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Lamb CM, Ramer K, Amodu O, Groenenboom K. The meaning of dying and death for children, their carers, and families: a scoping review. BMC Palliat Care 2023; 22:194. [PMID: 38044451 PMCID: PMC10694886 DOI: 10.1186/s12904-023-01295-1] [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: 04/01/2023] [Accepted: 10/23/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND The meaning of dying and death are underexplored concepts for Canadian children. Subsequently, it is unclear how children and stakeholders make meaning of children's holistic health needs at the end of life. METHODS A scoping review of the international scholarly literature was conducted. Thirteen data sources were searched to search the scholarly literature without date limits until January 2022. Studies were included on the basis of population: children (aged 0-19 years), families and caregivers; setting (in Canada and end-of-life or dying phases of living) and concepts of interest (dying and death). RESULTS Of the 7377 studies identified, 12 were included for data extraction and content thematic analysis. The themes and subthemes include: 1) valuing the whole person; 2) living while dying; 3) authentic death talk; 4) a supportive approach (with lack and presence of support as subthemes); and, 5) a personalist approach. CONCLUSIONS There is a pressing need for research into the meaning of dying and death for children, their carers and families in Canada. Lack of holistic care, authentic death talk, specialized pediatric palliative care providers, a personalist approach and communities of support present major gaps in care for Canadian children. Research is urgently needed to address these knowledge gaps to generate policy and support practice for dying children in Canada.
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Affiliation(s)
- Christina M Lamb
- St. Michael's College, University of Toronto, Toronto, ON, Canada, 81 St. Mary Street, M5S 1J4.
- Athabasca University, Athabasca, AB, Canada.
| | - Kianna Ramer
- Stollery Children's Hospital, Edmonton, AB, Canada
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Schembs L, Racine E, Shevell M, Jox RJ. Physicians' attitudes towards ethical issues and end-of-life decision-making for pediatric patients with unresponsive wakefulness syndrome: An international survey. Dev Med Child Neurol 2023; 65:1646-1655. [PMID: 36758014 DOI: 10.1111/dmcn.15540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023]
Abstract
AIM We examined physicians' perspectives on the mental capabilities of pediatric patients with unresponsive wakefulness syndrome (UWS) and their attitudes towards limiting life-sustaining treatment (LST) in an international context. METHOD A questionnaire survey was conducted among 267 neuropediatricians, practicing in 65 countries. Comparisons were made according to the Human Development Index (HDI) of the countries. The Idler Index of Religiosity was applied to determine religiosity. RESULTS Participants from countries with a very high HDI were generally more favorable to limiting LST (p < 0.001), specifically cardiopulmonary resuscitation (p = 0.021), intubation/ventilation (p = 0.014), hemodialysis/hemofiltration (p < 0.001), and antibiotic therapy (p < 0.001). Treatment costs that were too high had a weaker influence on their decisions (p < 0.001). Participants who found it never ethically justifiable to limit LST had a higher mean Idler Index of private (p = 0.001) and general (p = 0.020) religiosity and were less satisfied with treatment decisions (p < 0.001) and the communication during the process (p = 0.016). INTERPRETATION The perspectives towards limiting LST for pediatric patients with UWS are markedly different between physicians from countries with very high and lower HDIs.
