain at individual frequencies and in patients with a variety of pathological changes. The synchronised aided hearing threshold and functional gain at 2.0 kHz were significantly better than at 0.5, 1.0, and 4.0 kHz. There was no significant difference in the synchronised unaided hearing thresholds across individual frequencies between 0.5 and 4.0 kHz. The synchronised functional gain in patients with atresia was significantly greater than in patients with aural atresia or stenosis and middle ear pathologies with normal ear canals. The acceptability of CC-HAs in terms of purchase decision is influenced by the condition of the external auditory meatus and severity of hearing loss, with the highest purchase rate seen in patients with aural atresia or stenosis. CC-HAs' fitting procedure advantages and cosmetic considerations make these devices a viable and preferred choice for individuals with microtia and aural atresia. Additional research to evaluate the benefits towards emotional well-being is crucial to gain insights into the psychological impact of CC-HA use.

Free Online Decision Tools to Support Parents Making Decisions About Their Children's Chronic Health Condition: An Environmental Scan

BACKGROUND

Medical decisions parents make on their children's behalf can be challenging. Free online decision support tools are created to help parents faced with these decisions.

OBJECTIVE

We used an environmental scan to identify free, online tools that support parents in making decisions about their children's chronic health condition. We described the tools and assessed their potential to harm, content, development process, readability, and whether their use changed decision makers' knowledge and alignment of their preferences with their final decision.

DATA SOURCES AND ELIGIBILITY

Decision aid repositories, Google searches, and key informants identified decision support tools. Eligible tools were freely available online and for parents of children with chronic health conditions.

APPRAISAL METHODS

Two reviewers independently assessed the tools' quality based on the International Patient Decision Aid Standards (IPDAS). Tool readability was assessed using the Flesch Reading Ease test.

RESULTS

From 21 free, online decision support tools, 14 (67%) provided sufficient detail for making a specific decision (IPDAS qualifying criteria). None sufficiently met IPDAS certification criteria necessary to reduce the possibility of patient harms when using the tool. Three (14%) were fairly easy or easy to read. Of those evaluated by developers (n = 6), 2 improved knowledge and 4 improved alignment of preferences with the available options.

LIMITATIONS

Google searches and key informant sources are not replicable.

CONCLUSIONS

Free, online decision support tools for parents of children with chronic health conditions are of variable quality, most are difficult to read, and there is limited evidence their use achieves intended outcomes.

REGISTRATION NUMBER

Registered with Open Science Framework 20 July 2021(AEST) osf.io/b94yj.

Parent perspectives on the assessment of quality of life of their children with profound intellectual and multiple disabilities in the Netherlands

BACKGROUND

Assessing Quality of Life (QoL) of persons with profound intellectual and multiple disabilities (PIMD) is challenging, yet QoL plays an important role in medical decision-making processes concerning persons with PIMD. The perspectives of parents of children with PIMD on the assessment of their QoL have not been studied.

AIM

To explore the perspectives of parents on the assessment of QoL of their children.

METHODS

We conducted a qualitative study, forming three focus groups with 22 parents of children with PIMD to explore their views on what is necessary to assess QoL of their children and subsequently, who is best suited to assess QoL.

RESULTS

Parents describe a long-term relationship of the assessor with family (child and parents), with trust as an important aspect, as a requirement to assess QoL. Parents consider family members, preferably the parents themselves as the best assessors of QoL, followed by siblings. Professional caregivers, mostly mentioned by name, are considered the next alternative. Most parents thought that physicians do not know the child well enough to assess their QoL.

CONCLUSIONS

In conclusion, the parents of children with PIMD in our study consider trust and a long-term relationship essential for assessing QoL.

Shared decision-making in pediatric surgery: An overview of its application for the treatment of uncomplicated appendicitis

Nonoperative management (NOM) of uncomplicated appendicitis is a safe and effective treatment alternative to surgery that may be preferred by some families. Surgery and NOM differ significantly in their associated risks and benefits. Choosing a treatment for acute appendicitis requires patients and their caregivers to make timely, informed decisions that allow for incorporation of personal perspectives, values, and preferences. This article will address the concept of shared decision-making and establish its role in patient-centered care. It will demonstrate the effectiveness of shared decision-making in a high acuity surgical setting for children and highlight how the choice for management of acute appendicitis may be impacted by patients' and families' individualized circumstances and values.

Caregiver-Reported Roles in Treatment Decision Making in Advanced Cancer and Associated Caregiving Burden and Psychological Distress: A Longitudinal Study

OBJECTIVE

To longitudinally examine caregiver-reported treatment decision-making roles and to investigate the associations of these roles with caregiver burden, caregiving esteem, caregiver anxiety, and depression.

METHODS

281 caregivers of patients with stage IV solid cancers were recruited from outpatient clinics in Singapore. Caregivers were eligible if they were aged ≥21 y, primary informal caregiver, and involved in treatment decision making. We used 3 y of longitudinal data. The decision-making roles were grouped into 4 categories: no family involvement, patient/physician-led, joint, and family-led/alone decision making. Mixed-effects linear regressions were used to assess associations between decision-making roles and caregiver outcomes.

