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Lanocha N, Taub S, Webb JA, Wood M, Tate T. It Starts With a Story: A Four-Step Narrative-Based Framework for Serious Illness Conversations. J Palliat Med 2024; 27:1177-1183. [PMID: 38968377 DOI: 10.1089/jpm.2024.0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024] Open
Abstract
Background: As a key component of advance care planning, serious illness conversations form a core intervention in palliative care. To achieve effective serious illness conversations, acknowledgment and inclusion of patient sense of self and identity are critical. However, no framework exists to describe how goals, values, and choices relate to patient identity. This conceptual gap hinders the advancement of palliative care education and practice. Objective: This philosophical investigation aimed to explicate two items: first, a novel conceptual framework for serious illness conversations; second, a structured approach to optimize these conversations within the palliative care clinical context. Methods: A philosophical and theoretical analysis was performed within an interdisciplinary context, by scholars in palliative care, medical humanities, philosophy, and bioethics. Key literature in psychology, qualitative research on the experience of serious illness, medical ethics, and choice architecture in medical decision-making were reviewed, and a structured conceptual and narrative analysis was performed. Results: An original and innovative identity-centered conceptual framework for serious illness conversations was developed. The framework consists of a four-step, reproducible approach: (1) attend to patient narrative identity, (2) identify values, (3) cocreate goals, and (4) actively promote choices. In short: attend, identify, create, and promote (AICP). Discussion: By using this conceptual framework and four-step approach, clinicians can accomplish goal-concordant serious illness care and build rich clinical relationships that foster trust and goodwill.
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Affiliation(s)
| | - Sara Taub
- Knight Cancer Institute, Portland, Oregon, USA
| | - Jason A Webb
- Oregon Health and Science University, Portland, Oregon, USA
- University of Oregon, Eugene, Oregon, USA
| | - Mary Wood
- University of Oregon, Eugene, Oregon, USA
| | - Tyler Tate
- Stanford University School of Medicine, Palo Alto, California, USA
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Wilson K, Umana E, McCleary D, Waterfield T, Woolfall K. Exploring communication preferences and risk thresholds of clinicians and parents of febrile infants under 90 days presenting to the emergency department: a qualitative study. Arch Dis Child 2024:archdischild-2023-326727. [PMID: 38986575 DOI: 10.1136/archdischild-2023-326727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/17/2024] [Indexed: 07/12/2024]
Abstract
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.
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Affiliation(s)
- Kathryn Wilson
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
- Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Etimbuk Umana
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
| | - David McCleary
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
| | - Thomas Waterfield
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, Belfast, UK
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Quirke MB, Alexander D, Cassidy L, Walsh C, Masterson K, Hill K, Brenner M. Adolescents with Rett syndrome at critical care pathway junctures: Examining clinicians' decision to initiate invasive long-term ventilation. Eur J Paediatr Neurol 2024; 49:113-119. [PMID: 38484415 DOI: 10.1016/j.ejpn.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The initiation of invasive long-term ventilation (I-LTV) for an adolescent with Rett Syndrome (RTT) involves many serious bioethical considerations. In moving towards a more inclusive model of patient participation, transparency surrounding the main influencing factors around this decision is important. OBJECTIVE We aimed to identify the main drivers influencing a clinician's decision to support initiation of I-LTV for an adolescent with RTT. METHOD We used an anonymous online vignette-based factorial survey. The survey was distributed internationally through eight professional multi-disciplinary organisations to reach clinicians working in paediatrics. RESULTS We analysed 504 RTT vignettes completed by 246 clinicians using mixed effect regression modelling. The main three significant influencing factors identified were: parental agreement with the decision to support initiation, the family's support network, and proximity to a tertiary care centre. Additional comments from participants focused on family support, and the importance of on-going communication with the family. CONCLUSION As the rights of those with disabilities improve and participation of adolescents in decision-making becomes more established, effective communications with the family around goals of care and particular sensitivity and reflective practice around methods of consensus building will likely contribute to a positive decision-making process at this difficult time.
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Affiliation(s)
- Mary Brigid Quirke
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin, 4, Ireland.
| | - Denise Alexander
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin, 4, Ireland.
| | - Lorna Cassidy
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin, 4, Ireland.
| | - Cathal Walsh
- Department of Mathematics and Statistics, University of Limerick, Limerick, V94 T9PX, Ireland.
| | - Kate Masterson
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin, 4, Ireland.
| | - Katie Hill
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin, 4, Ireland.
| | - Maria Brenner
- School of Nursing, Midwifery and Health Systems, University College Dublin, Belfield, Dublin, 4, Ireland.
