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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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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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Edwards JD, Williams EP, Wagman EK, McHale BL, Malone CT, Kernie SG. A Single-Centered Randomized Controlled Trial of Primary Pediatric Intensivists and Nurses. J Intensive Care Med 2022; 37:1580-1586. [PMID: 35350919 DOI: 10.1177/08850666221090421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: For long-stay patients (LSP) in pediatric intensive care units (PICU), frequently rotating providers can lead to ineffective information sharing and retention, varying goals and timelines, and delayed decisions, likely contributing to prolonged admissions. Primary intensivists (one physician serves as a consistent resource for the patient/family and PICU providers) and primary nurses (a small team of PICU nurses provide consistent bedside care) seek to augment usual transitory PICU care, by enhancing continuity and, potentially, decreasing length of stay (LOS). Methods: A single-centered, partially blinded randomized controlled trial of primary intensivists and nurses versus usual care. PICU patients admitted for or expected to be admitted for >10 days and who had ≥1 complex chronic condition were eligible. A block randomization with 1:1 allocation was used. The primary outcome was PICU LOS. Multiple secondary outcomes were explored. Results: Two hundred LSPs were randomized-half to receive primaries and half to usual care. The two groups were not significantly different in their baseline and admission characteristics. LSPs randomized to receive primaries had a shorter, but non-significant, mean LOS than those randomized to usual care (32.5 vs. 37.1 days, respectively, p = .19). Compared to LSPs in the usual care group, LSPs in the primary group had fewer unplanned intubations. Among LSPs that died, DNR orders were more prevalent in the primary group. Other secondary outcome and balance metrics were not significantly different between the two groups. Conclusion: Primary intensivists and nurses may be an effective strategy to counteract transitory PICU care and serve the distinctive needs of LSPs. However, additional studies are needed to determine the ways and to what extent they may accomplish this.
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Affiliation(s)
- Jeffrey D Edwards
- Section of Pediatric Critical Care, Department of Pediatrics, 21611Columbia University Vagelos College of Physician and Surgeons, New York, New York, USA
| | - Erin P Williams
- Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York, USA.,21611Columbia University Vagelos College of Physician and Surgeons, New York, New York, USA
| | - Elizabeth K Wagman
- Emory College of Arts and Sciences, 1371Emory University, Atlanta, Georgia, USA
| | - Brittany L McHale
- 25065NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Caryn T Malone
- 25065NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Steven G Kernie
- 25065NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
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Edwards JD, Jia H, Baird JD. The impact of eligibility for primary attendings and nurses on PICU length of stay. J Crit Care 2020; 62:145-150. [PMID: 33383307 DOI: 10.1016/j.jcrc.2020.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/02/2020] [Accepted: 12/11/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine whether primary attendings and/or nurses impact pediatric intensive care unit (PICU) length of stay (LOS) in long-stay patients (LSP). MATERIALS AND METHODS Retrospective observational cross-sectional study from 2012 to 2016 of 29,170 LSP (LOS ≥ 10 days) admitted to 64 PICUs that participated in the Virtual Pediatric Systems, LLC. Generalized linear mixed models were used to examine the association between being eligible for primary practices and LOS. Secondary outcomes of proportions of limitations and withdrawal of aggressive, life-sustaining interventions were also explored. RESULTS After controlling for several factors, being eligible for primary nurses and for primary attendings and nurses were associated with significantly lower mean LOS (8.9% and 9.7% lower, respectively), compared to not being eligible for any primary practice. Being eligible for primary attendings was associated with significantly higher mean LOS (9.6% higher). When the primary attendings were used for larger proportions of LSP, the practice was associated with significantly lower mean LOS. Limitations and withdrawal of aggressive interventions were more common in LSPs cared for in PICUs that utilized primary attendings. CONCLUSIONS The findings of lower LOS in LSP who were eligible for primary practices should induce more rigorous research on the impact of these primary practices.
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Affiliation(s)
- Jeffrey D Edwards
- Division of Critical Care and Hospital Medicine, Department of Pediatrics, Columbia University Valegos College of Physicians and Surgeons, Morgan Stanley Children's Hospital, 3959 Broadway, New York, NY 10032, USA.
| | - Haomiao Jia
- School of Nursing, Columbia University, 617 West 168th Street, New York, NY 10032, USA; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
| | - Jennifer D Baird
- Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA.
