End-of-life decisions in abusive head trauma

A Venn diagram of vulnerability: The convergence of pediatric palliative care and child maltreatment a narrative review, and a focus on communication

Child maltreatment and end-of-life care independently represent two of the most emotion-laden and uncomfortable aspects of pediatric patient care. Their overlap can be uniquely distressing. This review explores ethical and legal principles in such cases and provides practical advice for clinicians. The review focuses on three archetypal scenarios of overlap: life-limiting illness in a child for whom parental rights have been terminated; life-threatening injury under CPS investigation; and complex end-of-life care which may warrant CPS involvement. While each scenario presents unique challenges, one consistent theme is the centrality of effective communication. This includes empathic communication with families and thoughtful communication with providers and community stakeholders. In almost all cases, everyone genuinely wants to do what is in the best interest of the child in these unthinkable circumstances. Transparent and collaborative communication can ensure that broad perspectives are considered to ensure that each child gets the best possible care in a manner adherent with ethical and legal standards, as they apply to each case.

End-of-life medical decision-making for children in custody: A collaborative, multi-stakeholder practical approach

BACKGROUND

Parents have a constitutionally-protected, fundamental right to make decisions concerning the health and well-being of their children, afforded by the Due Process Clause of the Fourteenth Amendment. However, parental rights are not absolute, and may be curtailed after a finding of parental "unfitness" including perpetration of egregious child abuse/neglect. Court intervention may be necessary to assert "parens patriae" authority to protect a child's well-being. Disagreements over medical care for a child (particularly when parent maltreatment resulted in life-altering clinical conditions and parents are suspected of perpetrating abusive injuries) often pose conflicts of interest. End-of-life decision-making involving abuse perpetrators may be influenced by self-interest, due to potential for escalation of criminal charges.

OBJECTIVE

Discuss medico-legal decision-making for children in child welfare custody using a detailed case example involving a child near-fatally, abusively injured by his parents; review of relevant case law/national legal precedents; and clinical policy statements guiding end-of-life decision-making for pediatric patients.

PARTICIPANTS/SETTING/METHODS

Using an exploratory, quasi-qualitative approach, perceived experiences of purposefully-selected taskforce members identified key themes that informed a care de-escalation protocol, implemented across the state.

RESULTS

Key themes included coordinated communication, expedited legal proceedings, and balancing child's best interest (the right not to suffer for a prolonged period of time or sustain complications) with parents' rights and due process concerns, and informed protocol development.

CONCLUSIONS

Practicable guidance established in the protocol can be theoretically adapted at the local level to address the complexity inherent in end-of-life decision-making for children in custody.

Abusive Injuries Are Worse Than Vehicular Injuries: Should We Refocus Prevention?

OBJECTIVES

The objective of this study was to compare the injury severity and outcome of motor vehicle and nonaccidental traumatic injuries and examine trends in mortality rates over time.

METHODS

We reviewed data from 2005 to 2013 from a level 1 pediatric trauma center including demographics, injury severity, and outcomes. Primary outcomes of interest were mortality rates and hospital length of stay.

RESULTS

Injury severity scores were significantly worse for nonaccidental traumas (NATs) (P < 0.001) compared with motor vehicle collisions and motor pedestrian collisions. Nonaccidental traumas were also found to have significantly longer length of stay and higher fatality rates (P < 0.001). Significant differences were also found for the types of injuries sustained for head, extremity, trunk, and other injuries (P < 0.001), and for internal injuries (P < 0.01. Admission rates also dropped for both motor vehicle collisions and motor pedestrian collisions across the 9-year period (P < 0.001) but remained stable for NATs.

CONCLUSION

In this study population, more severe injuries, higher mortality rates, and longer hospital stays were observed in pediatric NAT compared with those sustained through vehicular means. Furthermore, we observed statistically significant declines in motor vehicle-related injuries compared with NAT.

Ethics of End of Life Decisions in Pediatrics: A Narrative Review of the Roles of Caregivers, Shared Decision-Making, and Patient Centered Values

Background: This manuscript reviews unique aspects of end of life decision-making in pediatrics. Methods: A narrative literature review of pediatric end of life issues was performed in the English language. Results: While a paternalistic approach is typically applied to children with life-limiting medical prognoses, the cognitive, language, and physical variability in this patient population is wide and worthy of review. In end of life discussions in pediatrics, the consideration of a child’s input is often not reviewed in depth, although a shared decision-making model is ideal for use, even for children with presumed limitations due to age. This narrative review of end of life decision-making in pediatric care explores nomenclature, the introduction of the concept of death, relevant historical studies, limitations to the shared decision-making model, the current state of end of life autonomy in pediatrics, and future directions and needs. Although progress is being made toward a more uniform and standardized approach to care, few non-institutional protocols exist. Complicating factors in the lack of guidelines include the unique facets of pediatric end of life care, including physical age, paternalism, the cognitive and language capacity of patients, subconscious influencers of parents, and normative values of death in pediatrics. Conclusions: Although there have been strides in end of life decision-making in pediatrics, further investigation and research is needed in this field.

Nonaccidental trauma: guidance for nurses in the pediatric intensive care unit

Each year thousands of children are hospitalized for traumatic injuries associated with physical abuse. Nurses in the pediatric intensive care unit must be knowledgeable and skilled in caring for the physical, psychological, emotional, social, and developmental needs of such children and their families. This article provides direction for pediatric nurses working in the critical care setting. Specifically, it describes the nursing care of children in a pediatric intensive care unit where the mechanism of nonaccidental injury is blunt force to the head, abdomen, or musculoskeletal system, based on standards put forth by the American Association of Critical-Care Nurses.

The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective

Premature infants at the limits of viability raise difficult ethical, legal, social and economic questions. Neonatologists attending an international Collegium were surveyed about delivery room behaviour, and the approach taken by selected countries practicing 'modern' medicine was explored.

CONCLUSION

There were strong preferences for comfort care at 22 weeks and full resuscitation at 24 weeks. Resuscitation was a grey area at 23 weeks. Cultural, social and legal factors also had a considerable impact on decision-making.