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Affiliation(s)
- Leah Schembs
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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3
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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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George LS, Epstein RM, Akincigil A, Saraiya B, Trevino KM, Kuziemski A, Pushparaj L, Policano E, Prigerson HG, Godwin K, Duberstein P. Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis. J Gen Intern Med 2023; 38:1516-1525. [PMID: 36732436 PMCID: PMC10160244 DOI: 10.1007/s11606-022-08011-4] [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] [Received: 09/12/2022] [Accepted: 12/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized. OBJECTIVE Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others. METHODS Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings. RESULTS The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. CONCLUSIONS Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kendra Godwin
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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5
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Stoesslein S, Gramm JD, Bender HU, Müller P, Rabenhorst D, Borasio GD, Führer M. "More life and more days"-patient and care characteristics in a specialized acute pediatric palliative care inpatient unit. Eur J Pediatr 2023; 182:1847-1855. [PMID: 36795188 PMCID: PMC10167193 DOI: 10.1007/s00431-023-04813-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/30/2022] [Accepted: 01/06/2023] [Indexed: 02/17/2023]
Abstract
UNLABELLED Only a few acute hospital inpatient units dedicated to pediatric palliative care (PPC) patients exist today. Clinical data on the patients and care provided at specialized acute PPC inpatient units (PPCUs) are scarce. This study aims at describing patient and care characteristics on our PPCU to learn about the complexity and relevance of inpatient PPC. A retrospective chart analysis was performed on the 8-bed PPCU of the Center for Pediatric Palliative Care of the Munich University Hospital, including demographic, clinical, and treatment characteristics (487 consecutive cases; 201 individual patients; 2016-2020). Data were analyzed descriptively; the chi-square test was used for comparisons. Patients' age (1-35.5 years, median: 4.8 years) and length of stay (1-186 days, median 11 days) varied widely. Thirty-eight percent of patients were admitted repeatedly (range 2-20 times). Most patients suffered from neurological diseases (38%) or congenital abnormalities (34%); oncological diseases were rare (7%). Patients' predominant acute symptoms were dyspnea (61%), pain (54%), and gastrointestinal symptoms (46%). Twenty percent of patients suffered from > 6 acute symptoms, 30% had respiratory support incl. invasive ventilation, 71% had a feeding tube, and 40% had full resuscitation code. In 78% of cases, patients were discharged home; 11% died on the unit. CONCLUSION This study shows the heterogeneity, high symptom burden, and medical complexity of the patients on the PPCU. The high dependency on life-sustaining medical technology points to the parallelism of life-prolonging and palliative treatments that is typical for PPC. Specialized PPCUs need to offer care at the intermediate care level in order to respond to the needs of patients and families. WHAT IS KNOWN • Pediatric patients in outpatient PPC or hospices present with a variety of clinical syndromes and different levels of complexity and care intensity. • There are many children with life-limiting conditions (LLC) in hospitals, but specialized PPC hospital units for these patients are rare and poorly described. WHAT IS NEW • Patients on a specialized PPC hospital unit show a high symptom burden and a high level of medical complexity, including dependency on medical technology and frequent full resuscitation code. • The PPC unit is mainly a place for pain and symptom management as well as crisis intervention, and needs to be able to offer treatment at the intermediate care level.
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Affiliation(s)
- Sophie Stoesslein
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Julia D Gramm
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Hans-Ulrich Bender
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.,Pediatric Palliative Care, Department of Pediatrics, Bern University Hospital, Bern, Switzerland
| | - Petra Müller
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Dorothee Rabenhorst
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany
| | - Gian Domenico Borasio
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monika Führer
- Center for Pediatric Palliative Care, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Marchioninistraße 15, Munich, 81377, Germany.