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Joren CY, Aris-Meijer JL, Verhagen AAE, Lantos J. Pediatric palliative care across continents: Communication and shared-decision-making. Curr Probl Pediatr Adolesc Health Care 2024; 54:101552. [PMID: 38155022 DOI: 10.1016/j.cppeds.2023.101552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
Despite the significant growth and development of pediatric palliative care worldwide, significant challenges remain. One of those challenges is shared decision-making, by which parents, families and professionals all work together to develop a plan of care that reflects both the medical facts and the patient's family's values. Shared decision-making about palliative care and about death and dying may mean different things in different cultures and countries. It is therefore important to learn and compare practices around the world.
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Affiliation(s)
- Chantal Y Joren
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.
| | - Judith L Aris-Meijer
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
| | - A A Eduard Verhagen
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Hanzeplein 1, 9713 GZ Groningen, the Netherlands
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Vemuri S, Prentice TM. Seeking alignment of end-of-life goals within the Australian pediatric context. Curr Probl Pediatr Adolesc Health Care 2024; 54:101454. [PMID: 37977910 DOI: 10.1016/j.cppeds.2023.101454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
In this article, we highlight the Australian pediatric palliative care context. We describe the way in which pediatricians may adopt 'directive' shared decision-making to align care plans with their perceptions of harm avoidance for the child. The degree to which 'directive alignment' is ethically appropriate or proportionate in the context of the clinical and social context of the child must be considered. Shared decision-making within palliative care continues to be a challenging dynamic to navigate for pediatricians.
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Affiliation(s)
- Sid Vemuri
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Trisha M Prentice
- Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Neonatal Medicine, Royal Children's Hospital, Melbourne, Australia.
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Vemuri S, Hynson J, Williams K, O'Neill J, Gillam L. Shepherding parents to prepare for end-of-life decision-making: a critical phenomenological study of the communication approach of paediatricians caring for children with life-limiting conditions in Australia. BMJ Open 2023; 13:e075740. [PMID: 38159953 PMCID: PMC10759114 DOI: 10.1136/bmjopen-2023-075740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND/OBJECTIVES Shared decision-making is widely accepted as the best approach for end-of-life decision-making for children with life-limiting conditions. Both paediatricians and parents find benefit in preparing for such decisions. However, little detail is known about this preparatory process. This study aims to explore how paediatricians prepare parents for end-of-life decision-making for a child with a life-limiting condition using clinical simulation. DESIGN Individual, semistructured, post-simulation qualitative interviews of paediatricians and parent-actors. SETTING Acute intensive and long-term outpatient paediatric care in Victoria, Australia. PARTICIPANTS 18 purposively sampled paediatricians who treat children with life-limiting conditions and the two parent-actors involved in all simulations. Paediatricians were excluded if they assisted in the study design, worked within specialist palliative care teams or did not provide clinical care outside the neonatal period. RESULTS Three key themes in a preparatory process (termed 'shepherding') were identified: (1) paediatricians aim to lead parents along a pathway to future end-of-life decisions, (2) paediatricians prefer to control the pace of these discussions and (3) paediatricians recognise they need to have courage to face risk with this preparation. Paediatricians use a variety of shepherding strategies to influence the pace, content and framing of discussions, which may help prepare parents to make the best end-of-life treatment decisions when the time comes. CONCLUSIONS Shepherding is a newly identified, subtle process intended to influence parents by guiding their understanding of their child's health and potential suffering in advance of decision-making. Shepherding does not fit within current descriptions of physicians' decision-making influence. Paced reflection, thinking and provision of information are shepherding strategies preferred by paediatricians, and these appear the same regardless of whether paediatricians intend to steer parents towards particular treatment decisions or simply prepare them for the process of decision-making. Further study about the intention of this influence and parental perception of this communication is needed.
