Hopes, Therapeutic Honesty, and Adaptation in the Midst of Dying and Death

Pediatric neuropalliative care

Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.

Ethical considerations in the management of infants with severe intraventricular hemorrhage

Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.

Personalized communication with parents of children born at less than 25 weeks: Moving from doctor-driven to parent-personalized discussions

Communication with parents is an essential component of neonatal care. For extremely preterm infants born at less than 25 weeks, this process is complicated by the substantial risk of mortality or major morbidity. For some babies with specific prognostic factors, the majority die. Although many of these deaths occur after admission to the intensive care unit, position statements have focused on communication during the prenatal consultation. This review takes a more comprehensive approach and covers personalized and parent-centered communication in the clinical setting during three distinct yet inter-related phases: the antenatal consultation, the neonatal intensive care hospitalization, and the dying process (when this happens). We advocate that a 'one-size-fits-all' communication model focused on standardizing information does not lead to partnerships. It is possible to standardize personalized approaches that recognize and adapt to parental heterogeneity. This can help clinicians and parents build effective partnerships of trust and affective support to engage in personalized decision-making. These practices begin with self-reflection on the part of the clinician and continue with practical frameworks and stepwise approaches supporting personalization and parent-centered communication.

Listening to Patients' Own Goals: A Key to Goals of Care Decisions in Cardiac Care

Cardiology spans the spectrum of patient care from the stable outpatient to acute preterminal inpatient. This article provides a narrative account of challenges, learnings, and experiences that we have used as a means to reflect on our own goals of care (GOC) conversations. We detail experiential and evidence-based insights on identifying and overcoming common GOC discussion barriers and building frameworks for effectively addressing patient interests and values through the course of medical care. Existing practices around advance care planning result in GOC discussions being postponed in favour of task-focused medical care and physicians avoiding these discussions out of a perceived lack of time. Physicians struggle to be flexible with existing care plans and in an effort to respect patient autonomy sometimes inappropriately relegate care decisions solely onto patients and families. Instead, we suggest conceiving of the GOC process as involving multiple conversations, taking time to get to know a patient and their personal priorities, sharing a patient's expected medical course when having GOC discussions, admitting prognostic uncertainty when it exists, giving patients and families the space to adjust to these discussions and remaining flexible with plans as a patient's health course fluctuates. Furthermore, our approach stresses being decisive and proactive in providing GOC recommendations when properly equipped to do so and enables recognition and recourse for patient-physician goal misalignment. In conclusion, we stress the importance of advising a treatment course that is responsive to patient considerations via practical communication strategies.