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Alexander D, Quirke MB, Berry J, Eustace-Cook J, Leroy P, Masterson K, Healy M, Brenner M. Initiating technology dependence to sustain a child's life: a systematic review of reasons. JOURNAL OF MEDICAL ETHICS 2022; 48:1068-1075. [PMID: 34282042 PMCID: PMC9726963 DOI: 10.1136/medethics-2020-107099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/13/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Decision-making in initiating life-sustaining health technology is complex and often conducted at time-critical junctures in clinical care. Many of these decisions have profound, often irreversible, consequences for the child and family, as well as potential benefits for functioning, health and quality of life. Yet little is known about what influences these decisions. A systematic review of reasoning identified the range of reasons clinicians give in the literature when initiating technology dependence in a child, and as a result helps determine the range of influences on these decisions. METHODS Medline, EMBASE, CINAHL, PsychINFO, Web of Science, ASSIA and Global Health Library databases were searched to identify all reasons given for the initiation of technology dependence in a child. Each reason was coded as a broad and narrow reason type, and whether it supported or rejected technology dependence. RESULTS 53 relevant papers were retained from 1604 publications, containing 116 broad reason types and 383 narrow reason types. These were grouped into broad thematic categories: clinical factors, quality of life factors, moral imperatives and duty and personal values; and whether they supported, rejected or described the initiation of technology dependence. The majority were conceptual or discussion papers, less than a third were empirical studies. Most discussed neonates and focused on end-of-life care. CONCLUSIONS There is a lack of empirical studies on this topic, scant knowledge about the experience of older children and their families in particular; and little written on choices made outside 'end-of-life' care. This review provides a sound basis for empirical research into the important influences on a child's potential technology dependence.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Mary Brigid Quirke
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Jay Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | | | - Piet Leroy
- Pediatric Intensive Care Unit & Pediatric Procedural Sedation Unit, Maastricht UMC+, Maastricht, The Netherlands
| | - Kate Masterson
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Martina Healy
- Paediatric Intensive Care, Our Lady's Hospital Crumlin, Crumlin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Zhong Y, Cavolo A, Labarque V, Gastmans C. Physician decision-making process about withholding/withdrawing life-sustaining treatments in paediatric patients: a systematic review of qualitative evidence. BMC Palliat Care 2022; 21:113. [PMID: 35751075 PMCID: PMC9229823 DOI: 10.1186/s12904-022-01003-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background With paediatric patients, deciding whether to withhold/withdraw life-sustaining treatments (LST) at the end of life is difficult and ethically sensitive. Little is understood about how and why physicians decide on withholding/withdrawing LST at the end of life in paediatric patients. In this study, we aimed to synthesise results from the literature on physicians’ perceptions about decision-making when dealing with withholding/withdrawing life-sustaining treatments in paediatric patients. Methods We conducted a systematic review of empirical qualitative studies. Five electronic databases (Pubmed, Cinahl®, Embase®, Scopus®, Web of Science™) were exhaustively searched in order to identify articles published in English from inception through March 17, 2021. Analysis and synthesis were guided by the Qualitative Analysis Guide of Leuven. Results Thirty publications met our criteria and were included for analysis. Overall, we found that physicians agreed to involve parents, and to a lesser extent, children in the decision-making process about withholding/withdrawing LST. Our analysis to identify conceptual schemes revealed that physicians divided their decision-making into three stages: (1) early preparation via advance care planning, (2) information giving and receiving, and (3) arriving at the final decision. Physicians considered advocating for the best interests of the child and of the parents as their major focus. We also identified moderating factors of decision-making, such as facilitators and barriers, specifically those related to physicians and parents that influenced physicians’ decision-making. Conclusions By focusing on stakeholders, structure of the decision-making process, ethical values, and influencing factors, our analysis showed that physicians generally agreed to share the decision-making with parents and the child, especially for adolescents. Further research is required to better understand how to minimise the negative impact of barriers on the decision-making process (e.g., difficult involvement of children, lack of paediatric palliative care expertise, conflict with parents). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-01003-5.
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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, 3000, Leuven, Belgium.
