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Lenington K, Dudding KM, Fazeli PL, Dick T, Patrician P. Palliative Care in the Neonatal Intensive Care Unit: An Evolutionary Concept Analysis of Uncertainty in Anticipated Loss. Adv Neonatal Care 2024; 24:187-194. [PMID: 38241691 DOI: 10.1097/anc.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
BACKGROUND Although the concepts of uncertainty and anticipated loss have been explored in a variety of contexts, advances in genetic testing and life-sustaining technology rendered changes in the care of medically complex infants. The separate concepts no longer have the descriptive power to clarify new phenomena endured by parents in the changing neonatal landscape. A current concept analysis examining uncertainty in anticipated loss is necessary to generate knowledge concurrently with deviations observed in the neonatal intensive care unit. PURPOSE To explore the concept of uncertainty in anticipated loss among parents of infants with genetic disorders. METHODS Following Rodgers' method of concept analysis, the concept was named, surrogate terms, antecedents, attributes, and consequences were identified from the literature, and a model case was constructed. The databases CINAHL, PubMed, and PsycINFO were used to conduct the literature search. RESULTS Fifteen articles provided the data for this analysis. Uncertainty in anticipated loss is a complex, nonlinear, and multifaceted experience anteceded by an ultimately terminal diagnosis, an ambiguous prognosis, and a lack of clear knowledge to guide treatment. Its attributes include a loss of control, assumptive world remodeling, role/identity confusion, and prolonged emotional complexity that consequently leads to a cyclical pattern of positive and negative outcomes. IMPLICATIONS This newly defined concept empowers neonatal nurses to provide care that includes a holistic understanding of the experience of uncertainty in anticipated loss . Nurses are ideally positioned and have the responsibility to utilize this concept to become better advocates for infants and facilitators of parental wellness.
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Affiliation(s)
- Kathryn Lenington
- Author Affiliation: School of Nursing, The University of Alabama at Birmingham, Birmingham
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Callahan KP, Clayton EW, Lemke AA, Chaudhari BP, Wenger TL, Lyle ANJ, Brothers KB. Ethical and Legal Issues Surrounding Genetic Testing in the NICU. Neoreviews 2024; 25:e127-e138. [PMID: 38425196 PMCID: PMC10998684 DOI: 10.1542/neo.25-3-e127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Clinicians practicing in a modern NICU are noticing an increase in the proportion of patients who undergo genetic testing as well as changes in the types of genetic testing patients receive. These trends are not surprising given the increasing recognition of the genetic causes of neonatal illness and recent advances in genetic technology. Yet, the expansion of genetic testing in the NICU also raises a number of ethical questions. In this article, we will review the ethical issues raised by genetic testing, with a focus on the practical implications for neonatologists. First, we outline the complexities of measuring benefit, or utility, for neonatal genetic testing. Next, we discuss potential harms such as inequity, unexpected findings, disability biases, and legal risks. Finally, we conclude with a discussion of ethical issues related to consent for genetic testing. Throughout this article, we highlight solutions to challenges toward the ultimate goal of minimizing harms and maximizing the substantial potential benefits of genetic medicine in the NICU.
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Affiliation(s)
- Katharine P. Callahan
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
| | - Ellen W. Clayton
- Center for Biomedical Ethics and Society, Department of Pediatrics, Vanderbilt University Medical Center, and School of Law, Vanderbilt University, Nashville, Tennessee
| | - Amy A. Lemke
- Norton Children’s Research Institute Affiliated with the University of Louisville School of Medicine, Louisville, Kentucky
| | - Bimal P. Chaudhari
- Divisions of Neonatology, Genetics and Genomic Medicine, Steve and Cindy Rasmussen Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Tara L. Wenger
- Division of Medical Genetics, University of Washington, Seattle, Washington
| | - Allison N. J. Lyle
- Division of Neonatology, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
| | - Kyle B. Brothers
- Norton Children’s Research Institute Affiliated with the University of Louisville School of Medicine, Louisville, Kentucky
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Groden CM, Vetter CJ, Salih ZNI. Parental Experiences of Genetic Testing. Neoreviews 2024; 25:e151-e158. [PMID: 38425197 DOI: 10.1542/neo.25-3-e151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Genetic testing is increasingly used in clinical practice in the neonatal period, including in NICUs. This testing may have psychological consequences for parents. To best support families, neonatal clinicians should be aware of the various ways in which parents view and respond to genetic testing. In this review, we summarize research on the parental experience of having a newborn infant undergo genetic testing.