RESULTS

On average, 72% of caregivers reported family involvement in decision making. Compared with baseline, a higher proportion of caregivers at the 36-mo follow-up reported no family involvement (from 23% to 34%, P = 0.05) and patient/physician-led decision making (from 22% to 34%, P = 0.02), while a lower proportion reported family-led/alone (from 19% to 7%, P = 0.01) decision making. Compared with family-led/alone decision making, caregivers reporting no family involvement reported lower impact on finances (-0.15 [-0.28, -0.01], P = 0.03) while caregivers who reported patient/physician-led decision making reported lower impact on schedule and health (-0.12 [-0.20, -0.03], P = 0.01), and finances (-0.15 [-0.28, -0.03], P = 0.02), and lower anxiety (-0.69 [-1.17, -0.22], P < 0.01), and depressive symptoms (-0.69 [-1.12, -0.26], P < 0.01). Caregivers who reported joint decision making reported higher caregiving esteem (0.07 [0.01, 0.14], P = 0.02).

CONCLUSIONS

Higher family involvement in decision making was associated with higher caregiver burden and psychological distress. Help should be given so that family caregivers can support patient decision-making in a meaningful way.

HIGHLIGHTS

Compared with baseline, a lower proportion of caregivers at the 36-mo follow-up reported family-led or family-alone decision making, and a higher proportion of caregivers reported patient-led or physician-led decision making.Higher levels of family involvement in decision making were associated with burdens on caregivers' daily life, health, and finances and increased caregiver anxiety and depression.Support must be given so that family members can contribute to making medical decisions in a rewarding manner.

Artificial intelligence promotes shared decision-making through recommending tests to febrile pediatric outpatients

BACKGROUND

To promote the shared decision-making (SDM) between patients and doctors in pediatric outpatient departments, this study was designed to validate artificial intelligence (AI) -initiated medical tests for children with fever.

METHODS

We designed an AI model, named Xiaoyi, to suggest necessary tests for a febrile child before visiting a pediatric outpatient clinic. We calculated the sensitivity, specificity, and F1 score to evaluate the efficacy of Xiaoyi's recommendations. The patients were divided into the rejection and acceptance groups. Then we analyzed the rejected examination items in order to obtain the corresponding reasons.

RESULTS

We recruited a total of 11,867 children with fever who had used Xiaoyi in outpatient clinics. The recommended examinations given by Xiaoyi for 10,636 (89.6%) patients were qualified. The average F1 score reached 0.94. A total of 58.4% of the patients accepted Xiaoyi's suggestions (acceptance group), and 41.6% refused (rejection group). Imaging examinations were rejected by most patients (46.7%). The tests being time-consuming were rejected by 2,133 patients (43.2%), including rejecting pathogen studies in 1,347 patients (68.5%) and image studies in 732 patients (31.8%). The difficulty of sampling was the main reason for rejecting routine tests (41.9%).

CONCLUSION

Our model has high accuracy and acceptability in recommending medical tests to febrile pediatric patients, and is worth promoting in facilitating SDM.

La négligence en matière de soins médicaux : travailler auprès des enfants, des adolescents et des familles

Les soins de santé sont un droit fondamental pour tous les enfants. Lorsque les besoins de santé de l'enfant ne sont pas respectés, quelle qu'en soit la raison, les professionnels de la santé doivent réfléchir aux obstacles en cause et aux processus nécessaires pour trouver des solutions. Des obstacles sociaux, économiques ou autres peuvent empêcher les parents d'accéder aux soins pour leur enfant. Il arrive que les avis, les priorités ou les valeurs des professionnels de la santé de l'enfant divergent de ceux des parents, ce qui compromet les soins à l'enfant. Dans certains cas, l'abstention des personnes qui s'occupent de l'enfant à assurer les soins nécessaires peut être considérée comme de la négligence en matière de soins médicaux. Des habiletés et des connaissances particulières peuvent aider les professionnels de la santé à éviter de telles situations et à collaborer avec efficacité avec la famille lorsque ces situations se produisent. Le présent document de principes offre une approche que peuvent utiliser les professionnels de la santé pour promouvoir l'intérêt supérieur, le bien-être et la sécurité des enfants ou des adolescents vulnérables à la négligence en matière de soins médicaux.

Medical neglect: Working with children, youth, and families

All children have a basic right to health care. When a child's health care needs are not met, for any reason, health care providers (HCPs) must consider the barriers involved and the processes required to resolve the situation. Social, economic, or other barriers can prevent parents from accessing care for their child. Sometimes differing opinions, priorities, or values, between a child's HCPs and parents come to impede the child receiving needed medical care. In some cases, caregiver failure to ensure needed care may be considered medical neglect. Specific skills and knowledge can help HCPs to prevent such situations from arising, and to work effectively with the family if they do. This statement offers an approach that HCPs can use to promote the best interests, well-being, and safety of children or youth at risk for medical neglect.

Parents' priorities for decision-making of pediatric epilepsy treatments and perceived needs for decision support in multi-ethnic Asian clinical setting: A qualitative analysis

OBJECTIVE

To identify parents' priorities when making a decision on genetic testing and antiseizure drug (ASD) options for pediatric epilepsy and their support needs for informed decision-making in multi-ethnic Asian clinical settings.

METHODS

Qualitative in-depth interviews, using a semi-structured interview guide, were conducted with purposively selected parents of pediatric patients with newly diagnosed epilepsy or known diagnosis of epilepsy (n = 26). Interviews were audio recorded and transcribed verbatim. Thematic analysis was undertaken to generate themes.