| | - Alice Cavolo
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
| | - Veerle Labarque
- Centre for Molecular and Vascular Biology, Faculty of Medicine, KU Leuven/UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Kapucijnenvoer 35, block D, box 7001, 3000, Leuven, Belgium
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Carr K, Hasson F, McIlfatrick S, Downing J. Parents' experiences of initiation of paediatric advance care planning discussions: a qualitative study. Eur J Pediatr 2022; 181:1185-1196. [PMID: 34783898 PMCID: PMC8897342 DOI: 10.1007/s00431-021-04314-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
Advance care planning enables parents to discuss their goal and wishes for the future treatment and care of their life-limited or life-threatened child. Whilst research has identified the barriers clinicians face to initiate such discussions, the views of the parents have received scant attention. This qualitative study, using reflexive thematic analysis, aimed to explore parents' experience of the initiation of their child's advance care planning discussions, to help provide an understanding to inform future practice. Single interviews were undertaken with 17 non-bereaved and bereaved parents. Parents reported they had engaged with future thinking but needed time before initiating this with clinicians. They identified the need for a trusted professional and time for private, thorough, non-judgemental discussion without feeling clinicians were 'giving up'. Parents reported that advance care planning discussions were not always aligned to the dynamics of family life. They felt that health professionals were responsible for initiating advance planning conversations according to the families' individual requirements. There was an apparent lack of standardised protocols to assist paediatric advance care planning discussion initiation.Conclusion: Initiating advance care planning is a complicated process that needs to be tailored to the specific parent and child situation. Health professionals need to appreciate that parents are key contributors to initiate engagement with advance care planning discussions but that they also require support and care, recognising this may facilitate the building of trust, identified as a key corner stone, of paediatric advance care planning initiation and engagement. What is Known: • In paediatric palliative care, parents are challenged with wanting to sustain hope whilst thinking and planning for their child's end of life. Paediatric advance care planning discussions are often delayed or avoided and triggered by physical deterioration. What is New: • Previous relationship with HCP not essential but parental trust of the HCP is fundamental to Paediatric advance care planning initiation engagement. To build mutual trust health professionals' approach needs to be professional, respectful and empathetic to the parent and child's situation. • Subtle paediatric advance care planning parent initiation preparation by HCP is often unnoticed by parents but may be the crux of empowering parents to initiate advance care planning conversations themselves as they need to feel a sense of regaining control before planning ahead.
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Affiliation(s)
- Karen Carr
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road , Newtownabbey, BT37 0QB, UK.
| | - Felicity Hasson
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road , Newtownabbey, BT37 0QB UK
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, School of Nursing, Ulster University, Shore Road , Newtownabbey, BT37 0QB UK
| | - Julia Downing
- International Children’s Palliative Care Network, Bristol, UK ,Makerere University Uganda, Kampala, Uganda
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Alexander D, Eustace-Cook J, Brenner M. Approaches to the initiation of life-sustaining technology in children: A scoping review of changes over time. J Child Health Care 2021; 25:509-522. [PMID: 32966106 DOI: 10.1177/1367493520961884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is understood about the dynamic circumstances within which the initiation of technology dependence takes place in children. The aim of this scoping review was to identify the influences on the initiation of technology dependence and the issues that require further exploration and consideration. Scientific literature that directly or indirectly discussed the initiation of technology dependence in children was identified. A three-stage screening process of title and abstract scrutiny, full-text scanning and in-depth full-text reading resulted in 63 relevant articles from 1133 initially reviewed. These were then subjected to descriptive and thematic analysis. Articles ranged from the 1970s to the present, reflecting the evolution of ethical debates around the approaches to clinical practice and changes in cultural and societal attitudes. Three themes emerged: how technology alters the meaning of futile care, dissonance in the perspectives of decision makers and increasing support for joint decision-making. Only articles in English and predominantly from the clinician's rather than the patient's perspective were included. Societal and cultural factors as well as the structural, financial and cultural environment influence the initiation of technology dependence in children. However, to what extent these overt and implicit influences guide decision-makers in this field remains largely unknown.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, 8809Trinity College Dublin, Ireland
