Parental Personal Sense of Duty as a Foundation of Pediatric Medical Decision-making

Learning to Trust Yourself: Decision-Making Skills Among Parents of Children With Medical Complexity

CONTEXT

Children with medical complexity have substantial medical needs and their caregivers must make many challenging decisions about their care. Caregivers often become more involved in decisions over time, but it is unclear what skills they develop that facilitate this engagement.

OBJECTIVES

To describe the skills that caregivers developed as they gained experience making medical decisions.

METHODS

Eligible caregivers had a child who met referral criteria for their centre's Complex Care program for >1 year, were adults responsible for their child's medical decisions, and spoke English or a language with an available interpreter. We followed a semistructured interview guide to ask caregivers to describe and reflect on two challenging medical decisions that they made for their child-one early and one recent. Guided by interpretive description, we identified and refined themes in an iterative process.

RESULTS

We conducted 15 interviews with 16 parents (14 [88%] women, two [13%] men) of a child with medical complexity (aged 1-17 years). Parents described 1) becoming more adept at managing decisional information, 2) recognizing the influence of the decision's context, 3) building stronger relationships with providers, and 4) becoming more effective at guiding their child's care as a decision-maker. As parents built these skills, they developed a greater sense of agency and confidence as decision-makers.

CONCLUSION

Parents of children with medical complexity change how they approach decision making over time as they acquire relevant skills. These findings can inform the development of interventions to support skill-building among new caregivers.

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 in food allergy: Navigating an exciting era

OBJECTIVE

Shared decision-making (SDM) is increasingly used in food allergy. We review its use in the areas of prevention, diagnosis, and management.

DATA SOURCES

PubMed and online SDM resources.

STUDY SELECTIONS

Studies and reviews relevant to SDM and areas in food allergy that decision-making may be applied were selected for discussion.

RESULTS

Food allergy represents an area with multiple opportunities for SDM. Patients, on one hand, need to obtain the necessary information and understanding of existing options from the allergist. The allergist, on the other hand, needs to understand "where the patient is coming from," their needs, preferences, and values, so that jointly they can reach a decision that is responsive to these. Benefits of SDM include a better understanding of disease by patients, improved compliance with medication, better health outcomes, decreased health care costs, and improved ability of patients to manage their disease and make informed choices.

CONCLUSION

In food allergy prevention, diagnosis, and management, multiple preference-sensitive options exist for patients where SDM may be used during allergy consultations, alongside decision aids. Decision aids are tools that assist and support patients during the SDM process, by supplementing the patient-physician interaction.

Factors Involved in Decision-Making Dilemmas Faced by Parents of Children with Severe Asthma in PICU During the Development of Discharge Care Plans: A Phenomenological Study

Purpose

This study aims to explore the complicated decision-making dilemma and challenges confronted by parents of children suffering from severe asthma within the Pediatric Intensive Care Unit (PICU) when participating in the development of their children's discharge care plans.

Patients and Methods

Employing a phenomenological methodology, a purposive sampling was performed to engage with 17 parents who participated in in-depth and semi-structured interviews between October 2022 and February 2023. The transcripts of these interviews were transcribed into textual data, which was then subjected to Colaizzi's seven-step analysis for meticulous coding and comprehensive thematic elucidation.

Results

The comprehensive analysis of the factors involved in the intricate decision-making dilemmas faced by parents of children with severe asthma during the process of crafting discharge care plans in the PICU revealed five themes and eight sub-themes: 1) Complexity of asthma-related information; 2) Insufficient provision of comprehensive decision-making support; 3) Encountering negative emotions and wavering confidence; 4) Navigating realistic constraints impacting both parents and HCPs; 5) Balancing the advantages and disadvantages of various plans.

Conclusion

Parents of children with severe asthma in the PICU encounter intricate and multifaceted decision-making dilemmas while engaging in the formulation of discharge care plans. These complexities significantly dampen their decision-making enthusiasm and introduce potential risks to the children's prognosis and recovery. In the future, it is imperative to leverage the guidance provided by healthcare professionals (HCPs) in the decision-making process, develop tailored decision support tools specifically designed for the formulation of discharge care plans for children with severe asthma in the PICU.

Goals of Care Among Parents of Children Receiving Palliative Care

Importance

While knowing the goals of care (GOCs) for children receiving pediatric palliative care (PPC) are crucial for guiding the care they receive, how parents prioritize these goals and how their priorities may change over time is not known.