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Experience in Rehabilitation Medicine Affects Prognosis and End-of-Life Decision-Making of Neurologists: A Case-Based Survey. Neurocrit Care 2020; 31:125-134. [PMID: 30607828 PMCID: PMC6611059 DOI: 10.1007/s12028-018-0661-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Outcome predictions in patients with acute severe neurologic disorders are difficult and influenced by multiple factors. Since the decision for and the extent of life-sustaining therapies are based on the estimated prognosis, it is vital to understand which factors influence such estimates. This study examined whether previous professional experience with rehabilitation medicine influences physician decision-making. Methods A case vignette presenting a typical patient with an extensive brain stem infarction was developed and distributed online to clinical neurologists. Questions focused on prognosis, interpretation of an advanced directive, whether to withdraw life-sustaining treatments and information on prior rehabilitation experience from the survey respondent. Results Of the participating neurologists, 77% opted for the withdrawal of life-sustaining therapies (n = 70; response rate: 14.8%). This decision was not affected by age, gender, or length of clinical experience. Neurologists with experience in rehabilitation medicine tended to estimate a more positive prognosis than neurologists without, but this result was not significant (p = .13). There was an association between the intervention chosen and previous experience in rehabilitation; neurologists with experience in rehabilitation medicine opted significantly more often (31.8%) for continuing life-sustaining treatments than neurologists without such experience (8.7%, p = .04). Conclusion Our results indicate that there are subjective factors influencing decisions to limit life-sustaining treatments that are based on previous professional experience. This finding emphasizes the variability and cognitive bias of such decision processes and should be integrated into future guidelines for specialist training on end-of-life decision-making.
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Masri C, Farrell CA, Lacroix J, Rocker G, Shemie SD. Decision Making and End-of-Life Care in Critically Ill Children. J Palliat Care 2019. [DOI: 10.1177/082585970001601s09] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives 1) To comment on the medical literature on decision making regarding end-of-life therapy, 2) to analyze the data on disagreement about such therapy, including palliative care, and withholding and withdrawal practices for critically ill children in the pediatric intensive care unit (PICU), and 3) to make some general recommendations. Data Sources and Study Selection All papers published in peer-reviewed journals, and all chapters on end-of-life therapy, or on conflict between parents and caregivers about end-of-life decisions in the PICU were retrieved. Results We found three case series, three systematic descriptive studies, two qualitative studies, four surveys, and many legal opinions, editorials, reviews, guidelines, and book chapters. The main determinants of end-of-life decisions are the child's age, premorbid cognitive condition and functional status, pain or discomfort, probability of survival, and quality of life. Risk factors in persistent conflict between parents and caregivers about end-of-life care include a grave underlying condition or an unexpected and severe event. Conclusion Making decisions about end-of-life care is a frequent event in the PICU. Children may need both intensive care and palliative care concurrently at different stages of their illness. Disagreements are more likely to be resolved if the root cause of the conflict is better understood.
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Affiliation(s)
- Christian Masri
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Catherine Ann Farrell
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Jacques Lacroix
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Graeme Rocker
- Department of Medicine, The Queen Elizabeth II Health Center, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Sam D. Shemie
- Pediatric Intensive Care Unit, The Hospital For Sick Children, and Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Ho KM, Liang J. Withholding and Withdrawal of Therapy in New Zealand Intensive Care Units (ICUs): A Survey of Clinical Directors. Anaesth Intensive Care 2019; 32:781-6. [PMID: 15648988 DOI: 10.1177/0310057x0403200609] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Withdrawing and withholding life-support therapy in patients who are unlikely to survive despite treatment are common practices in intensive care units (ICUs). The literature suggests there is a large variation in practice between different ICUs in different parts of the world. We conducted a postal survey among all public ICUs in New Zealand to investigate the pattern of practice in withholding and withdrawal of therapy. Nineteen ICUs responded to this survey and they represented 74% of all the public ICU beds and 83% of the annual ICU admissions. The percentage of ICU admissions with therapy withdrawn or withheld was less than 10% in most ICUs. Only a small percentage (21%) of ICUs had a formal policy in withholding and withdrawal of therapy. The timing of making the decision to withhold or withdraw therapy was very variable. The patient and/or the family, the primary medical team consultant, two or more ICU consultants, and ICU nurses were usually involved in the decision making process. ICU nurses were more commonly involved in the decision making process in smaller ICUs (5 beds vs 10 beds, P=0.03). The patient's pre-ICU quality of life, medical comorbidities, predicted mortality, predicted post-ICU quality of life, and the family's wishes were important factors in deciding whether ICU therapy would be withheld or withdrawn. Hospice ward or the patient's home was the preferred place for palliative care in 32% of the responses.