| | | | - Maria Brenner
- School of Nursing and Midwifery, 8809Trinity College Dublin, Ireland
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Ewuoso C, Hall S, Dierickx K. How do healthcare professionals respond to ethical challenges regarding information management? A review of empirical studies. Glob Bioeth 2021; 32:67-84. [PMID: 33897255 PMCID: PMC8023626 DOI: 10.1080/11287462.2021.1909820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim This study is a systematic review that aims to assess how healthcare professionals manage ethical challenges regarding information within the clinical context. Method and Materials We carried out searches in PubMed, Google Scholar and Embase, using two search strings; searches generated 665 hits. After screening, 47 articles relevant to the study aim were selected for review. Seven articles were identified through snowballing, and 18 others were included following a system update in PubMed, bringing the total number of articles reviewed to 72. We used a Q-sort technique for the analysis of identified articles. Findings This study reveals that healthcare professionals around the world generally employ (to varying degrees) four broad strategies to manage different types of challenges regarding information, which can be categorized as challenges related to confidentiality, communication, professional duty, and decision-making. The strategies employed for managing these challenges include resolution, consultation, stalling, and disclosure/concealment. Conclusion There are a variety of strategies which health professionals can adopt to address challenges regarding information management within the clinical context. This insight complements current efforts aimed at enhancing health professional-patient communication. Very few studies have researched the results of employing these various strategies. Future empirical studies are required to address this. Abbreviations CIOMS: Council of International Organization of Medical Sciences; WHO: World Health Organization; AMA: American Medical Association; WMA: World Medical Association; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis; ISCO: International Standard Classification of Occupations; ILO: International Labour Office; SPSS: The Statistical Package for the Social Sciences
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Affiliation(s)
| | - Susan Hall
- Center for Applied Ethics, Stellenbosch University, Western-Cape, South Africa
| | - Kris Dierickx
- Centre for Biomedical Ethics and Law, Katholieke Universiteit Leuven, Leuven, Belgium
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Sasazuki M, Sakai Y, Kira R, Toda N, Ichimiya Y, Akamine S, Torio M, Ishizaki Y, Sanefuji M, Narama M, Itai K, Hara T, Takada H, Kizawa Y, Ohga S. Decision-making dilemmas of paediatricians: a qualitative study in Japan. BMJ Open 2019; 9:e026579. [PMID: 31431444 PMCID: PMC6707677 DOI: 10.1136/bmjopen-2018-026579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To delineate the critical decision-making processes that paediatricians apply when treating children with life-threatening conditions and the psychosocial experience of paediatricians involved in such care. DESIGN We conducted semistructured, individual face-to-face interviews for each participant from 2014 to 2015. The content of each interview was subjected to a comprehensive qualitative analysis. The categories of dilemma were extracted from a second-round content analysis. PARTICIPANTS Participants were board-certified paediatricians with sufficient experience in making decisions in relation to children with severe illnesses or disabilities. We repeated purposive sampling and analyses until we reached saturation of the category data. RESULTS We performed interviews with 15 paediatricians. They each reported both unique and overlapping categories of dilemmas that they encountered when making critical decisions. The dilemmas included five types of causal elements: (1) paediatricians' convictions; (2) the quest for the best interests of patients; (3) the quest for medically appropriate plans; (4) confronting parents and families and (5) socioenvironmental issues. Dilemmas occurred and developed as conflicting interactions among these five elements. We further categorised these five elements into three principal domains: the decision-maker (decider); consensus making among families, colleagues and society (process) and the consequential output of the decision (consequence). CONCLUSIONS This is the first qualitative study to demonstrate the framework of paediatricians' decision-making processes and the complex structures of dilemmas they face. Our data indicate the necessity of establishing and implementing an effective support system for paediatricians, such as structured professional education and arguments for creating social consensus that assist them to reach the best plan for the management of severely ill children.