Objective

To determine parental prioritization of GOCs and patterns of change over time for parents of children receiving palliative care.

Design, Setting, and Participants

A Pediatric Palliative Care Research Network's Shared Data and Research cohort study with data collected at 0, 2, 6, 12, 18, and 24 months in hospital, outpatient, or home settings from April 10, 2017, to February 15, 2022, at 7 PPC programs based at children's hospitals across the US. Participants included parents of patients, birth to 30 years of age, who received PPC services.

Exposures

Analyses were adjusted for demographic characteristics, number of complex chronic conditions, and time enrolled in PPC.

Main Outcomes

Parents' importance scores, as measured using a discrete choice experiment, of 5 preselected GOCs: seeking quality of life (QOL), health, comfort, disease modification, or life extension. Importance scores for the 5 GOCs summed to 100.

Results

A total of 680 parents of 603 patients reported on GOCs. Median patient age was 4.4 (IQR, 0.8-13.2) years and 320 patients were male (53.1%). At baseline, parents scored QOL as the most important goal (mean score, 31.5 [SD, 8.4]), followed by health (26.3 [SD, 7.5]), comfort (22.4 [SD, 11.7]), disease modification (10.9 [SD, 9.2]), and life extension (8.9 [SD, 9.9]). Importantly, parents varied substantially in their baseline scores for each goal (IQRs more than 9.4), but across patients in different complex chronic conditions categories, the mean scores varied only slightly (means differ 8.7 or less). For each additional study month since PPC initiation, QOL was scored higher by 0.06 (95% CI, 0.04-0.08) and comfort scored higher by 0.3 (95% CI, 0-0.06), while the importance score for life extension decreased by 0.07 (95% CI, 0.04-0.09) and disease modification by 0.02 (95% CI, 0-0.04); health scores did not significantly differ from PPC initiation.

Conclusions and Relevance

Parents of children receiving PPC placed the highest value on QOL, but with considerable individual-level variation and substantial change over time. These findings emphasize the importance of reassessing GOCs with parents to guide appropriate clinical intervention.

Video tools in pediatric goals of care communication: A systematic review

•Goals of Care resources are primarily in written format and for adult patients.•Video tools can support families of pediatric patients facing prognostic uncertainty.•Videos represent an effective but underutilized Goals of Care communication tool.

The Case for Advance Care Planning in the NICU

Many NICUs have reached an inflection point where infant deaths following limitation of life-sustaining treatments outnumber those following unsuccessful resuscitations, and many infants who survive continue to require intensive supports. Families of such infants with serious illness may benefit from a standardized, process-oriented approach in decisional-support. Advance care planning (ACP), or communication that supports patients, or their surrogate decision-makers, in sharing values, goals, and preferences for future medical care, is recognized as a valuable strategy in supporting adults with serious and chronic illness. Although the role of ACP in older children and adolescents is evolving, its utility has not been systematically explored in the perinatal context. This article builds a case for formalizing a role for ACP in the NICU by defining ACP and appraising recent outcomes research, reviewing the current state of parental needs for decisional support and serious illness in the NICU, and describing how ACP may address current limitations in primary and specialty pediatric palliative care and challenges for decision-making in the newborn period.

Decision-Making for Extremely Preterm Infants: A Qualitative Systematic Review

OBJECTIVE

To synthesize and describe important elements of decision-making during antenatal consultation for threatened preterm delivery at the margin of gestational viability.

STUDY DESIGN

Data sources including PubMed, EMBASE, Web of Science, and CINAHL Plus were searched. We included all qualitative literature published on decision-making from 1990 to July 2021. Two authors independently screened and evaluated each study using the Critical Appraisal Skills Programme checklist; studies reaching moderate and high quality were included. We developed an extraction tool to collect and categorize data from each qualitative article, then used thematic analysis to analyze and describe the findings.

RESULTS

Twenty-five articles incorporating the views of 504 providers and 352 parents were included for final review. Thematic analysis revealed 4 main themes describing the experience of health care providers and parents participating in decision-making: factors that influence decision-making, information sharing, building a partnership, and making the decision. Parents and providers were not always in agreement upon which elements were most essential to the process of decision-making. Articles published in languages other than English were excluded.