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Affiliation(s)
- K M Ho
- Department of Anaesthesia and Intensive Care, North Shore Hospital, Auckland 1309, New Zealand
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Wosinski B, Newman CJ. Physicians' attitudes when faced with life-threatening events in children with severe neurological disabilities. Dev Neurorehabil 2019; 22:61-66. [PMID: 29648486 DOI: 10.1080/17518423.2018.1461946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Children with severe neurological disabilities are at an increased risk of acute, life-threatening events. We assessed physicians' attitudes when making decisions in these situations. METHODS We surveyed physicians in pediatric intensive care, neurology, and rehabilitation units in Swiss hospitals. The questionnaire explored participants' attitudes toward life-threatening situations in two scenarios: a child with profound intellectual and multiple disabilities (PIMD) and an infant with spinal muscular atrophy (SMA) type I. RESULTS The participation rate was 55% (52/95). There was a consensus favoring non-invasive ventilation and comfort care as well as avoiding tracheostomy and invasive ventilation. For the child with PIMD, 61% of participants opposed cardiopulmonary resuscitation (CPR), 51% for the child with SMA. Physicians with over 20 years of experience were significantly more opposed to providing CPR than less experienced colleagues. CONCLUSIONS Physicians held different views, influenced by personal factors. This highlights the importance of standardizing multidisciplinary processes toward approaching these complex situations.
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Affiliation(s)
- Benjy Wosinski
- a Paediatrics department , Lausanne University Hospital , Lausanne , Switzerland
| | - Christopher J Newman
- b Paediatric Neurology and Neurorehabilitation Unit , Lausanne University Hospital , Lausanne , Switzerland
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Hansen TWR, Aasland O, Janvier A, Førde R. Physician characteristics influence the trends in resuscitation decisions at different ages. Acta Paediatr 2018; 107:2115-2119. [PMID: 29570850 DOI: 10.1111/apa.14326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/08/2018] [Accepted: 03/15/2018] [Indexed: 11/29/2022]
Abstract
AIM We examined how physicians in different medical specialties would evaluate treatment decisions for vulnerable patients in need of resuscitation. METHODS A survey depicting six acutely ill patients from newborn infant to aged, all in need of resuscitation with similar prognoses, was distributed (in 2009) to a representative sample of 1650 members of the Norwegian Medical Association and 676 members of the Norwegian Pediatric Association. RESULTS There were 1335 respondents (57% participation rate). The majority of respondents across all specialties thought resuscitation was in the best interest of a 24 weeks' gestation preterm infant and would resuscitate the patient, but would also accept palliative care on the family's demand. Accepting a family's refusal of resuscitation was more common for the newborn infants. Specialists were overall similar in their answers, but specialty, age and gender were associated with different answers for the patients at both ends of the age spectrum. CONCLUSION Resuscitation decisions for the very young do not always seem to follow the best interest principle. Specialty and personal characteristics still have an impact on how we consider important ethical issues. We must be cognisant of our own valuations and how they may influence care.