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Affiliation(s)
- Momoko Sasazuki
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Health and Welfare, Seinan Jogakuin University, Kitakyushu, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryutaro Kira
- Department of Pediatric Neurology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Naoko Toda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuko Ichimiya
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoshi Akamine
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Michiko Torio
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshito Ishizaki
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Sanefuji
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Miho Narama
- Department of Nursing, Kyoto Tachibana University, Kyoto, Japan
| | - Koichiro Itai
- Department of Bio/Medical Ethics, Interdisciplinary Graduate School of Medicine and Veterinary Medicine, University of Miyazaki, Miyazaki, Japan
| | - Toshiro Hara
- President, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hidetoshi Takada
- Department of Child Health, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Stuart B, Danaher T, Awdish R, Berry L. Finding Hope and Healing When Cure Is Not Possible. Mayo Clin Proc 2019; 94:677-685. [PMID: 30922692 DOI: 10.1016/j.mayocp.2019.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/03/2018] [Accepted: 01/09/2019] [Indexed: 01/30/2023]
Abstract
Traditional medical training focused on curing disease may not prepare clinicians to provide comfort and solace to their patients facing life-limiting illness. But dying patients and their families still need healing, and clinicians can actively facilitate it. We explore the clinician's role in the healing journey through the lens of pediatric brain cancer. Specifically, we examine how clinicians can help affected families find their way from "focused hope" (which centers on cure) to "intrinsic hope," which offers a more realistic and resilient emotional foundation as the child's death approaches and letting go becomes essential. Drawing on their clinical experience and medical knowledge, clinicians can help families comprehend the lessons that their seriously ill child's body has to teach, highlighting the importance of cherishing the present and creating new memories that outlast the disease. Clinicians can avoid the mindset of "nothing more can be done," emphasizing that there is plenty to do in providing physical, emotional, and spiritual comfort. Clinicians can learn how to be "unconditionally present" for patients and families without immersing themselves in anguish and, eventually, how to help the family find freedom from despair and a full life that still honors the child's memory.
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Affiliation(s)
- Brad Stuart
- Coalition to Transform Advanced Care, Washington, DC.
| | - Tracey Danaher
- Department of Marketing, Monash University, Melbourne, Australia
| | - Rana Awdish
- Department of Pulmonary and Critical Care Medicine, Wayne State University School of Medicine, Detroit, MI
| | - Leonard Berry
- Mays Business School, Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Boston, MA
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Schneider K, Metze B, Bührer C, Cuttini M, Garten L. End-of-Life Decisions 20 Years after EURONIC: Neonatologists' Self-Reported Practices, Attitudes, and Treatment Choices in Germany, Switzerland, and Austria. J Pediatr 2019; 207:154-160. [PMID: 30772016 DOI: 10.1016/j.jpeds.2018.12.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/07/2018] [Accepted: 12/31/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess changes in attitudes of neonatologists regarding the care of extremely preterm infants and parental involvement over the last 20 years. STUDY DESIGN Internet-based survey (2016) involving 170 tertiary neonatal intensive care units in Austria, Switzerland, and Germany using the European Project on Parents' Information and Ethical Decision Making in Neonatal Intensive Care Units questionnaire (German edition) with minor modifications to the original survey from 1996 to 1997. RESULTS The 2016 survey included 104 respondents (52.5% response rate). In 2016, significantly more neonatologists reported having ever withheld intensive care treatment (99% vs 69%) and withdrawn mechanical ventilation (96% vs 61%) or life-saving drugs (99% vs 79%), compared with neonatologists surveyed in 1996-1997. Fewer considered limiting intensive care as a slippery slope possibly leading to abuse (18% vs 48%). In the situation of a deteriorating clinical condition despite all treatment, significantly more neonatologists would ask parental opinion about continuation of intensive care (49% vs 18%). In 2016, 21% of German neonatologists would resuscitate a hypothetical infant at the limits of viability, even against parental wishes. CONCLUSIONS Withholding or withdrawing intensive care for extremely preterm infants at the limits of viability with parental involvement has become more acceptable than it was 20 years ago. However, resuscitating extremely preterm infants against parental wishes remains an option for up to one-fifth of the responding neonatologists in this survey.
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Affiliation(s)
- Katja Schneider
- Department of Neonatology, GFO Kliniken Bonn, Bonn, Germany.
| | - Boris Metze
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Lars Garten
- Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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