RESULTS

Parents' narratives showed difficulty assimilating information, while knowledge deficit and emotional vulnerability led parents' desire to defer a decision for testing and ASDs to mitigate decisional burden. Priorities for decisions were primarily based on intuitive ideas of the treatment's risks and benefits, yet very few could elaborate on tradeoffs between risks and efficacy. Priorities outside the purview of the healthcare team, such as children's emotional wellbeing and family burden of ASD administration, were also considered important. Authority-of-medical-professional heuristic facilitated the ASD decision for parents who preferred shared rather than sole responsibility for a decision. Importantly, parents' support needs for informed decision-making were very much related to the availability of support mechanisms in post-treatment decisions owing to perceived uncertainty of the chosen ASD.

CONCLUSIONS

Findings suggest that multiple priorities influenced ASD decision process. To address support needs of parents for informed decision-making, more consideration should be given to post-treatment decision support through the provision of educational opportunities, building peer support networks, and developing a novel communication channel between healthcare providers and parents.

Decision-making experiences of health professionals in withdrawing treatment for children and young people: A qualitative study

OBJECTIVE

To explore factors that influence professionals in deciding whether to withdraw treatment from a child and how decision making is managed amongst professionals as an individual and as a team.

STUDY DESIGN

Semi-structured interviews were conducted with a purposive sample of health professionals working at a UK Children's Hospital, with children with life-limiting illnesses whose treatment has been withdrawn. Data were transcribed verbatim, anonymized and analysed using a thematic framework method.

RESULTS

A total of 15 participants were interviewed. Five interrelated themes with associated subthemes were generated to help understand the experiences of health professionals in decision making on withdrawing a child's treatment: (1) understanding the child's best interests, (2) multidisciplinary approach, (3) external factors, (4) psychological well-being and (5) recommendations to support shared decision making.

CONCLUSION

A shared decision-making approach should be adopted to support professionals, children and their families to make decisions collectively.

Patient-Family and Provider Partnerships in the Management of Pediatric Uncomplicated Appendicitis

In recent years, studies have demonstrated non-operative management with antibiotics alone to be a safe and effective treatment option for children with uncomplicated acute appendicitis. Shared decision-making is critical in the treatment of uncomplicated appendicitis due to the markedly different risks and benefits associated with surgery and non-operative management. In this report, we discuss the importance of shared decision-making in surgery using a case of uncomplicated appendicitis as an example. We present both the patient-family and provider perspectives on evaluating and deciding between operative and non-operative management and discuss the value of shared decision-making in the unique setting of an acute pathologic process with surgical and medical treatment options.

Physicians' Speech Complexity and Interrupting Behavior in Pediatric Consultations

Pediatricians' communication behavior affects a variety of outcomes in both children and their parents. This study analyzes how speech complexity and interruptions as indicators of accommodative behaviors relate to parental recall of medical information and to their satisfaction with the medical encounter. We recruited 19 pediatricians and 68 parents at pediatric inpatient and outpatient consultations in two Swiss clinics. All medical interactions were videotaped and transcripts were analyzed to assess pediatricians' speech complexity and interrupting behavior was coded from the videos. At the end of the encounter, parents rated their satisfaction with the medical encounter and were probed regarding their recall of medical information. Our results show recall of medical information to be unrelated to pediatricians' speech complexity and negatively associated with their interrupting behavior for parents who report low positive mood. We also found less educated parents to report lower satisfaction when pediatricians employed more complex language. Furthermore, parental satisfaction was negatively associated with pediatricians' interrupting behavior, especially when displayed by male pediatricians. Overall, these findings suggest that pediatricians' speech complexity and interruptions indicate a nonaccommodative stance reducing advantageous parent outcomes.

Health professionals' perceptions of complex feeding decision-making in school-aged children

AIM

Whilst prevalence of paediatric feeding disorders is high amongst children in specialist schools, there is little guidance for professionals supporting families with a child feeding orally with established risk of aspiration. We sought perceptions of the complex feeding decision-making process amongst health professionals supporting families in the specialist school setting in New Zealand.

METHODS

An observational, cross-sectional, national online survey of speech-language therapists was followed by in-depth interviews with seven health professionals associated with one specialist school.

RESULTS

Survey responses from 32 speech-language therapists showed inconsistency in assessment processes and how family, children and school staff are involved in feeding decisions, with 71% reporting a doctor had been involved. Respondents were not confident in their ability to predict aspiration risk, with 41% reporting that they could often determine risk, 41% sometimes and 16% never. Sixty-three percent of respondents indicated that level of risk was written in a report for a child and 50% reported that every child at high risk had a management plan. Speech-language therapists valued professional supervision, but it was not always available. Health professionals were broadly positive about the collaborative nature of decision-making in most but not all situations. They described communication, access/institutional and emotional barriers to timely, shared decision-making.

CONCLUSION

These findings demonstrate variability in how families are supported to make complex feeding decisions. Health professionals identified a need for clearer processes and strengthened communication between family, school and health professionals. Trusting relationships are critical if all families are to be well-supported.

What hinders and helps in the end-of-life decision-making process for children: Parents' and physicians' views

AIM

To investigate the main factors which facilitate or hinder end-of-life decision-making (EoLDM) in neonates and children.