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Affiliation(s)
| | - Cecelia J Vetter
- Ruth Lily Medical Library, Indiana University School of Medicine, Indianapolis, IN
| | - Zeynep N I Salih
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN
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Layman AAK, Callahan KP, Nathanson P, Lechtenberg L, Hill D, Feudtner C. Simple Interventions for Pediatric Residents' Moral Distress: A Randomized, Controlled Experiment. Pediatrics 2023; 151:e2022060269. [PMID: 37153965 PMCID: PMC10416266 DOI: 10.1542/peds.2022-060269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric residents are at high risk for moral distress, knowing the moral or ethically right thing to do but feeling unable to do it, which is associated with poor patient care and burnout. Researchers have proposed numerous interventions to reduce distress, but few (if any) have been supported by experimental evidence. In this study, we used an experimental method to provide proof-of-concept evidence regarding the effect of various simple supports on pediatric residents' reported degree of moral distress. METHODS We conducted a study of pediatric residents using a split sample experimental design. The questionnaire contained 6 clinical vignettes describing scenarios expected to cause moral distress. For each case, participants were randomly assigned to see 1 of 2 versions that varied only regarding whether they included a supportive statement. After reading each of the 6 cases, participants reported their level of associated moral distress. RESULTS Two hundred and twenty respondents from 5 residency programs completed the experiment. Cases were perceived to represent common scenarios that cause distress for pediatric residents. The addition of a supportive statement reduced moral distress in 4 of the 6 cases. CONCLUSIONS In this proof-of-concept study, simple yet effective interventions provided support by offering the resident empathy and shared perspective or responsibility. Interventions that were purely informational were not effective in reducing moral distress.
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Affiliation(s)
| | - Katharine Press Callahan
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
| | | | | | - Douglas Hill
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
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Mueller R, Lee BM, Callahan KP. Managing Prognosis in Precision Medicine: Utility, Imagination, and Communication. CHILDREN 2023; 10:children10040664. [PMID: 37189913 DOI: 10.3390/children10040664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
Research on how physicians predict and communicate prognosis focuses primarily on end-of-life care. Unsurprisingly, as genomic technology gains traction as a prognostic tool, the focus has also been on terminality, with research focused on how genetic results may be used to terminate pregnancies or redirect care towards palliation for neonates. However, genomic results also have powerful impacts on how patients who live prepare for their futures. Genomic testing provides broad-reaching and early—albeit complex, uncertain, and shifting—prognostic information. In this essay, we argue that as genomic testing occurs earlier and increasingly in a screening context, researchers and clinicians must strive to understand and manage the prognostic implications of results. While our understanding of the psychosocial and communicational aspects of prognosis in symptomatic populations is incomplete, it has progressed further than our understanding in a screening context and therefore provides useful lessons and feasible opportunities for further research. By providing an interdisciplinary and inter-specialty perspective on the psychosocial and communicational aspects of prognosis in genetics, we discuss prognostication with respect to genetics from the neonatal period through adulthood, highlighting medical specialties and patient populations that are especially informative for considering the longitudinal management of prognostic information in genomic medicine.