CONCLUSIONS

Qualitative literature highlighting key factors which are important during antenatal counseling can inform and guide providers through the process of shared decision-making. Communicating clear, honest, and balanced information; avoiding artificially dichotomized options; and focusing on partnership building with families will help providers use the antenatal consultation to reach personalized decisions for each infant.

Pierre Nelson W, Kantrowitz-Gordon I. Age, Autonomy, and Authority of Knowledge: Discursive Constructions of Youth Decision-Making Capacity and Parental Support in Transgender Minors’ Accounts of Healthcare Access

While access to care is known to improve health outcomes for transgender youth, these youth often face challenges in accessing care related to decision-making capacity and the legal limitations regarding age of consent. In this study, we utilize discourse analytic methods to identify how notions of age, autonomy, and authority of knowledge influence transgender youths’ ability to make agentic decisions about their bodies and health, and better understand the power dynamics present in youths’ relations with parents and providers. We conducted 11 one-on-one interviews with transgender youth between the ages of 13 to 17 and one focus group with high school-age trans youth ( n = 8) in the Seattle-Tacoma area of Washington state. We identified two sets of discourses: (1) discourses of autonomy, which included self-determination, confidentiality, and authority of knowledge and (2) discourses of support, which included role ambiguity, trust/mistrust, and good and bad parents. Findings from this study highlight power dynamics present in trans youths’ relations with parents and providers.

Relationships and Resources Supporting Children With Serious Illness and Their Parents

OBJECTIVE

Children with complex chronic conditions (CCCs) and their parents benefit from supportive serious illness care when their conditions are severe and impact their quality of life and stress. This includes not only expert medical care but also effective relationships with the clinical team. Existing data suggest that there are opportunities for improvement. This study's aim was to explore important aspects of the relationships and resources that facilitate supportive serious illness care among children with CCCs and their parents.

METHODS

We conducted semistructured interviews with adolescents and young adults (AYAs) with CCCs (aged 13-35 years), and parents of children with CCCs across 2 academic pediatric centers in the United States from December 2018 to April 2019. Transcripts were iteratively coded and analyzed by a team that included a sociologist, pediatric intensivist, and palliative care researcher by using inductive and deductive thematic analysis.

RESULTS

Seven AYAs with CCCs and 9 parents participated (16 total; 1 AYA-parent dyad). Two key categories were identified around relationships with the clinical team: trust and fostering collaboration. Three key categories related to resources are information needs, making sense of life with illness, and supportive community. Many of the key categories and themes identified by participants had both tangible and intangible components and revealed the distinct yet interconnected nature of these aspects of care.

CONCLUSIONS

Awareness and cultivation of relationship and resource support through innovative interventions and attention to those with increased needs in these areas may improve the serious illness care provided to children with CCCs and their parents.

Protecting my injured child: a qualitative study of parents' experience of caring for a child with a displaced distal radius fracture

Background

Childhood fractures can have a significant impact on the daily lives of families affecting children’s normal activities and parent’s work. Wrist fractures are the most common childhood fracture. The more serious wrist fractures, that can look visibly bent, are often treated with surgery to realign the bones; but this may not be necessary as bent bones straighten in growing children. The children’s radius acute fracture fixation trial (CRAFFT) is a multicentre randomised trial of surgery versus a cast without surgery for displaced wrist fractures. Little is known about how families experience these wrist fractures and how they manage treatment uncertainty. This study aimed to understand families’ experience of this injury and what it is like to be asked to include their child in a clinical trial.

Methods

Nineteen families (13 mothers, 7 fathers, 2 children) from across the UK participated in telephone interviews. Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis.

Results

Our findings highlight parents’ desire to be a good parent through the overarching theme “protecting my injured child”. To protect their child after injury, parents endeavoured to make the right decisions about treatment and provide comfort to their child but they experienced ongoing worry about their child’s recovery. Our findings show that parents felt responsible for the decision about their child’s treatment and their child’s recovery. They also reveal the extent to which parents worried about the look of their child’s wrist and their need for reassurance that the wrist was healing.

Conclusion

Our findings show that protecting their child after injury can be challenging for parents who need support to make decisions about treatment and confidently facilitate their child’s recovery. They also highlight the importance of providing information about treatments, acknowledging parents’ concerns and their desire to do the right thing for their child, reassuring parents that their child’s wrist will heal and ensuring parents understand what to expect as their child recovers.

