1
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Zhong Y, Cavolo A, Labarque V, Gastmans C. Physicians' attitudes and experiences about withholding/withdrawing life-sustaining treatments in pediatrics: a systematic review of quantitative evidence. BMC Palliat Care 2023; 22:145. [PMID: 37773128 PMCID: PMC10540364 DOI: 10.1186/s12904-023-01260-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND One of the most important and ethically challenging decisions made for children with life-limiting conditions is withholding/withdrawing life-sustaining treatments (LST). As important (co-)decision-makers in this process, physicians are expected to have deeply and broadly developed views. However, their attitudes and experiences in this area remain difficult to understand because of the diversity of the studies. Hence, the aim of this paper is to describe physicians' attitudes and experiences about withholding/withdrawing LST in pediatrics and to identify the influencing factors. METHODS We systematically searched Pubmed, Cinahl®, Embase®, Scopus®, and Web of Science™ in early 2021 and updated the search results in late 2021. Eligible articles were published in English, reported on investigations of physicians' attitudes and experiences about withholding/withdrawing LST for children, and were quantitative. RESULTS In 23 included articles, overall, physicians stated that withholding/withdrawing LST can be ethically legitimate for children with life-limiting conditions. Physicians tended to follow parents' and parents-patient's wishes about withholding/withdrawing or continuing LST when they specified treatment preferences. Although most physicians agreed to share decision-making with parents and/or children, they nonetheless reported experiencing both negative and positive feelings during the decision-making process. Moderating factors were identified, including barriers to and facilitators of withholding/withdrawing LST. In general, there was only a limited number of quantitative studies to support the hypothesis that some factors can influence physicians' attitudes and experiences toward LST. CONCLUSION Overall, physicians agreed to withhold/withdraw LST in dying patients, followed parent-patients' wishes, and involved them in decision-making. Barriers and facilitators relevant to the decision-making regarding withholding/withdrawing LST were identified. Future studies should explore children's involvement in decision-making and consider barriers that hinder implementation of decisions about withholding/withdrawing LST.
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Affiliation(s)
- Yajing Zhong
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, Block D, box 7001, Leuven, 3000, Belgium.
| | - Alice Cavolo
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, Block D, box 7001, Leuven, 3000, Belgium
| | - Veerle Labarque
- Centre for Molecular and Vascular Biology, Faculty of Medicine, KU Leuven/UZ Leuven, Herestraat 49, Leuven, 3000, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, Block D, box 7001, Leuven, 3000, Belgium
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2
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Moore B. The Fraught Notion of a "Good Death" in Pediatrics. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2023; 48:60-72. [PMID: 36516411 DOI: 10.1093/jmp/jhac036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In this article, I sort through some of the confusion surrounding what constitutes the controversial notion of a "good death" for children. I distinguish, first, between metaphysical and practical disagreements about the notion of a good death, and, second, between accounts of a good death that minimally and maximally promote the dying child's interests. I propose a narrowed account of the dying child's interests, because they differ from the interests of non-dying children. Importantly, this account illustrates how disagreements at the end of a child's life are sometimes the result of a shift from a future to a present-oriented understanding of the child's interests on the part of some stakeholders but not others, and sometimes the result of a values-based disagreement about how different interests should be weighted. This brings into sharper focus the questions of for whom, and in what way, a child's death might be considered good.
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Affiliation(s)
- Bryanna Moore
- University of Texas Medical Branch, Galveston, Texas, USA
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3
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Wolfe ID. When Clinicians Marginalize Decision-Makers. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:26-28. [PMID: 35616975 DOI: 10.1080/15265161.2022.2063447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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4
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Rothschild CB, Chaiyachati BH, Finck KR, Atwood MA, Leuthner SR, Christian CW. A Venn diagram of vulnerability: The convergence of pediatric palliative care and child maltreatment a narrative review, and a focus on communication. CHILD ABUSE & NEGLECT 2022; 128:105605. [PMID: 35367899 PMCID: PMC11000825 DOI: 10.1016/j.chiabu.2022.105605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
| | - Barbara H Chaiyachati
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kara R Finck
- Interdisciplinary Child Advocacy Clinic, University of Pennsylvania Carey Law School, Philadelphia, PA, USA
| | - Melissa A Atwood
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steven R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cindy W Christian
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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5
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Garaycochea Cannon V. Cuidados intensivos y cuidados paliativos pediátricos. REVISTA IBEROAMERICANA DE BIOÉTICA 2022. [DOI: 10.14422/rib.i18.y2022.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
La tecnificación biomédica de la segunda mitad del siglo XX ha llevado a considerar a la ciencia omnipotente. Esto ha influido en las instituciones sanitarias y en el personal de salud, y ha llevado a cambios en las conceptualizaciones de salud, enfermedad y muerte.