METHODS

A qualitative inductive, thematic analysis was performed of interviews with a total of 73 parents and 71 physicians. The end-of-life decisions mainly concern decisions to withhold or withdraw life-sustaining treatment.

RESULTS

The importance of taking sufficient time and exchanging clear, neutral and relevant information was main facilitators expressed by both parents and physicians. Lack of time, uncertain information and changing doctors were seen as important barriers by both parties. Most facilitators and barriers could be seen as two sides of the same coin, but not always. For example, some parents and physicians considered the fact that parents hold strong opinions as a barrier while others considered this a facilitator. Furthermore, parents and physicians showed differences. Parents especially underlined the importance of physician-related facilitators, such as a personalised approach, empathy and trust. On the contrary, physicians underlined the importance of the child's visible deterioration and parents' awareness of the seriousness of their child's condition and prognosis as facilitators of EoLDM.

CONCLUSIONS

This study gained insight into what parents and physicians experience as the main barriers and facilitators in EoLDM for neonates and children.

Exploring parents' experience in the decision-making process for children with haematological diseases receiving haematopoietic stem cell transplantation in China based on genograms

PURPOSE

To explore parents' experience in the decision-making process for children with haematological diseases receiving haematopoietic stem cell transplantation (HSCT) based on genograms.

DESIGN AND METHODS

A qualitative study based on genogram was conducted. Seven pairs of parents completed their genogram and a semi-structured interview. Two related donors were interviewed to discuss their experiences in the decision-making process of donating bone marrow to their loved ones. Interviews were transcribed verbatim and analysed using interpretative phenomenological analysis.

RESULTS

The genogram presents the complete family structure, family member relationships and incident-related conflicts. Two superordinate themes emerged from the data analysis. The first theme was transplantation decision motivations, including four subthemes: the values of life priority, empathy based on kinship, inheritance of family blood, trust in doctors and medical science. The second theme was transplantation decision conflicts, including four subthemes: decision-making conflicts among family members, related-donor decision-making conflicts, risk-benefit game, blind optimism and insufficient cognition conflict.

CONCLUSIONS

Genogram can show the hidden resources and conflicts of each family and help the care providers better understand parents' experience and the decision-making dilemmas in the decision-making process for children with haematological diseases receiving HSCT. The needs of transplant families for treatment-related information were not fully met.

PRACTICE IMPLICATIONS

It is necessary for medical staff to increase psychological and informational support for donors and their families when the parents of patients make bone marrow transplant decisions. Medical staff should engage in family-focused systematic interventions to reduce the psychological burden and conflicts of decision makers.

Attending to child agency in paediatric palliative care consultations: Adults' use of tag questions directed to the child

Children's agency in their own lives is increasingly recognised as important, including within paediatric health care. The issue of acknowledging child agency is complex in the context of paediatric palliative care, where children have serious and complex conditions that often impact their ability to verbally communicate with others. This study explores how clinicians and parents/guardians direct talk towards a child patient when they are present in a consultation. Conversation analysis methods were used to examine 74 video-recorded paediatric palliative care consultations. Detailed turn-by-turn examination of the recorded consultations identified the recurrent use of a practice described by linguists as a 'tag question', which follows some statement (e.g. 'he loves that, don't ya'). Both clinicians and parents/guardians often directed these tag questions towards the child patient. Analysis demonstrated how these tag questions: (1) validated the child's epistemic authority over what was being said and (2) made a child's response a possible, but not necessary, next action. The findings are discussed in relation to the sociology of child agency and how this agency is acknowledged and displayed within and through social interaction. This research provides direct evidence of children's competence as informants about their own symptoms.

Attending to child agency in paediatric palliative care consultations: Adults' use of tag questions directed to the child

Children's agency in their own lives is increasingly recognised as important, including within paediatric health care. The issue of acknowledging child agency is complex in the context of paediatric palliative care, where children have serious and complex conditions that often impact their ability to verbally communicate with others. This study explores how clinicians and parents/guardians direct talk towards a child patient when they are present in a consultation. Conversation analysis methods were used to examine 74 video-recorded paediatric palliative care consultations. Detailed turn-by-turn examination of the recorded consultations identified the recurrent use of a practice described by linguists as a 'tag question', which follows some statement (e.g. 'he loves that, don't ya'). Both clinicians and parents/guardians often directed these tag questions towards the child patient. Analysis demonstrated how these tag questions: (1) validated the child's epistemic authority over what was being said and (2) made a child's response a possible, but not necessary, next action. The findings are discussed in relation to the sociology of child agency and how this agency is acknowledged and displayed within and through social interaction. This research provides direct evidence of children's competence as informants about their own symptoms.

Patient, parental and multi-disciplinary team rationale for non-implantation following the paediatric cochlear implantation assessment

OBJECTIVES

To assess paediatric patients referred to the cochlear implant team, who despite undergoing the assessment, did not receive cochlear implantation. To identify the underlying reasons for this.

METHODS

A retrospective case-note review of patients was assessed from June 2014 to June 2019 at two separate London teaching hospitals with paediatric cochlear implantation programmes.

RESULTS

A total of 921 paediatric patients were assessed during the study period across both institutions. And, 196 (21%) did not proceed with the surgery. The decision not to undergo surgery was primarily parental/patient-directed in 114 (61%) and cochlear implant team-directed in 74 (39%). In total, eight (4%) patients exited the programme without a documented reason.