Moral equivalence theory in neonatology

This article explores the ethical concept of "the equivalence thesis" (ET), or the idea that withdrawing and withholding life sustaining treatments are morally equivalent practices, within neonatology. We review the historical origins, theory, and clinical rationale behind ET, and provide an analysis of how ET relates to literature that describes neonatal mode of death and healthcare professional and parent attitudes towards end-of-life care. While ET may serve as an ethical tool to optimize resource allocation in theory, its clinical utility is limited given the complexity of end-of-life care decisions.

Bereaved Parent Perspectives on the Benefits and Burdens of Technology Assistance among Children with Complex Chronic Conditions

Background: Many children with complex chronic conditions (CCCs) are supported by medical technologies. Objective: The aim of this study was to understand bereaved parent perspectives on technology assistance among this unique population. Design: Mixed methods design was used to analyze data from the cross-sectional Survey of Caring for Children with CCCs.Setting/Subjects: Bereaved parents of children with CCCs who received care at a large academic institution in the United States and died between 2006 and 2015. Measurements: Survey items were analyzed descriptively and integrated with thematic analysis of open-response items to identify key themes pertaining to parents' perspectives on technology. Results: 110/211 (52%) parents completed the survey and at least 1 open-response item. More than 60% of parents had children with congenital/chromosomal or central nervous system progressive CCCs, used technology at baseline, and died in the hospital. A subset of parents recalled making decisions either not to initiate (n = 26/101, 26%) or to discontinue (n = 46/104, 44%) technology at end of life. Parents described both the benefits and burdens of technology. Two themes emerged regarding technology's association with the (1) intersection with goals of care and (2) complications and regret. Within goals of care, two subthemes arose: (a) technology was necessary to give time for life extension and/or to say goodbye, and (b) technology greatly impacted the child's quality of life and symptoms. Conclusions: Parents have nuanced perspectives about the benefits and burdens of technology. It is essential to understand parent's most important goals when supporting decisions about technology assistance for children with CCCs.

Decision-making for Parents of Children With Medical Complexities: Activity Theory Analysis

Background

Shared decision-making (SDM), a collaborative approach to reach decisional agreement, has been advocated as an ideal model of decision-making in the medical encounter. Frameworks for SDM have been developed largely from the clinical context of a competent adult patient facing a single medical problem, presented with multiple treatment options informed by a solid base of evidence. It is difficult to apply this model to the pediatric setting and children with medical complexity (CMC), specifically since parents of CMC often face a myriad of interconnected decisions with minimal evidence available on the multiple complex and co-existing chronic conditions. Thus, solutions that are developed based on the traditional model of SDM may not improve SDM practices for CMCs and may be a factor contributing to the low rate of SDM practiced with CMCs.

Objective

The goal of our study was to address the gaps in the current approach to SDM for CMC by better understanding the decision-making activity among parents of CMCs and exploring what comprises their decision-making activity.

Methods

We interviewed 12 participants using semistructured interviews based on activity theory. Participants identified as either a parent of a CMC or a CMC over the age of 18 years. Qualitative framework analysis and an activity theory framework were employed to understand the complexity of the decision-making process in context.

Results

Parents of CMCs in our study made decisions based on a mental model of their child’s illness, informed by the activities of problem-solving, seeking understanding, obtaining tests and treatment, and caregiving. These findings suggest that the basis for parental choice and values, which are used in the decision-making activity, was developed by including activities that build concrete understanding and capture evidence to support their decisions.

Conclusions

Our interviews with parents of CMCs suggest that we can address both the aims of each individual activity and the related outcomes (both intended and unintended) by viewing the decision-making activity as a combination of caregiving, problem-solving, and seeking activities. Clinicians could consider using this lens to focus decision-making discussions on integrating the child’s unique situation, the insights parents gain through their decision-making activity, and their clinical knowledge to enhance the understanding between parents and health care providers, beyond the narrow concept of parental values.

"The stakes could not be higher": A mixed methods study of parental social media use in pediatric oncology

BACKGROUND

To describe how parents and families of children with cancer evaluate the benefits and risks of using social media (SM) and how they navigate disagreements between oncologists' advice and information found on SM.

PROCEDURE

Parents of children who had been previously diagnosed with cancer, and who had used SM for a purpose related to that child's health were recruited through SM sites and nonprofit organizations across the United States and were invited to complete questionnaires about their experiences using SM; a subset of participants also completed a follow-up in-depth interview. Open-ended responses and interviews were analyzed using thematic analysis.