La tecnificación de las unidades de cuidados intensivos dirigidas a revertir enfermedades graves ha priorizado el aspecto biológico de la persona, deshumanizando la medicina. Los cuidados paliativos pediátricos rescatan la integralidad del ser humano y proporcionan cuidados apropiados y respetuosos, acordes a la dignidad de la persona, especialmente al final de la vida, lo que constituye una propuesta humanizadora.
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6
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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7
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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8
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Fay M, Guadarrama J, Colmenares-Roa T, Moreno-Licona I, Cruz-Martin AG, Peláez-Ballestas I. The relationship between proxy agency and the medical decisions concerning pediatric patients in palliative care: a qualitative study. BMC Palliat Care 2021; 20:27. [PMID: 33541339 PMCID: PMC7863456 DOI: 10.1186/s12904-021-00723-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 01/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The children's agency and that exercised by parents and health professionals in palliative care, along with structural limitations imposed by the conditions of inequality, will provide a new perspective from medical anthropology and biomedicine to improve pediatric palliative care in complex therapeutic scenarios. The main purpose of the study was to analyze the ways in which pediatric patients have agency in relation to their parents and palliative care (PC) professionals within the hospital setting, as well as the structural circumstances that constrain said agency. METHOD A hospital ethnography (by means of non-participant observation and interviews) of the palliative care (PC) unit in a children's hospital was conducted over the course of six months. A thematic analysis was performed using the ATLAS.ti software . RESULTS Thirteen cases were reconstructed of underage patients of both sexes patients together with their families; five health professionals were interviewed. The analysis identified the following 6 thematic axes, around which this article is organized: 1. The relationship between the exercise of proxy agency and the medical decisions concerning underage patients. 2. Negotiating agency and support in decision-making. 3. Child autonomy. 4. The experiences of health professionals. 5. Limitations of palliative care. 6. Bureaucratization of palliative care. CONCLUSIONS In pediatric palliative care, agency is a process whereby different agencies intertwine: lack of pediatric patients 'agency, the parents' agency, the parents' agency as representatives of their children (proxy agency), and the agency of health professionals. The concept of relational agency is proposed, defined as a set of group actions and decision-making centered around the pediatric patients's agency and the proxy agency.
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Affiliation(s)
- Martina Fay
- Universidad Nacional de Rosario, Rosario City, Argentina
| | - Jessica Guadarrama
- Palliative Care Unit, Hospital Infantil de Mexico "Federico Gómez", Mexico City, Mexico
| | - Tirsa Colmenares-Roa
- Research Department, Hospital General de Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Iraís Moreno-Licona
- Palliative Care Unit, Hospital Infantil de Mexico "Federico Gómez", Mexico City, Mexico
| | | | - Ingris Peláez-Ballestas
- Rheumatology Department, Hospital General de Mexico "Dr. Eduardo Liceaga", Mexico City, Mexico.
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9
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Wolfe ID, Carter BS. Active or passive guidance? Decision-making in fetal health consultation. J Matern Fetal Neonatal Med 2020; 35:1787-1788. [PMID: 32366147 DOI: 10.1080/14767058.2020.1760835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Prenatal consults are full of uncertainty. But, what are physicians contributing to this, and what is parents understanding of the intricacies of the complex decisions we present to them? Might the way we actively or passively guide parents affect how they make decisions in the complex world of fetal health consultations? For instance, how does "recommending" versus "not recommending" impact how parents view their choices? Reviewing the literature, there is a paucity of data on this topic. There are studies detailing experience but not of how guidance affects decision-making. We review some of this literature and discuss concepts relevant to this observation. We hypothesize that passive or active guidance by fetal health consultation members influences the moral deliberation and ethical decision-making of parents in different ways and propose a possible research idea.