DISCUSSION

A myriad of factors influenced the decision-making process for clinicians, patients and parents. The most cited parental/patient rationale against implantation was the wish to continue current means of communication 40 (35%), followed by concern regarding the risks of surgery 18 (15.8%) and the wish to allow the patient to make future decisions independently in view of the future technology 7 (6.1%). Cochlear implant team-directed decisions were largely due to being outside of the NICE criteria 27 (36.5%) or the risks of general anaesthesia 19 (25.7%) in addition to communication concerns 11 (14.9%).

CONCLUSION

Decision-making in cochlear implantation should not be underestimated. Extensive discussion and exploration of options with the multi-disciplinary team can aid decision-making, but the timescale and appreciation of the consequences of the decision inevitably lead to pressure. Exploration of reasons for non-implantation emphasises the importance of a multi-professional approach to manage these patients.

Consensus Approach to a Treat to Target Strategy in Juvenile Idiopathic Arthritis Care: Report from the 2020 PR-COIN Consensus Conference

Objective

Treat to target (T2T) is a strategy of adjusting treatment until a target is reached. An international task force recommended T2T for juvenile idiopathic arthritis (JIA) treatment. Implementing T2T in a standard and reliable way in clinical practice requires agreement on critical elements of: (1) target setting, (2) T2T strategy, (3) identifying barriers to implementation, and (4) eligible patients. A consensus conference was held amongst Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) stakeholders to inform a statement of understanding regarding the PR-COIN approach to T2T.

Methods

PR-COIN stakeholders including health care providers (16) and parents (4), were invited to form a voting panel. Using the nominal group technique, two rounds of voting were held to address the above four areas to select the top 10 responses in rank order.

Results

Incorporation of patient goals ranked most important when setting a treatment target. Use of shared decision making (SDM), tracking measurable outcomes, and adjusting treatment to achieve goals were voted as top elements of T2T strategy. Workflow considerations, and provider buy-in were identified as key barriers to T2T implementation. Patients with JIA, with poor prognostic factors and at risk for high disease burden were leading candidates for a T2T approach.

Conclusion

This consensus conference identified the importance of incorporating patient goals as part of target setting, and influence of patient stakeholder involvement in drafting treatment recommendations. The network approach to T2T will be modified to address the above findings including solicitation of patient goals, optimizing SDM, and better workflow integration.

How 'significant others' may support parents with decision-making about their child's cancer care: An integrative literature review

AIM

To synthesise what is known from current international evidence about how parents are supported by significant others when they are faced with making decisions about their child's cancer care.

BACKGROUND

Parents are faced with making challenging decisions when their child has cancer and may benefit from support. Whilst previous research has comprehensively explored how healthcare professionals can offer support, little attention has been given to how support may be informally provided from a parent's network of significant others.

METHOD

An integrative literature review was undertaken and reported following the ENTREQ framework. Literature was identified from comprehensive database searching across four relevant databases (CINAHL, PubMed, PsychINFO and British Nursing Database) and hand-searching reference lists of retrieved studies. Studies that met the inclusion criteria were critically appraised and then analysed using the Constant Comparative Analysis method.

RESULTS

Twenty-six articles were included in the review. Two overarching themes were identified. Theme 1-Dimensions of Decision-Making support-included three sub-themes: informational, emotional and instrumental mechanisms of support. Theme 2-Expectations of Decision-Making support-identified that parents' expectations of their own role, and the role of their significant others, affected how decision-making was supported.

CONCLUSIONS

Parents may seek and receive support from various significant members of their network, but there is a fine line between supportive and unsupportive behaviours.

RELEVANCE TO CLINICAL PRACTICE

Each family's unique personal, social and cultural context strongly impacts on their support needs, and nurses and other healthcare professionals should be mindful of how parents may access support from their significant others. Further in-depth research around this area would contribute important knowledge around parents' support needs.

Parental Regret Following Decision to Revise Circumcision

PURPOSE

Revision surgery for the removal of excess foreskin after circumcision is a common procedure. The decision regret scale (DRS) is a validated questionnaire which assesses regret after medical decision making. The aim was to evaluate parental regret by means of the DRS and querying about factors associated with regret about deciding to revise their child's circumcision.

PATIENTS AND METHODS

Included were all pediatric patients who underwent revision of neonatal circumcision in a single center between 2010 and 2016. Excluded were children who underwent revision for reasons other than excess foreskin, those who underwent additional surgical procedures during the same anesthetic session, and those who had undergone previous penile surgery other than circumcision. Response to the DRS questionnaire was by a telephone call with the patient's parent. Regret was classified as none (a score of 0), mild (1-25), or moderate-to-strong (26-100). Surgical and baseline demographic data were obtained from the departmental database and compared between the no regret and regret groups.

RESULTS

Of the 115 revisions of circumcisions performed during the study period, 52 fulfilled the inclusion criteria, and the parents of 40 (77%) completed the DRS questionnaire. Regret was reported by 11/40 [28%: nine as mild (23%) and two as moderate-to-strong (5%)]. The average age of the child in the regret group was 17 months compared to 18 months in the no regret group (p = 0.27). The median weight percentile was 43% in both groups. Surgical variables, including anesthesia type (caudal vs. no block, p = 0.65), suture type (polyglactin vs. poliglecaprone, p = 0.29), operation time (28 vs. 25 min, p = 0.59), and anesthesia time (55 vs. 54 min, p = 0.57) were not significantly different between the groups.