RESULTS

Ninety parents completed written questionnaires; 21 completed follow-up interviews. Seventy percent reported experiencing a situation in which information shared on SM conflicted with information provided by their child's oncologist. Although 86% reported that they discussed the conflicting information with the oncologist and 70% described the oncologist's response as positive, 78% also described ongoing negative feelings about the experience. Parents described openness to discussing SM, honesty, transparency, and humility regarding the limits of medicine, and shared decision-making regarding information found on SM as increasing their trust in their oncologist.

CONCLUSIONS

Parents offered valuable insights regarding their experiences navigating SM, including eight recommendations for how pediatricians might approach discussing parental SM use. Future studies will evaluate the utility of these recommendations for pediatric clinicians.

Resilience, preparedness, and distress among family caregivers of patients with advanced cancer

OBJECTIVE

Resilience has been proposed as a primary factor in how many family caregivers of patients with advanced cancer are able to resist psychological strain and perform effectively in the role while bearing a high load of caregiving tasks. To evaluate this hypothesis, we examined whether self-perceived resilience is associated with distress (anxiety and depressive symptoms), caregiver preparedness, and readiness for surrogate decision-making among a racially diverse sample of family caregivers of patients with newly diagnosed advanced cancer.

METHODS

Secondary analysis of baseline data from two small-scale, pilot clinical trials that both recruited family caregivers of patients with newly diagnosed advanced cancer. Using multivariable linear regression, we analyzed relationships of resilience as a predictor of mood, caregiving preparedness, and readiness for surrogate decision-making, controlling for sociodemographics.

RESULTS

Caregiver participants (N = 112) were mean 56 years of age and mostly female (76%), the patient's spouse/partner (52%), and White (56%) or African-American/Black (43%). After controlling for demographics, standardized results indicated that higher resilience was relevantly associated with higher caregiver preparedness (beta = .46, p < .001), higher readiness for surrogate decision-making (beta = .20, p < .05) and lower anxiety (beta =  - .19, p < .05), and depressive symptoms (beta =  - .20, p < .05).

CONCLUSIONS

These results suggest that resilience may be critical to caregivers' abilities to manage stress, be effective sources of support to patients, and feel ready to make future medical decisions on behalf of patients. Future work should explore and clinicians should consider whether resilience can be enhanced in cancer caregivers to optimize their well-being and ability to perform in the caregiving and surrogate decision-making roles.

Clinical Care Strategies That Support Parents of Children With Complex Chronic Conditions

OBJECTIVES

Children with complex chronic conditions often receive inpatient and end-of-life care in the ICU, yet little is known about the clinical care strategies that best support this unique group of parents. This study aimed to elucidate supportive clinical care strategies identified by bereaved parents of children with complex chronic conditions.

DESIGN

Qualitative analysis of 21 open-response items from the cross-sectional "Survey of Caring for Children with Complex Chronic Conditions" querying communication, decision-making, and end-of-life experiences.

SETTING

Large tertiary care children's hospital.

PATIENTS

Parents of children with complex chronic conditions who received care at a large academic institution and died between 2006 and 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

An iterative multistage thematic analysis of responses was used to identify key themes pertaining to clinical care strategies that support parents of children with complex chronic conditions. Open-ended responses were analyzed from 110 of 114 (96%) of survey respondents. The majority of parents had children with congenital/chromosomal complex chronic conditions who died 3.9 years (interquartile range, 2.2-6.7 yr) prior to their parents' study participation. Although informational themes related to clear honest communication, consistent messaging, and enhanced care coordination were identified, parents emphasized the relational aspects of clinical care including inclusivity of their expertise about their child's needs, recognition of their unique experience as parents, and maintenance of connection with clinicians through bereavement.

CONCLUSIONS

Clinical care strategies that support parents of children with complex chronic conditions reflect the unique needs of this group of children. Relational strategies such as including parents as experts in their child's care were paramount to parents of children with complex chronic conditions throughout their child's medical journey and at end of life.

Care Provider Behaviors That Shape Parent Identity as a "Good Parent" to Their Seriously Ill Child

Background: Parents of medically complex children hold deeply personal definitions of how to be “good parents” that guide their medical decision making and interactions with providers and are impacted by provider behaviors.

Objective: This study explored whether and how these beliefs are shaped by interactions with care providers and which provider behaviors foster or impede parents' ability to achieve their “good parent” definitions.