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Affiliation(s)
- Ian D Wolfe
- Children's Mercy Bioethics Center, Kansas City, MO, USA
| | - Brian S Carter
- Children's Mercy Bioethics Center, Kansas City, MO, USA.,Department of Pediatrics, Neonatology, and Bioethics, University of Missouri-Kansas City, Kansas City, MO, USA
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10
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Kon AA, Dudzinski DM. Navigating End-of-Life Decisions Using Informed Nondissent. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:42-43. [PMID: 31543053 DOI: 10.1080/15265161.2018.1563652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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11
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Miller KE, Coleman RD, Eisenberg L, Henriksen J, Lantos JD, Weiss EM. Unilateral Withdrawal of Life-sustaining Therapy in a Severely Impaired Child. Pediatrics 2018; 142:peds.2018-0131. [PMID: 30315121 DOI: 10.1542/peds.2018-0131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2018] [Indexed: 11/24/2022] Open
Abstract
An infant with complex congenital heart disease suffers a prolonged cardiac arrest with minutes of anoxia. He is left with severe brain damage and profound neurologic impairment. He no longer responds to caregivers. Much of the time, he cries and grimaces as if in pain. He has required increasing sedation to control these symptoms. His parents live hours from the hospital and seldom visit. When their infant's situation is explained to them over the telephone, they request that doctors "do everything to keep him alive." His bedside caregivers report high levels of moral and psychological distress and frequently discuss J.S.'s "suffering." An ethics consultation is requested, asking whether it is permissible to withdraw life support despite the parents' request that therapy continue.
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Affiliation(s)
- Kathryn E Miller
- Division of Pediatric Critical Care, Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Ryan D Coleman
- Sections of Pediatric Critical Care Medicine and Pulmonary Medicine, Department of Pediatrics and Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
| | - Leah Eisenberg
- Division of Medical Humanities, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Joan Henriksen
- Office of Clinical Ethics, Mayo Clinic, Rochester, Minnesota
| | - John D Lantos
- Center for Bioethics, Children's Mercy Hospital, Kansas City, Missouri;
| | - Elliott Mark Weiss
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington
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12
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Morrison W, Clark JD, Lewis-Newby M, Kon AA. Titrating Clinician Directiveness in Serious Pediatric Illness. Pediatrics 2018; 142:S178-S186. [PMID: 30385625 DOI: 10.1542/peds.2018-0516i] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 11/24/2022] Open
Abstract
Shared decision-making in pediatrics is based on a trusting partnership between parents, clinicians, and sometimes patients, wherein all stakeholders explore values and weigh options. Within that framework, clinicians often have an obligation to provide guidance. We describe a range of ethically justifiable clinician directiveness that could be appropriate in helping families navigate serious pediatric illness. The presentation of "default" options and informed nondissent as potential strategies are discussed. The degree of clinician directiveness may vary even for decisions that are equally "shared." A myriad of factors affect how directive a clinician can or should be. Some of the most important factors are the degree of prognostic certainty and the family's desire for guidance, but others are important as well, such as the urgency of the decision; the relationship between the clinician, patient, and family; the degree of team consensus; and the burdens and benefits of therapy. Directiveness should be considered an important tool in a clinician's armamentarium and is one that can be used to support families in stressful and emotionally difficult situations.
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Affiliation(s)
- Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Jonna D Clark
- Divisions of Pediatric Critical Care Medicine and Pediatric Bioethics, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Mithya Lewis-Newby
- Divisions of Pediatric Critical Care Medicine and Pediatric Bioethics, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Alexander A Kon
- Department of Pediatrics, University of California, San Diego, San Diego, California
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13
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Abstract
ECMO has proven to be a life-saving intervention for a variety of disease entities with a high rate of survival in the neonatal population. However, ECMO requires clinical teams to engage in many ethical considerations. Even with ongoing improvements in technology and expertise, some patients will not survive a course of ECMO. An unsuccessful course of ECMO can be difficult to accept and cause a great deal of angst. These questions can result in real conflict both within the care team, and between the care team and the family. Herein we explore a range of ethical considerations that may be encountered when caring for a patient on ECMO, with a particular focus on those courses where it appears likely that the patient will not survive. We then consider how a palliative care approach may provide a tool set to help engage the team and family in confronting the difficult decision to discontinue ECMO.