CONCLUSIONS

Regret for deciding upon revision surgery for removal of excess foreskin post-circumcision was reported by 27.5% of parents of children who underwent revision. No clinical, surgical, or demographic characteristics predicted parental decisional regret.

Respect for Persons in the Psychiatric Treatment of Children and Adolescents

Child and adolescent psychiatry involves simultaneously balancing duties to various vulnerable parties. Balancing autonomy and protection for adolescents is complex; state laws governing these situations often add confusion. Common prescribing patterns in child psychiatry lack robust evidence, and utilization of stimulants, atypical antipsychotics, and polypharmacy has skyrocketed. Significant concerns about distributive justice arise from alarming patterns in psychiatric treatment of vulnerable populations, like those affected by poverty, racism, adverse childhood experiences, and certain legal statuses. Principles of justice and respect for persons support the need for safe, adequate, and appropriate psychiatric treatment, including psychosocial interventions and resources, for all children.

How doctors actually (do not) involve families in decisions to continue or discontinue life-sustaining treatment in neonatal, pediatric, and adult intensive care: A qualitative study

BACKGROUND

Intensive care doctors have to find the right balance between sharing crucial decisions with families of patients on the one hand and not overburdening them on the other hand. This requires a tailored approach instead of a model based approach.

AIM

To explore how doctors involve families in the decision-making process regarding life-sustaining treatment on the neonatal, pediatric, and adult intensive care.

DESIGN

Exploratory inductive thematic analysis of 101 audio-recorded conversations.

SETTING/PARTICIPANTS

One hundred four family members (61% female, 39% male) and 71 doctors (60% female, 40% male) of 36 patients (53% female, 47% male) from the neonatal, pediatric, and adult intensive care of a large university medical center participated.

RESULTS

We identified eight relevant and distinct communicative behaviors. Doctors' sequential communicative behaviors either reflected consistent approaches-a shared approach or a physician-driven approach-or reflected vacillating between both approaches. Doctors more often displayed a physician-driven or a vacillating approach than a shared approach, especially in the adult intensive care. Doctors did not verify whether their chosen approach matched the families' decision-making preferences.

CONCLUSIONS

Even though tailoring doctors' communication to families' preferences is advocated, it does not seem to be integrated into actual practice. To allow for true tailoring, doctors' awareness regarding the impact of their communicative behaviors is key. Educational initiatives should focus especially on improving doctors' skills in tactfully exploring families' decision-making preferences and in mutually sharing knowledge, values, and treatment preferences.

The impact of shared decision-making on the treatment of anxiety and depressive disorders: systematic review

Background

Shared decision-making encourages patients to explore treatment options/choices in collaboration with their healthcare provider, inclusive of the best available evidence and the patient's values/preferences. Several effective treatments exist for people with anxiety and/or depressive disorders; shared decision-making may be particularly useful in this context.

Aims

To investigate whether shared decision-making enhances clinical outcomes in adults with anxiety and/or depressive disorders.

Method

A systematic review was conducted. Five electronic health databases were searched from database inception until August 2019, in addition to reference lists of included studies. Prospective controlled studies of shared decision-making in adults (aged 18–64 years) diagnosed with an anxiety and/or depressive disorder were included. Two reviewers independently conducted each stage of the review process.

Results

Six randomised controlled trials (N = 1834 participants) were included. Patient satisfaction improved in four studies. Patients were more likely to receive adequate treatment for depression in three studies. Anxiety symptoms decreased in one study. Patient involvement in decision-making increased in three studies. Because of the lack of blinded interventions and outcome assessment, the included studies were at moderate risk of bias. The certainty of evidence ranged from low to moderate, per GRADE criteria.

Conclusions

Shared decision-making shows promise for enhancing quality-of-care outcomes such as patient satisfaction, without increasing consultation time, but appears unlikely to improve symptoms of depression. However, it appears to be understudied in patients with anxiety disorders. Heterogeneity regarding definition and measurement of shared decision-making posed challenges for interpreting the results. More research is recommended to advance the field.

Parental decisional regret after surgical treatment in young boys born with hypospadias

BACKGROUND/PURPOSE

Parental decisional conflict and decisional regret are aspects in parental adjustment to childhood elective surgery. This study assessed correlates of parental decisional regret in parents of young boys treated for hypospadias.

METHODS

Parents of 261 boys treated for hypospadias at the Radboudumc between 2006 and 2014 were approached to complete questionnaires on socio-demographics, clinical details, postoperative outcomes, decisional conflict and decisional regret.

RESULTS

Of the 97 participating parents, 50.5% reported some form of decisional regret, in 11.3% this was moderate to strong. Decisional conflict (β = .68, p < .001) and psychosocial behavior problems of the child (β = .20, p < .05) significantly predicted decisional regret. Demographic and medical variables did not correlate with parental decisional regret.

CONCLUSIONS

A substantial number of parents report some form of decisional regret regarding the elective surgery for hypospadias in their child. Although most parents only show mild forms of regret, in the perspective of discussions on this surgery in early childhood, future research could shed more light on the interrelationship between medical and psychosocial factors in the process of decision-making around surgery, in boys with hypospadias and their parents.