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Affiliation(s)
- Sidharth Vemuri
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jenny Hynson
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Katrina Williams
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Jenny O'Neill
- Children's Bioethics Centre, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Lynn Gillam
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Children's Bioethics Centre, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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Cai S, Cheng L, Wang R, Zhou X, Peng X. A shared decision-making model in pediatric palliative care: a qualitative study of healthcare providers. BMC Palliat Care 2023; 22:190. [PMID: 38012611 PMCID: PMC10683132 DOI: 10.1186/s12904-023-01307-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Pediatric shared decision-making (SDM) is a fundamental part of family-centered care. Pediatric palliative care (PPC) is one of the more difficult fields for healthcare providers when choosing to utilize SDM. However, to our knowledge, there are still few structured approaches of SDM in PPC. We aimed to build a model of SDM in PPC that achieves better care and outcomes for children and their family members. METHODS This study is a descriptive phenomenology study. Participants included physicians, nurses, and social workers in the PPC team. Participants were individually interviewed face-to-face or via an online meeting software. Data were collected in semi-structured interviews and analyzed using a thematic framework analysis. RESULTS In total, 27 healthcare providers were interviewed. The model of SDM in PPC identified three themes, including the participants, the principle and the process of SDM. Decision participants involved the children, parents, the PPC team and others. The decision principle had three sub-themes including type, standard and precondition. The decision process describes the fundamental process of SDM and provides suggestions for mobilizing patients and parents to engage in decision-making and seeking conflict resolution. CONCLUSIONS This is the first study to develop a SDM model in PPC. This model can provide guidance to PPC teams on SDM practices. In addition, the model contributes to the existing body of knowledge by providing a conceptual model for SDM in the context of PPC.
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Affiliation(s)
- Siyu Cai
- Center for Clinical Epidemiology and Evidence-based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 South Lishi Road, Beijing, 100045, China
| | - Lei Cheng
- School of Nursing, Fudan University, Shanghai, 200032, China
| | - Ruixin Wang
- Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 South Lishi Road, Beijing, 100045, China
| | - Xuan Zhou
- Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 South Lishi Road, Beijing, 100045, China.
| | - Xiaoxia Peng
- Center for Clinical Epidemiology and Evidence-based Medicine, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, 56 South Lishi Road, Beijing, 100045, China.
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Vemuri S, Hynson J, Williams K, Gillam L. Navigating two 'truths': a qualitative study of physician-led end-of-life decision-making for children with life-limiting conditions. Arch Dis Child 2023; 108:725-729. [PMID: 37188494 DOI: 10.1136/archdischild-2022-324963] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/30/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To describe how paediatricians undertake the process of end-of-life decision-making for a child with a life-limiting condition who is unable to participate in decision-making for themselves. DESIGN A qualitative phenomenological study using semistructured interviews based around a clinical vignette matched to the clinical practice of individual paediatricians. Verbatim transcripts underwent thematic analysis. SETTING Paediatricians practising in Victoria (Australia) between mid-2019 and mid-2020. PARTICIPANTS Twenty-five purposively sampled paediatricians caring for children with specific life-limiting conditions: children with severe neurodisability, oncological or haematological malignancies or complex cardiac disease in an inpatient intensive care or outpatient clinic setting. RESULTS A process of physician-led end-of-life decision-making was described. Paediatricians first contemplate that the child's death is approaching, then prepare themselves by ensuring there are no reversible factors at play. They then inform parents of this view and, if needed, hold discordant views between parents and themselves about the child's death in a 'fruitful tension'. Ultimately, they seek to bring parents' views of their child in line with theirs to facilitate goal alignment. CONCLUSIONS Paediatricians feel responsible for facilitating the alignment of parental understanding of the child's health status with their own. This is achieved either through direction or by holding differences between parental and medical truths about the child's health in tension to provide time, space, and clarity. This alignment was seen as key to enabling end-of-life treatment decisions, without which conflict in end-of-life decision-making can arise or persist.