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Affiliation(s)
- Roxanne Kirsch
- Department of Critical Care, The Hospital for Sick Children, Toronto, Canada; Department of Bioethics, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada.
| | - David Munson
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
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Hernandez E, Fawcett A, Brouwer E, Rau J, Turner PV. Speaking Up: Veterinary Ethical Responsibilities and Animal Welfare Issues in Everyday Practice. Animals (Basel) 2018; 8:E15. [PMID: 29361786 PMCID: PMC5789310 DOI: 10.3390/ani8010015] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 12/31/2017] [Accepted: 01/17/2018] [Indexed: 02/06/2023] Open
Abstract
Although expectations for appropriate animal care are present in most developed countries, significant animal welfare challenges continue to be seen on a regular basis in all areas of veterinary practice. Veterinary ethics is a relatively new area of educational focus but is thought to be critically important in helping veterinarians formulate their approach to clinical case management and in determining the overall acceptability of practices towards animals. An overview is provided of how veterinary ethics are taught and how common ethical frameworks and approaches are employed-along with legislation, guidelines and codes of professional conduct-to address animal welfare issues. Insufficiently mature ethical reasoning or a lack of veterinary ethical sensitivity can lead to an inability or difficulty in speaking up about concerns with clients and ultimately, failure in their duty of care to animals, leading to poor animal welfare outcomes. A number of examples are provided to illustrate this point. Ensuring that robust ethical frameworks are employed will ultimately help veterinarians to "speak up" to address animal welfare concerns and prevent future harms.
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Affiliation(s)
- Elein Hernandez
- Department of Pathobiology, University of Guelph, Guelph, ON N1G 2W1, Canada.
| | - Anne Fawcett
- Sydney School of Veterinary Science, University of Sydney, Camperdown, NSW 2006, Australia.
| | - Emily Brouwer
- Department of Pathobiology, University of Guelph, Guelph, ON N1G 2W1, Canada.
| | - Jeff Rau
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada.
| | - Patricia V Turner
- Department of Pathobiology, University of Guelph, Guelph, ON N1G 2W1, Canada.
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15
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Chen D, Epstein E, Almarode S, Winter J, Marshall MF. What the "F"? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:16-19. [PMID: 29313770 DOI: 10.1080/15265161.2017.1401178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Donna Chen
- a University of Virginia School of Medicine
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16
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Wocial L, Ackerman V, Leland B, Benneyworth B, Patel V, Tong Y, Nitu M. Pediatric Ethics and Communication Excellence (PEACE) Rounds: Decreasing Moral Distress and Patient Length of Stay in the PICU. HEC Forum 2017; 29:75-91. [PMID: 27815753 DOI: 10.1007/s10730-016-9313-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This paper describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers' moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were 60 patients in the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings (PEACE rounds) to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer (MDT) scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised (MDS-R), were lower for respondents in all categories (non-significant), and on three specific items (significant). Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS (4.94 control vs 3.37 PEACE, p = 0.015), a statistically significant increase in both code status changes DNR (11 % control, 28 % PEACE, p = 0.013), and in-hospital death (9 % control, 25 % PEACE, p = 0.015), with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients.
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Affiliation(s)
- Lucia Wocial
- Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, IN, USA.
- Indiana University School of Nursing, Indianapolis, IN, USA.
| | - Veda Ackerman
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
| | - Brian Leland
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
| | - Brian Benneyworth
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
- Children's Health Services Research Unit, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Vinit Patel
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
| | - Yan Tong
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
| | - Mara Nitu
- Section of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Hospital for Children, Indianapolis, IN, USA
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O'Meara M, Trethewie S. Managing paediatric death in the emergency department. J Paediatr Child Health 2016; 52:164-7. [PMID: 26147905 DOI: 10.1111/jpc.12957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2015] [Indexed: 11/29/2022]
Abstract
Death of a child in an emergency department is a rare occurrence, but one with significant impact on the family and staff involved. The rarity means few emergency department clinicians feel 'expert' in the overall management process. However, most have some knowledge and experience which can be augmented by collaborating with other health professionals. By exploring some of the main management issues and challenges for the emergency department, key aspects of care are identified for emergency department clinicians to consider in reviewing local procedures and guidelines.