Parent-Adolescent Concordance Regarding Fertility Perspectives and Sperm Banking Attempts in Adolescent Males With Cancer

OBJECTIVE

Approximately half of male childhood cancer survivors experience impaired fertility, yet fertility preservation (FP) remains underutilized. Although parent recommendation influences adolescents' decision-making, parents may be uncertain and/or underrate their sons' parenthood goals. This study assessed parent-adolescent and family-level concordance regarding adolescent fertility perspectives (i.e., values, goals) and associations with FP attempts.

METHODS

A prospective pilot study examined the impact of a family-centered values clarification tool (FAST) on banking attempts among adolescent males newly diagnosed with cancer at risk for infertility. The FAST assessed adolescent and parent perceptions of adolescents' fertility values and goals (i.e., perceived threat of infertility, perceived benefits/barriers to banking). Parent-adolescent concordance and family-level concordance on fertility perspectives were examined, along with associations with banking attempts and salient demographic factors.

RESULTS

Ninety-eight participants (32 adolescents aged 12-20, 37 mothers, 29 fathers) from 32 families completed the FAST before treatment initiation. Parent-adolescent dyads were concordant on approximately one-half of responses. Banking attempts were associated with higher family-level concordance regarding perceived benefits, r(32) = .40, p = .02. Older adolescent age was associated with higher family-level concordance regarding perceived threat, r(31) = .37, p = .04, and benefits, r(32) = .40, p = .03. Fathers' education was associated with higher family-level concordance regarding barriers, r(21) = .53, p = .01.

CONCLUSIONS

When parents were concordant with their son's fertility values and goals, particularly perceived benefits, adolescents were more likely to attempt FP. Clinicians should facilitate sharing of fertility perspectives within families before cancer treatment, especially with younger adolescents. Psychosocial support for families facing FP decisions is recommended at diagnosis and across the care continuum.

Family communication about fertility preservation in adolescent males newly diagnosed with cancer

BACKGROUND

Approximately half of male childhood cancer survivors experience fertility impairment, which can cause psychological distress. Sperm banking remains underutilized among adolescent males with cancer. Parent recommendation influences banking decisions, yet multi-informant studies have not been conducted to examine fertility preservation (FP) communication and decision making in this population. This study explored FP communication among mothers, fathers, and their male adolescents newly diagnosed with cancer.

PROCEDURE

Thirty-three male adolescents, 32 mothers, and 22 fathers completed semi-structured interviews 1-2 months after cancer diagnosis addressing this question: Tell me more about conversations you had about fertility preservation/sperm banking with your health care providers, parents/son, other family members, or anyone else. Interviews were audio-recorded and transcribed verbatim for thematic content analysis.

RESULTS

Five process themes emerged: (1) reliance on health care team and social support networks to facilitate FP decisions (only parents); (2) withholding parental opinion and deferring the decision to the adolescent; (3) ease of communication (primarily adolescents); (4) communication barriers/facilitators; (5) not being present or not remembering details of FP conversations with health care providers (primarily fathers and adolescents). Four content themes included: (1) preference for biological (grand)parenthood; (2) consideration of adolescent's future partner's desire for biological parenthood (primarily parents); (3) banking while it is a viable option; (4) openness to alternative parenthood options (e.g., adoption/fostering, primary parents).

CONCLUSIONS

Understanding variation in what family members discuss and consider relevant when making FP decisions is an important step toward improving pediatric oncofertility care. Interventions are needed to facilitate family FP-related conversations and optimize decisional satisfaction over time.

A Caregiver Digital Intervention to Support Shared Decision Making in Child and Adolescent Mental Health Services: Development Process and Stakeholder Involvement Analysis

Background

Parents and caregivers are generally recognized by literature and the law as key to child and adolescent mental health decisions. Digital interventions are increasingly being used to support care and treatment in child and adolescent mental health services (CAMHS). However, evidence of the design and development process is generally not made available.

Objective

In light of calls for more transparency, this paper aims to describe the development of an evidence-based, theoretically informed digital decision support intervention for parents and caregivers of young people accessing CAMHS.

Methods

The intervention was developed in line with the UK Medical Research Council framework for developing complex interventions. The process incorporated the steps for developing patient decision aids, as follows: assessing need, assessing feasibility; defining objectives; identifying the framework of decision support; and selecting the methods, designs, and dissemination approach. We synthesized theory, research, international guidelines, and input from relevant stakeholders using an iterative design approach.

Results

The development steps resulted in Power Up for Parents, a decision support intervention, with five key features (ie, decisions, goals, journey, support, and resources). The intervention aims to encourage discussion, allow parents to ask questions during sessions or seek further information between sessions, and allow service providers to tailor the shared decision-making process to accommodate the needs of the parent and child.

Conclusions

We confirmed that it is possible to use input from end users—integrated with theory and evidence—to create digital interventions to be used in CAMHS. Key lessons with implications for practice, policy, and implementation science, along with preliminary findings, are presented.

International Registered Report Identifier (IRRID)

RR2-10.2196/14571

Treatment recommendations to parents during pediatric tonsillectomy consultations: A mixed methods analysis of surgeon language

OBJECTIVE

A deeper understanding of the dialogue clinicians use to relay treatment recommendations is needed to fully understand their influence on patient decisions about surgery. We characterize how otolaryngologists provide treatment recommendations and suggest a classification framework.