Methods: A 63-item web-based survey distributed by an online support network for parents of medically complex children. Responses to closed- and open-ended questions from 67 caregivers based in the United States and Europe were analyzed.

Results: Respondents' medical decisions are driven by goals of unselfishly doing what is best for my child (61%) and being my child's voice (18%). Almost half indicated that their personal “good parent” definition was impacted by provider behaviors or interactions with physicians or nurses. Although most parents reported wanting trusted care providers to ask them about their personal “good parent” definition, only 7% had ever been directly asked by members of their care teams about this topic. Provider behaviors such as kind and caring interactions, acknowledging the parents' role in caring for the child, and truly seeing the child as more than a diagnosis were reported as fostering caregivers' ability to achieve their “good parent” beliefs.

Conclusions: The findings indicate that trusted provider-initiated conversations about “good parent” beliefs would be well received and are an opportunity to improve family-centered care. Care provider behaviors deemed by parents as supportive facilitate their efforts to achieve their “good parent” beliefs.

"You Have Made All the Loving Choices": Good Parent Praise in Pediatric Critical Care Conferences

BACKGROUND AND OBJECTIVES

Parents' ideas about what it means to be a "good parent" to their seriously ill child influence parental decision-making. Little is known about when, why, and how clinicians offer good-parent praise or how parents react. Our objective was to describe clinicians' spontaneous use of good-parent praise statements to parents during PICU care conferences and how parents respond.

METHODS

Single-center, cross-sectional review of 72 transcripts of audio-recorded PICU care conferences in a quaternary medical center. Qualitative analysis was conducted to code triggers for clinician good-parent statements and parent responses.

RESULTS

Clinicians made at least one statement of good-parent praise in 32% of family conferences. Triggers for clinician statements of good-parent praise were categorized into 6 themes: decision making, gratitude to the clinical team, defense of parenting, parental body language, parental guilt, and intention to close the meeting. Parental responses to clinician statements of good-parent praise fell into 6 themes: acknowledgment, medical talk, deepening of feelings expressed in conversation, focusing on a decision, redirecting on the patient, and gratitude.

CONCLUSIONS

Clinicians spontaneously praised parents for their role in being a good parent in less than one-third of family conferences. Clinician statements were triggered by verbal and nonverbal parental behaviors, a critical decision-making point in the conversation, and an intention to close the meeting. In response, parents frequently responded positively to the praise and often returned the gratitude or reflected on their feelings about caregiving for their child.

Perspectives of Urban Adolescent Black Males and Their Parents on Well Care

OBJECTIVE

Adolescents have fewer well-care visits than all other age groups. Males and ethnic minorities are seen least often. We elicited from Black adolescent males and their parents key drivers of teen well-care seeking.

METHODS

We conducted separate semistructured interviews with Black adolescent males and their parents. We recruited parent-teen dyads from West Philadelphia. Eligible teens were age 13 to 18, with no complex chronic health conditions. We purposively sampled teens who had not received preventive care in at least 2 years, some of whom had since returned to care and some not. Interviews were recorded, transcribed, and coded by 2 coders using the constant comparative method, resolving discrepancies by consensus. Interviews continued until thematic saturation.

RESULTS

We interviewed 23 Black adolescent males (mean age 15) and 22 parents (20 mothers). Participants understood that teens should routinely receive preventive care. Four themes emerged: receiving preventive care is important to knowing teens are mentally and physically well; remembering to schedule/attend visits is challenging - participants find appointment reminders helpful; mothers noted that males of all ages are generally disengaged from health care; teens and parents felt that a "good" parent ensures teens receive preventive care.

CONCLUSIONS

Black adolescent males and their parents value regular preventive care as an opportunity to ensure the teen is physically and mentally well, but competing priorities interfere with care receipt. Results support testing the impact of reminders on receipt of care in this population. These reminders may be most effective if directed at mothers and focused on "good parenting."