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Affiliation(s)
- Rebecca Mueller
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA 19104, USA
- Masters Genetic Counseling Program, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Brittany M. Lee
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
- Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Katharine Press Callahan
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA 19104, USA
- Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Callahan KP, Radack J, Wojcik MH, Jenkins SM, Nye RT, Skraban C, Wild KT, Feudtner C. Hospital-level variation in genetic testing in children's hospitals' neonatal intensive care units from 2016 to 2021. Genet Med 2023; 25:100357. [PMID: 36521640 PMCID: PMC9991964 DOI: 10.1016/j.gim.2022.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE This study aimed to examine variation in genetic testing between neonatal intensive care units (NICUs) across hospitals over time. METHODS We performed a multicenter large-scale retrospective cohort study using NICU discharge data from the Pediatric Hospital Information System database between 2016 and 2021. We analyzed the variation in the percentage of NICU patients who had any genetic testing across hospitals and over time. We used a multivariable multilevel logistic regression model to investigate the potential association between patient characteristics and genetic testing. RESULTS The final analysis included 207,228 neonates from 38 hospitals. Overall, 13% of patients had at least 1 genetic test sent, although this varied from 4% to 50% across hospitals. Over the study period, the proportion of patients tested increased, with the increase disproportionately borne by hospitals already testing high proportions of patients. On average, patients who received genetic testing had higher illness severity. Controlling for severity, however, only minimally reduced the degree of hospital-level variation in genetic testing. CONCLUSION The percentage of NICU patients who undergo genetic testing varies among hospitals and increasingly so over time. Variation is largely unexplained by differences in severity between hospitals. The degree of variation suggests that clearer guidelines for NICU genetic testing are warranted.
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Affiliation(s)
- Katharine Press Callahan
- Division of Neonatology, Children's Hospital of Philadelphia Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Joshua Radack
- Division of Neonatology, Children's Hospital of Philadelphia Philadelphia, PA
| | - Monica H Wojcik
- Divisions of Newborn Medicine and Genetics and Genomics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Sabrina Malone Jenkins
- Division of Neonatology, Department of Pediatrics, School of Medicine, Health University of Utah, Salt Lake City, UT
| | - Russell T Nye
- Division of Neonatology, Children's Hospital of Philadelphia Philadelphia, PA
| | - Cara Skraban
- Division of Neonatology, Children's Hospital of Philadelphia Philadelphia, PA
| | | | - Chris Feudtner
- Division of Neonatology, Children's Hospital of Philadelphia Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Lantos J, Janvier A, Barrington K. Reply to Letter about whole genome sequencing in newborns. Hum Genet 2023; 142:165-166. [PMID: 36607419 DOI: 10.1007/s00439-022-02499-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/20/2022] [Indexed: 01/07/2023]
Affiliation(s)
- John Lantos
- JDL Consulting, Pleasantville, New York, USA
| | - Annie Janvier
- Centre Hospitalier Universitaire Sainte-Justine, 3175 Côte-Sainte-Catherine Road, Montréal, QC, H3T 1C5, Canada
| | - Keith Barrington
- Centre Hospitalier Universitaire Sainte-Justine, 3175 Côte-Sainte-Catherine Road, Montréal, QC, H3T 1C5, Canada
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Lynch F, Prentice T, Gillam L, Stark Z, Gyngell C. Rapid Genome Sequencing: Consent for New Technologies in the Neonatal Intensive Care Context. Pediatrics 2022; 150:190125. [PMID: 36443237 DOI: 10.1542/peds.2022-058222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2022] [Indexed: 11/30/2022] Open
Abstract
The clinical utility of rapid genome sequencing (rGS) in critically unwell infants has been consistently demonstrated, and there are calls for rGS to be implemented as a first-line test in the NICU. A diagnosis from rGS can enable rapid initiation of precision treatment, making it potentially lifesaving. However, in many patients rGS leads to the diagnosis of severe and life-limiting conditions, prompting discussion with families about withdrawal of life-sustaining treatment. The complexity of information about rGS, together with the heightened emotions of parents in the NICU, poses significant challenges for informed decision making in this context. We present a case where both parents are unable to provide informed consent, and the treating team must decide whether to proceed with rGS. Our discussion highlights the important differences between genome sequencing and other types of genetic testing, and the crucial role played by pre-test counseling in facilitating informed consent and preparing parents for a range of possible outcomes. We then discuss the consent paradigms at play in NICUs; whereas admission generally comes with an understanding that the treating team will perform interventions thought to be in the best interest of the child, rGS is substantially different because of its long-term implications for patients and family members. Finally, we look at the ethical interplay between parental consent and the interests of the child. We conclude by showing how cases like this are resolved at our tertiary center and how they may be resolved differently in future.