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Affiliation(s)
- Matthew O'Meara
- Pain and Palliative Care, Sydney Children's Hospital, Sydney, New South Wales, Australia.,Paediatric Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Susan Trethewie
- Pain and Palliative Care, Sydney Children's Hospital, Sydney, New South Wales, Australia
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18
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Edwards JD. Palliative Care and End-of-Life Considerations in Children on Chronic Ventilation. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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19
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Sustaining life or prolonging dying? Appropriate choice of conservative care for children in end-stage renal disease: an ethical framework. Pediatr Nephrol 2015; 30:1761-9. [PMID: 25330877 DOI: 10.1007/s00467-014-2977-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/22/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Abstract
Due to technological advances, an increasing number of infants and children are surviving with multi-organ system dysfunction, and some are reaching end-stage renal disease (ESRD). Many have quite limited life expectancies and may not be eligible for kidney transplantation but families request dialysis as alternative. In developed countries where resources are available there is often uncertainty by the medical team as to what should be done. After encountering several of these scenarios, we developed an ethical decision-making framework for the appropriate choice of conservative care or renal replacement therapy in infants and children with ESRD. The framework is a practical tool to help determine if the burdens of dialysis would outweigh the benefits for a particular patient and family. It is based on the four topics approach of medical considerations, quality-of-life determinants, patient and family preferences and contextual features tailored to pediatric ESRD. In this article we discuss the basis of the criteria, provide a practical framework to guide these difficult conversations, and illustrate use of the framework with a case example. While further research is needed, through this approach we hope to reduce the moral distress of care providers and staff as well as potential conflict with the family in these complex decision-making situations.
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20
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Brown A, Clark JD. A Parent's Journey: Incorporating Principles of Palliative Care into Practice for Children with Chronic Neurologic Diseases. Semin Pediatr Neurol 2015; 22:159-65. [PMID: 26358425 DOI: 10.1016/j.spen.2015.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Rather than in conflict or in competition with the curative model of care, pediatric palliative care is a complementary and transdisciplinary approach used to optimize medical care for children with complex medical conditions. It provides care to the whole child, including physical, mental, and spiritual dimensions, in addition to support for the family. Through the voice of a parent, the following case-based discussion demonstrates how the fundamentals of palliative care medicine, when instituted early in the course of disease, can assist parents and families with shared medical decision making, ultimately improving the quality of life for children with life-limiting illnesses. Pediatric neurologists, as subspecialists who provide medical care for children with chronic and complex conditions, should consider invoking the principles of palliative care early in the course of a disease process, either through applying general facets or, if available, through consultation with a specialty palliative care service.
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Affiliation(s)
- Allyson Brown
- Department of Pediatrics, Division of Critical Care Medicine, University of Washington School of Medicine, Seattle, WA; Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Jonna D Clark
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA; Treuman Katz Center for Pediatric Bioethics, University of Washington School of Medicine, Seattle, WA.
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21
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Dudzinski DM. Attend to the middle. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:46-47. [PMID: 25562228 DOI: 10.1080/15265161.2015.975584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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23
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Mercurio MR, Murray PD, Gross I. Unilateral pediatric "do not attempt resuscitation" orders: the pros, the cons, and a proposed approach. Pediatrics 2014; 133 Suppl 1:S37-43. [PMID: 24488539 DOI: 10.1542/peds.2013-3608g] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A unilateral do not attempt resuscitation (DNAR) order is written by a physician without permission or assent from the patient or the patient's surrogate decision-maker. Potential justifications for the use of DNAR orders in pediatrics include the belief that attempted resuscitation offers no benefit to the patient or that the burdens would far outweigh the potential benefits. Another consideration is the patient's right to mercy, not to be made to undergo potentially painful interventions very unlikely to benefit the patient, and the physician's parallel obligation not to perform such interventions. Unilateral DNAR orders might be motivated in part by the moral distress caregivers sometimes experience when feeling forced by parents to participate in interventions that they believe are useless or cruel. Furthermore, some physicians believe that making these decisions without parental approval could spare parents needless additional emotional pain or a sense of guilt from making such a decision, particularly when imminent death is unavoidable. There are, however, several risks inherent in unilateral DNAR orders, such as overestimating one's ability to prognosticate or giving undue weight to the physician's values over those of parents, particularly with regard to predicted disability and quality of life. The law on the question of unilateral DNAR varies among states, and readers are encouraged to learn the law where they practice. Arguments in favor of, and opposed to, the use of unilateral DNAR orders are presented. In some settings, particularly when death is imminent regardless of whether resuscitation is attempted, unilateral DNAR orders should be viewed as an ethically permissible approach.