Decisions for Long-Term Ventilation for Children. Perspectives of Family Members

Rationale: The decision whether to initiate or forgo long-term ventilation for children can be difficult and impactful. However, little has been published on the informational and decisional needs of families facing this decision.Objectives: To assess what families with children with chronic respiratory failure and life-limiting conditions need and want for informed decision-making.Methods: English- and Spanish-speaking parents who were facing (contemporaneous decision makers) or had previously faced (former decision makers) a decision regarding invasive or noninvasive long-term ventilation for their children were recruited using convenience sampling. Patients who were older and cognitively capable also were invited to participate. We performed semistructured interviews using an open-ended interview guide developed de novo to assess parents' decisional needs and experiences. Qualitative data analysis used a thematic approach based on framework analysis, and thematic saturation was a goal.Results: A sample of 44 parents and 2 patients from 43 families was interviewed. All contemporaneous decision makers (n = 28) favored or believed that they would choose long-term ventilation. Fifteen of 16 former decision makers chose long-term ventilation. Thematic saturation was achieved from the perspective of parents who favored or chose long-term ventilation. Four domains were identified: parents' emotional and psychological experiences with decision-making, parents' informational needs, parents' communication and decision support needs, and parents' views on the option not to initiate long-term ventilation. For most parents, making a decision regarding long-term ventilation was stressful, even though they articulated goals and values that could/did guide their decision-making. In general, parents wanted comprehensive information, including what life would be like at home for the child and the family. They wanted their medical providers to be honest, tactful, patient, and supportive. Parents reported that they felt being presented with the option not to initiate was acceptable.Conclusions: In this study, we identified specific informational and decision-making needs regarding long-term ventilation that parents facing decisions feel are important. These data suggest that providers should present families with comprehensive, balanced information on the impact of long-term ventilation and, when the child has a profoundly serious and life-limiting condition, explore the option not to initiate long-term ventilation.

Critical decision-making in neonatology and pediatrics: the I-P-O framework

Critical decision-making in neonatology and other areas of pediatrics often carries with it a complex and difficult ethical component. For any treatment under consideration, the impermissible-permissible-obligatory (I-P-O) spectrum provides a useful framework for determining how to proceed. Any proposed treatment can be located along this spectrum, and identified as either ethically impermissible, permissible, or obligatory. Treatments determined to be ethically impermissible should not be made available by physicians. Those deemed ethically permissible should be explained to parents, commonly with a specific recommendation. Informed parents should then be free to choose from among permissible options. Potential treatments deemed ethically obligatory should be provided to the patient, even in the face of parental objection. The fundamental ethical work in neonatology and pediatrics is determining where on the I-P-O spectrum a treatment under consideration should be located. This should be determined by the prognosis for the patient with and without the treatment, the feasibility of providing the treatment, and consideration of all relevant rights and obligations. Location on the line is dynamic, and clinicians should be open to movement of a given treatment along the spectrum as new information, particularly regarding effectiveness, toxicity, and/or alternatives, becomes available. This framework provides a structure for ethical conversation and decision-making related to a specific patient, as well as in the formation of institutional and national guidelines.

Honoring the Good Parent Intentions of Courageous Parents: A Thematic Summary from a US-Based National Survey

BACKGROUND

Parents of children with complex medical needs describe an internal, personal definition of "trying to be a good parent" for their loved child. Gaps exist in the current "good parent concept" literature: (1) When the idea of "trying to be a good parent" comes into existence for parents, (2) How parents' definition of "being a good parent" may change over time and may influence interactions with the child, and (3) Whether parents perceive attainment of their personal definition.

AIM

The purpose of this study was to explore these current gaps in the "good parent concept" knowledge base from the perspective of parents of children with chronic or complex illness.

MATERIALS AND METHODS

These themes were explored through a 63-item, mixed-method web-based survey distributed by the Courageous Parents Network (CPN), an organization and online platform that orients, educates, and empowers families and providers caring for seriously ill children.

RESULTS

The term "trying to be a good parent" resonated with 85% of the 67 responding parents. For the majority of parents, the concept of "being a good parent" started to exist in parental awareness before the child's birth (70.2%) and evolved over time (67.5%) to include less judgment and more self-compassion. Parents identified their awareness of their child's prognosis and changing health as influential on their "trying to be a good parent" concept. Parental advocacy, child's age, and duration of illness were reported as influencing parental perceptions of having achieved their definition of "being a good parent".

CONCLUSIONS

Familiarity with parental perspectives on their parenting goodness and goals is a necessary core of family-centric health care.