METHODS

We qualitatively analyzed surgeon recommendations from 55 encounters between otolaryngologists and parents of children evaluated for tonsillectomy, and classified recommendation types by phrasing. Multilevel logistic regression identified predictors of recommendation phrasing.

RESULTS

Clinicians provided 183 recommendations (mean/visit = 3.3). We identified four domains of recommendation-phrasing (direct, passive, acceptable, parent-oriented). Direct recommendations (n = 68, 37%) included presumptive statements phrasing intentions as inevitable. Passive recommendations (n = 65, 36%) included practice-based recommendations utilizing general statements. Acceptable recommendations (n = 29, 16%) included speaking positively about treatment options. Parent-oriented recommendations (n = 21, 11%) included parent choice statements. Clinicians more commonly made direct recommendations to parents who were racial minorities (OR = 2.7, p = .02, 95% CI [1.7, 5.9]) or had an annual income <$50,000 (OR = 2.2, p = .03, 95% CI [1.1, 4.4]).

CONCLUSION

Clinicians provide treatment recommendations in a variety of ways that may introduce more or less certainty and choice to parental treatment decisions.

PRACTICE IMPLICATIONS

Findings may be implemented into training which increases clinician awareness of dialogue use when recommending treatment alternatives to patients.

Non-operative treatment versus suture refixation of the nail plate in paediatric fingernail avulsion injuries

The study compared a non-operative treatment, consisting of ointment dressing only, with the standard surgical nail plate refixation for simple fingernail avulsion injuries in children. A non-inferiority hypothesis was tested in a single-centre, prospective cohort study. The quality of the new nail was the primary outcome and was assessed with the Nail Appearance Score. The secondary outcome was patient and parental satisfaction, which was assessed with the Patients' and Parental Nail Satisfaction Score. Fifty-one patients were enrolled; 39 (76%) chose the non-operative treatment and 12 (24%) the standard operative therapy. Comparison of the two groups confirmed the non-inferiority hypothesis with a risk difference for the new nail of -0.02 with a 95% confidence interval of (-0.05, 0.01). The outcome was excellent in all fingers with no significant differences regarding either the primary or secondary outcome. In view of associated risks and costs for surgery, we recommend ointment dressings for such injuries.Level of evidence: II.

Attitudes towards involving children in decision-making surrounding lung transplantation

BACKGROUND

Medical care has shifted from a paternalistic model towards one centered around patient autonomy and shared decision-making (SDM), yet the role of the pediatric patient in decision-making is unclear. Studies suggest that many children with chronic disease are capable of making medical decisions at a young age, yet no standardized approaches have been developed for involving children in these decisions.

METHODS

This is a single-center survey study investigating the attitudes of pediatric pulmonologists towards involvement of children in decisions regarding lung transplantation, utilizing a hypothetical case scenario with systematic manipulation of age and maturity level. We evaluated physician belief regarding ultimate decision-making authority, reconciliation of parent-child discordance, and utility of ethics and psychiatry consultation services.

RESULTS

The majority of pediatric pulmonologists at this center believe decision-making authority rests with the parents. The effects of age and maturity are unclear. In instances of parent-child disagreement, physicians are more likely to try to convince parents to defer to the child if the child is both older and more mature. Physicians are divided on the utility of ethics and psychiatry consultations.

CONCLUSION

Involvement of children with cystic fibrosis in SDM is broadly supported but inconsistently implemented. Despite evidence that children with chronic disease may have decisional capacity at a young age, the majority of physicians still grant decisional authority to parents. There are numerous barriers to involving children in decisions, including legal considerations. The role of age and maturity level in influencing these decisions appears small and warrants further investigation.

Listening to the experts: Parents' perspectives around infection risk and returning to education and social activities following their child's diagnosis of acute lymphoblastic leukemia

Background

During a child's prolonged treatment for acute lymphoblastic leukemia (ALL), there is a need to balance their increased risk of developing infection‐related complications with meeting their educational and social needs.

Aims

To determine the safe timing of return to social activities for children undergoing treatment for ALL and to determine how parents perceive and act on advice related to infection risk while navigating their child's “return to normal.”

Methods and results

Medical and educational attendance records were reviewed for 47 children who were diagnosed with ALL and 24 semi‐structured qualitative interviews were conducted with a representative sample of their parents. The majority of children (69%) did not return to education prior to the start of maintenance therapy regardless of the advice that the families received from their healthcare team. Those who returned earlier were at no greater risk of major infection complications (mean = 0.5) than those who did not return until after commencing maintenance (mean = 0.4, P = .74). Parents spoke of the difficulty in obtaining practical, consistent, and timely advice and of balancing infection risk with a desire to return to normalcy. Inconsistent advice and constant vigilance placed a burden on parents which often profoundly affected their mental wellbeing. Overall, parents wanted to make their own decisions about how and when their child returned to education and social activities. They made these decisions based on many factors, of which infection risk was just one.

Conclusion

Following the study conclusion, a national working group was established—including parent representatives—to implement the study recommendations. This includes the development of a range of practical resources to better support families. Health professional guidelines provide quantitative data pertaining to infection risk, while emphasizing that the returning decisions ultimately rest with the families. This research demonstrates that listening to parents—who are the experts through their lived experiences—is a critical element in creating policies that are responsive, meaningful, and widely accepted.