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Affiliation(s)
- Mark R Mercurio
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, and
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Morrison W, Kang T. Judging the quality of mercy: drawing a line between palliation and euthanasia. Pediatrics 2014; 133 Suppl 1:S31-6. [PMID: 24488538 DOI: 10.1542/peds.2013-3608f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Clinicians frequently worry that medications used to treat pain and suffering at the end of life might also hasten death. Intentionally hastening death, or euthanasia, is neither legal nor ethically appropriate in children. In this article, we explore some of the historical and legal background regarding appropriate end-of-life care and outline what distinguishes it from euthanasia. Good principles include clarity of goals and assessments, titration of medications to effect, and open communication. When used appropriately, medications to treat symptoms should rarely hasten death significantly. Medications and interventions that are not justifiable are also discussed, as are the implications of palliative sedation and withholding fluids or nutrition. It is imperative that clinicians know how to justify and use such medications to adequately treat suffering at the end of life within a relevant clinical and legal framework.
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Wilfond BS. Tracheostomies and assisted ventilation in children with profound disabilities: navigating family and professional values. Pediatrics 2014; 133 Suppl 1:S44-9. [PMID: 24488540 DOI: 10.1542/peds.2013-3608h] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Parental requests for gastrostomies, tracheostomies, or assisted ventilation in children with profound disabilities raise ethical concerns about children's interests, parental decision-making, and health care costs. The underlying concern for many relates to the perceived value of these children. Clinicians should make efforts to appreciate the family's perspective regarding children with profound disabilities who require respiratory and nutritional medical support. Finding opportunities to learn about the family members' lives outside of the health care setting may facilitate a deeper understanding of what it means to live with a child who has profound disabilities. In conversations with families, referring to interventions as futile and conditions as lethal will obscure the value-based nature of these decisions. Respiratory and nutritional interventions are not clearly against the interests of most children. Even for children with a limited life span, life-sustaining interventions may be important for the child and family. Health care costs are a serious societal issue; however, the costs associated with profound disabilities are not the most significant contributor. Societal decisions not to provide life-sustaining health care to children with profound disabilities would require a public process. Clinicians may have personal views regarding decisions for their own family or for their vision for society. However, clinicians have professional obligations to families who have different values. It is important to present balanced information and support parental decision-making so parents may decide to forgo or use life-sustaining interventions according to their values and goals.
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Affiliation(s)
- Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
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Anderson WG, Cimino JW, Lo B. Seriously ill hospitalized patients' perspectives on the benefits and harms of two models of hospital CPR discussions. PATIENT EDUCATION AND COUNSELING 2013; 93:633-40. [PMID: 24005002 PMCID: PMC3864765 DOI: 10.1016/j.pec.2013.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Revised: 07/26/2013] [Accepted: 08/12/2013] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To describe seriously ill patients' perspectives on expert-endorsed approaches for hospital cardiopulmonary resuscitation (CPR) discussions. METHODS We created two videos depicting a hospital doctor discussing CPR with a seriously ill patient. One depicted a values-based approach with a doctor's recommendation, and one an information-focused approach without a recommendation. During semi-structured interviews, 20 seriously ill hospitalized patients viewed and commented on both videos. We conducted a thematic analysis to describe benefits and harms of specific discussion components. RESULTS Half of participants reported no preference between the videos; 35% preferred the information-focused, and 15% the values-based. Participants' reactions to the discussion components varied. They identified both benefits and harms with components in both videos, though most felt comfortable with all components (range, 60-65%) except for the doctor's recommendation in the values-based video. Only 40% would feel comfortable receiving a recommendation, while 65% would feel comfortable with the doctor eliciting their CPR preference as in the information-focused video, p=0.03. CONCLUSION Participants' reactions to expert-endorsed discussion components varied. Most would feel uncomfortable receiving a doctor's recommendation about CPR. PRACTICE IMPLICATIONS Participants' varied reactions suggest the need to tailor CPR discussions to individual patients. Many patients may find doctor's recommendations to be problematic.
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Affiliation(s)
- Wendy G Anderson
- Division of Hospital Medicine, University of California, San Francisco, USA; Palliative Care Program, University of California, San Francisco, USA; Department of Medicine, University of California, San Francisco, USA.
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Recent Literature Feature Editor: Paul C. Rousseau. J Palliat Med 2013. [DOI: 10.1089/jpm.2013.9487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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