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Affiliation(s)
- Sidharth Vemuri
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jenny Hynson
- Victorian Paediatric Palliative Care Program, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Katrina Williams
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Lynn Gillam
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Neurodisability and Rehabilitation, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Children's Bioethics Centre, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
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Jacobs S, Davies N, Butterick KL, Oswell JL, Siapka K, Smith CH. Shared decision-making for children with medical complexity in community health services: a scoping review. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2023-001866. [PMID: 37012004 PMCID: PMC10083859 DOI: 10.1136/bmjpo-2023-001866] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/02/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Children with medical complexity is an increasing population whose parents and healthcare providers face multiple decisions. Shared decision-making is a process where patients, their families and healthcare providers collaborate to make decisions based on clinical evidence and informed preferences of the family. Shared decision-making has benefits for the child, family and healthcare providers, including improved parental understanding of the child's difficulties, increased participation, improved coping skills and more efficient healthcare use. It is, however, poorly implemented. AIMS AND METHODS A scoping review was conducted to explore shared decision-making for children with medical complexity in community health services, including how shared decision-making is defined in research, how it is implemented, including barriers and facilitators and recommendations for research. Six databases were systematically searched for papers published in English up to May 2022: Medline, CINAHL, EMBASE, PsycINFO, PubMed, Cochrane Database of Systematic Reviews and sources of grey literature. The review is reported according to the Preferred Reporting Items for Scoping Reviews. RESULTS Thirty sources met the inclusion criteria. Most factors can either be a facilitator or barrier to shared decision-making depending on the context. Two significant barriers to shared decision-making in this population include uncertainty about the child's diagnosis, prognosis, and treatment options and the presence of hierarchy and power imbalance during clinical encounters with healthcare providers. Further influencing factors include continuity of care, the availability of accurate, accessible, adequate, and balanced information and the interpersonal and communication skills of parents and healthcare providers. CONCLUSION Uncertainty about diagnosis, prognosis and treatment outcomes for children with medical complexity are additional challenges to the known barriers and facilitators to shared decision-making in community health services. Effective implementation of shared decision-making requires advancement of the evidence base for children with medical complexity, reducing power imbalance in clinical encounters, improving continuity of care, and improving the availability and accessibility of information resources.
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Affiliation(s)
- Sonja Jacobs
- Community Children's Therapies, Barts Health NHS Trust, London, UK
| | - Nathan Davies
- Research Department of Primary Care & Population Health, University College London, London, UK
| | | | - Jane L Oswell
- Community Children's Therapies, Barts Health NHS Trust, London, UK
| | | | - Christina H Smith
- Division of Psychology and Language Sciences, University College London, London, UK
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Sellaiah V, Merlo F, Malacrida R, Albanese E, Fadda M. Physician-reported characteristics, representations, and ethical justifications of shared decision-making practices in the care of paediatric patients with prolonged disorders of consciousness. BMC Med Ethics 2023; 24:19. [PMID: 36882830 PMCID: PMC9993525 DOI: 10.1186/s12910-023-00896-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/24/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Despite consensus about the importance of implementing shared decision-making (SDM) in clinical practice, this ideal is inconsistently enacted today. Evidence shows that SDM practices differ in the degree of involvement of patients or family members, or in the amount of medical information disclosed to patients in order to "share" meaningfully in treatment decisions. Little is known on which representations and moral justifications physicians hold when realizing SDM. This study explored physicians' experiences of SDM in the management of paediatric patients with prolonged disorders of consciousness (PDOC). Specifically, we focused on physicians' SDM approaches, representations, and ethical justifications for engaging in SDM. METHODS We used a qualitative approach to explore the SDM experiences of 13 ICU physicians, paediatricians, and neurologists based in Switzerland who have been or were involved in the care of paediatric patients living with PDOC. A semi-structured interview format was used and interviews were audio-recorded and transcribed. Data were analysed through thematic analysis. RESULTS We found that participants followed three main decision-making approaches: the "brakes" approach, characterized by maximized family's decisional freedom, though conditional to physician's judgment regarding the medical appropriateness of a treatment; the "orchestra director" approach, characterized by a multi-step decision-making process led by the main physician aimed at eliciting the voices of the care team members and of the family; and the "sunbeams" approach, characterized by a process oriented to reach consensus with family members through dialogue, where the virtues of the physician are key to guide the process. We also found that participants differed in the moral justifications sustaining each approach, citing the duty to respect parental autonomy, to invest in an ethics of care, and to employ physicians' virtues to guide the decision-making process. CONCLUSION Our results show that physicians come to perform SDM in different ways, with several representations, and distinct ethical justifications. SDM training among health care providers should clarify the ductility of SDM and the several ethical motivations underpinning it, rather than insisting on the principle of respect for patient's autonomy as its only moral foundation.
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Affiliation(s)
- Vinurshia Sellaiah
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Via Buffi 13, 6900, Lugano, Switzerland
| | - Federica Merlo
- Institute of Public Health, Faculty of Biomedical Sciences, Università della Svizzera italiana, Via Buffi 13, 6900, Lugano, Switzerland.,Sasso Corbaro Foundation, Bellinzona, Switzerland
| | | | - Emiliano Albanese
- Institute of Public Health, Faculty of Biomedical Sciences, Università della Svizzera italiana, Via Buffi 13, 6900, Lugano, Switzerland
| | - Marta Fadda
- Institute of Public Health, Faculty of Biomedical Sciences, Università della Svizzera italiana, Via Buffi 13, 6900, Lugano, Switzerland.
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