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Affiliation(s)
- Fiona Lynch
- Murdoch Children's Research Institute, Melbourne, Australia.,Melbourne Law School, The University of Melbourne, Melbourne, Australia
| | - Trisha Prentice
- Murdoch Children's Research Institute, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Lynn Gillam
- The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Zornitza Stark
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia.,Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia.,Australian Genomics Health Alliance, Melbourne, Australia
| | - Christopher Gyngell
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Australia.,Melbourne Law School, The University of Melbourne, Melbourne, Australia
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Callahan KP, Mueller R, Flibotte J, Largent EA, Feudtner C. Measures of Utility Among Studies of Genomic Medicine for Critically Ill Infants: A Systematic Review. JAMA Netw Open 2022; 5:e2225980. [PMID: 35947384 PMCID: PMC9366540 DOI: 10.1001/jamanetworkopen.2022.25980] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Genomic medicine holds promise to revolutionize care for critically ill infants by tailoring treatments for patients and providing additional prognostic information to families. However, measuring the utility of genomic medicine is not straightforward and has important clinical and ethical implications. OBJECTIVE To review the ways that researchers measure or neglect to measure the utility of genomic medicine for critically ill infants. EVIDENCE REVIEW This systematic review included prospective full-text studies of genomic medicine of both whole exome and genome sequencing in critically ill infants younger than 1 year. PubMed, Embase, Scopus, and Cochrane Library databases, the Cochrane Database of Systematic Reviews, and the ClinicalTrials.gov register were searched with an English language restriction for articles published from the inception of each database through May 2022. Search terms included variations of the following: gene, sequencing, intensive care, critical care, and infant. From the included articles, information on how utility was defined and measured was extracted and synthesized. Information was also extracted from patient cases that authors highlighted by providing additional information. Spearman rank-order correlation was used to evaluate the association between study size and utility. FINDINGS Synthesized data from the 21 included studies reflected results from 1654 patients. A mean of 46% (range, 15%-72%) of patients had a positive genetic test result, and a mean of 37% (range, 13%-61%) met the criteria for experiencing utility. Despite heterogeneity in how studies measured and reported utility, a standardized framework was created with 5 categories of utility: treatment change, redirection of care, prognostic information, reproductive information, and screening or subspecialty referral. Most studies omitted important categories of utility, notably personal utility (patient-reported benefits) (20 studies [95%]), utility of negative or uncertain results (15 [71%]), and disutility (harms) (20 [95%]). Studies disproportionally highlighted patient cases that resulted in treatment change. Larger studies reported substantially lower utility (r = -0.65; P = .002). CONCLUSIONS AND RELEVANCE This systematic review found that genomic medicine offered various categories of utility for a substantial proportion of critically ill infants. Studies measured utility in heterogeneous ways and focused more on documenting change than assessing meaningful benefit. Authors' decisions about which cases to highlight suggest that some categories of utility may be more important than others. A more complete definition of utility that is used consistently may improve understanding of potential benefits and harms of genetic medicine.
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Affiliation(s)
- Katharine Press Callahan
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rebecca Mueller
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - John Flibotte
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emily A. Largent
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Chris Feudtner
- The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Callahan KP, Feudtner C. Genetic Testing Is Messier in Practice than in Theory: Lessons from Neonatology. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:37-39. [PMID: 35089833 PMCID: PMC8936853 DOI: 10.1080/15265161.2021.2013978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Katharine Press Callahan
- The Children's Hospital of Philadelphia; Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
| | - Chris Feudtner
- The Children's Hospital of Philadelphia; Philadelphia, Pennsylvania
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
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