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Affiliation(s)
- Thor Willy Ruud Hansen
- Division of Paediatric and Adolescent Medicine and Clinical Ethics Committee; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; Faculty of Medicine; University of Oslo; Oslo Norway
| | - Olaf Aasland
- The Institute for Studies of the Medical Profession; University of Oslo; Oslo Norway
- Institute of Health and Society; Faculty of Medicine; Center for Medical Ethics; University of Oslo; Oslo Norway
| | - Annie Janvier
- Division of Neonatology and Centre de Recherche; Department of Pediatrics; Université de Montréal; CHU Sainte-Justine; Montréal QC Canada
- Bureau de l’Éthique Clinique; Université de Montréal; Montréal QC Canada
- Unité D’éthique Clinique; Unité de Soins Palliatifs; Unité de Recherche en Éthique Clinique et Partenariat Famille; Hôpital Sainte-Justine; Montréal QC Canada
| | - Reidun Førde
- Institute of Health and Society; Faculty of Medicine; Center for Medical Ethics; University of Oslo; Oslo Norway
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Abstract
OBJECTIVES To evaluate hospital-level variability in resource utilization and mortality in children with new leukemia who require ICU support, and identify factors associated with variation. DESIGN Retrospective cohort study. SETTING Children's hospitals contributing to the Pediatric Health Information Systems administrative database from 1999 to 2011. PATIENTS Inpatients less than 25 years old with newly diagnosed acute lymphocytic leukemia or acute myeloid leukemia requiring ICU support (n = 1,754). INTERVENTIONS, MEASUREMENTS, AND MAIN RESULTS Evaluated exposures included leukemia type, year of diagnosis, and hospital-wide proportion of patients with public insurance. The main outcome was hospital mortality. Wide variability existed in the ICU resources used across hospitals. Combined acute lymphocytic leukemia and acute myeloid leukemia mortality varied by hospital from 0% (95% CI, 0-14.8%) to 42.9% (95% CI, 17.7-71.1%). A mixed-effects model with a hospital-level random effect suggests significant variation across hospitals in mortality (p = 0.007). When including patient and hospital factors as fixed effects into the model, younger age, acute myeloid leukemia versus acute lymphocytic leukemia diagnosis, leukemia diagnosis prior to 2005, hospital-wide proportion of public insurance patients, and hospital-level proportion of leukemia patients receiving ICU care are significantly associated with mortality. The variation across hospitals remains significant with all patient factors included (p = 0.021) but is no longer significant after adjusting for the hospital-level factors proportion of public insurance and proportion receiving ICU care (p = 0.48). CONCLUSIONS Wide hospital-level variability in ICU resource utilization and mortality exists in the care of children with leukemia requiring ICU support. Hospital payer mix is associated with some mortality variability. Additional study into how ICU support could be standardized through clinical practice guidelines, impact of payer mix on hospital resources allocation to the ICU, and subsequent impact on patient outcomes is warranted.
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Professional Responsibility, Consensus, and Conflict: A Survey of Physician Decisions for the Chronically Critically Ill in Neonatal and Pediatric Intensive Care Units. Pediatr Crit Care Med 2017; 18:e415-e422. [PMID: 28658198 DOI: 10.1097/pcc.0000000000001247] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe neonatologist and pediatric intensivist attitudes and practices relevant to high-stakes decisions for children with chronic critical illness, with particular attention to physician perception of professional duty to seek treatment team consensus and to disclose team conflict. DESIGN Self-administered online survey. SETTING U.S. neonatal ICUs and PICUs. SUBJECTS Neonatologists and pediatric intensivists. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We received 652 responses (333 neonatologists, denominator unknown; 319 of 1,290 pediatric intensivists). When asked about guiding a decision for tracheostomy in a chronically critically ill infant, only 41.7% of physicians indicated professional responsibility to seek a consensus decision, but 73.3% reported, in practice, that they would seek consensus and make a consensus-based recommendation; the second most common practice (15.5%) was to defer to families without making recommendations. When presented with conflict among the treatment team, 63% of physicians indicated a responsibility to be transparent about the decision-making process and reported matching practices. Neonatologists more frequently reported a responsibility to give decision making fully over to families; intensivists were more likely to seek out consensus among the treatment team. CONCLUSIONS ICU physicians do not agree about their responsibilities when approaching difficult decisions for chronically critically ill children. Although most physicians feel a professional responsibility to provide personal recommendations or defer to families, most physicians report offering consensus recommendations. Nearly all physicians embrace a sense of responsibility to disclose disagreement to families. More research is needed to understand physician responsibilities for making recommendations in the care of chronically critically ill children.