Decision-Making for Children with Medical Complexity: The Role of the Primary Care Pediatrician

Families of children with medical complexity (CMC) face many types of health-related decisions. These decisions vary in magnitude of consequences, degree of risk, time scale, degree of tradeoffs, degree of uncertainty, degree of linkage with other decisions, and reversibility. There are many influences on decision-making, including evidence, hopes, and values. Primary care pediatricians are in a unique position to assist families of CMC with decision-making. Pediatric clinicians have an opportunity to establish a trusting relationship with a family over time and to understand the family's values, beliefs, and preferences during periods of relative health and stability. This allows primary care pediatricians to support families in decision-making by helping to clarify their values and goals and apply those values to the decision at hand. [Pediatr Ann. 2020;49(11):e473-e477.].

Caregiver Decisional Conflict Before and After Consultation About Gastrostomy Tube Placement

OBJECTIVES

Families describe decision-making about gastrostomy tube (g-tube) placement as challenging. We measured caregiver decisional conflict before and after initial g-tube consultation to evaluate the potential benefit of a decision aid and feasibility in testing it.

METHODS

Families presenting for initial consultation about g-tube placement completed the decisional conflict scale (DCS) at 1 or 2 of 3 time points: before consultation, after consultation, and after viewing a video. The decision support consultation was a 2-hour structured meeting with a pediatric hospitalist, nurse practitioner, and dietitian that was focused on clarifying the indication, feasibility, safety, and family values around tube placement. The video described decision-making and lived experiences of families with tube feeding.

RESULTS

We measured the decisional conflict of 61 caregivers. Preconsultation decisional conflict scores were high (mean = 38.7), but there was substantial variation between families (SD = 19.4). Baseline scores did not vary between clinically relevant subgroups. Postconsultation DCS scores were lower (17.9 and SD = 13.5 for consult alone; 12.7 and SD = 13.2 for consult with video). Three caregivers (7.7%) of families had residual decisional conflict scores >37.5, the threshold conventionally associated with decision delay.

CONCLUSIONS

Measuring decisional conflict among caregivers deciding about pediatric g-tube is feasible during the clinical encounter. Residual decisional conflict after our institution's current decision support consultation model (with or without an additional video) was low, so development of an additional structured decision aid is not warranted. Further study of preconsult DCS variability across different clinical subgroups may help identify families benefiting from additional decisional support.

Identifying as a Good Parent: Considering the Communication Theory of Identity for Parents of Children Receiving Palliative Care

Background: Parents of seriously ill children are at risk of psychosocial morbidity, which may be mitigated by competent family-centered communication and role-affirming conversations. Parent caregivers describe a guiding desire to do a good job in their parenting role but also depict struggling under the intense weight of parental duty. Objectives and Design: Through this case study, the Communication Theory of Identity (CTI) provides a framework for conceptualizing how palliative care teams can help parents cope with this reality. CTI views communication with care teams as formative in the development and enablement of parental perceptions of their "good parenting" role. Results: Palliative care teams may consider the four frames of identity (personal, enacted, relational, and communal) as meaningful dimensions of the parental pursuit to care well for an ill child. Conclusion: Palliative care teams may consider compassionate communication about parental roles to support the directional virtues of multilayered dynamic parental identity.

"Good-Parent Beliefs": Research, Concept, and Clinical Practice

Parents of ill children have willingly identified their personal beliefs about what they should do or focus on to fulfill their own internal definition of being a good parent for their child. This observation has led to the development of the good-parent beliefs concept over the past decade. A growing qualitative, quantitative, and mixed-methods research base has explored the ways that good-parent beliefs guide family decision-making and influence family relationships. Parents have expressed comfort in speaking about their good-parent beliefs. Whether parents achieve their unique good-parent beliefs definition affects their sense of whether they did a good job in their role of parenting their ill child. In this state-of-the-art article, we offer an overview of the good-parent beliefs concept over the past decade, addressing what is currently known and gaps in what we know, and explore how clinicians may incorporate discussions about the good-parent beliefs into clinical practice.

Historical Perspectives: Shared Decision Making in the NICU

The ethical dilemmas and predominant frameworks surrounding decision making for critically ill newborns have evolved substantially over the last 40 years. A shared decision-making approach is now favored, involving an exchange of information between parents and clinicians that emphasizes parental values and preferences, resulting in a personalized approach to decision making. In this review, we summarize the history of clinical decision making with a focus on the NICU, highlight different models of decision making, describe the advantages and current limitations of shared decision making, and discuss the ongoing and future challenges of decision making in the NICU amidst medical innovations and emerging technologies.