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Hirschi R, Rommel C, Hawryluk GWJ. Should we have a guard against therapeutic nihilism for patients with severe traumatic brain injury? Neural Regen Res 2017; 12:1801-1803. [PMID: 29239321 PMCID: PMC5745829 DOI: 10.4103/1673-5374.219037] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Ryan Hirschi
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Casey Rommel
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Gregory W J Hawryluk
- Department of Neurological Surgery, University of Utah, Clinical Neurosciences Center, Salt Lake City, UT, USA
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13
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Grosek S, Orazem M, Kanic M, Vidmar G, Groselj U. Attitudes of Slovene paediatricians to end-of-life care. J Paediatr Child Health 2016; 52:278-83. [PMID: 26515146 DOI: 10.1111/jpc.13006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2015] [Indexed: 11/27/2022]
Abstract
AIMS The aims of this study were to assess the attitudes of Slovene paediatricians to aspects of end-of-life (EOL) care and compare these attitudes between paediatric intensivists, paediatric specialists and paediatric residents. METHODS We performed a cross-sectional survey, using a specifically designed 43-item anonymous questionnaire. RESULTS We included 323 out of 586 Slovene paediatricians and residents, while 46.7% (151 of 323) of them responded to our questionnaire. More than half of intensivists (54.2%) had sought counsel from the Committee for Medical Ethics in the past as compared with 12.0% and 12.1% of specialists and residents, respectively (P < 0.001). The decision to limit life-sustaining treatment (LST) was found to be ethically acceptable in all groups of respondents. The highest level of agreement was found in residents (90.2%), followed by 83.3% among intensivists and 73.8% among specialists (P = not statistically significant (NS)). Disagreement with termination of hydration was highest among residents (85%) and intensivists (79.2%) while it was lower among specialists (66.7%) (P = NS). Patient's best interest, good clinical practice and patient's autonomous decision were graded as the top three aspects of the EOL care, while cost effectiveness and availability of patient's bed in intensive care were the least important. CONCLUSIONS The decision to limit LST measures was found to be ethically acceptable for Slovene paediatricians. No major differences were found among paediatric intensivists, specialist paediatricians and paediatric residents in the attitudes towards the EOL care.
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Affiliation(s)
- Stefan Grosek
- Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Orazem
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Kanic
- Department for Rhythmology, Heartcenter Leipzig, Leipzig, Germany
| | - Gaj Vidmar
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Medical Department, University Rehabilitation Institute of the Republic of Slovenia, Ljubljana, Slovenia
| | - Urh Groselj
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
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15
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Samsel C, Lechner BE. End-of-life care in a regional level IV neonatal intensive care unit after implementation of a palliative care initiative. J Perinatol 2015; 35:223-8. [PMID: 25341197 DOI: 10.1038/jp.2014.189] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/28/2014] [Accepted: 09/02/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We hypothesized that the implementation of a neonatal palliative care initiative will result in improved markers of end-of-life care. STUDY DESIGN A retrospective and prospective chart review of neonatal intensive care unit deaths was performed for 24 months before, 16 months during and 24 months after the implementation of palliative care provider education and practice guidelines (n=106). Ancillary care, redirection of care, palliative medication usage and outcome meetings in the last 48 h of life and basic demographic data were compared between epochs. Parametric and nonparametric analysis was performed. RESULT There was an increase in redirection of care and palliative medication usage and a decrease in variability of use of end-of-life interventions (P=0.012, 0.022 and <0.001). CONCLUSION The implementation of a neonatal palliative care initiative was associated with increases in palliative interventions for neonates in their final 48 h of life, suggesting that such an initiative may enhance end-of-life care.
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Affiliation(s)
- C Samsel
- 1] Department of Neonatology, Women and Infants Hospital, Providence, RI, USA [2] Triple Board Residency Program, Brown University and Rhode Island Hospitals, Providence, RI, USA
| | - B E Lechner
- 1] Department of Neonatology, Women and Infants Hospital, Providence, RI, USA [2] Warren Alpert Medical School of Brown University, Providence, RI, USA
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Maude SL, Fitzgerald JC, Fisher BT, Li Y, Huang YS, Torp K, Seif AE, Kavcic M, Walker DM, Leckerman KH, Kilbaugh TJ, Rheingold SR, Sung L, Zaoutis TE, Berg RA, Nadkarni VM, Thomas NJ, Aplenc R. Outcome of pediatric acute myeloid leukemia patients receiving intensive care in the United States. Pediatr Crit Care Med 2014; 15:112-20. [PMID: 24366507 PMCID: PMC4407366 DOI: 10.1097/pcc.0000000000000042] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Children with acute myeloid leukemia are at risk for sepsis and organ failure. Outcomes associated with intensive care support have not been studied in a large pediatric acute myeloid leukemia population. Our objective was to determine hospital mortality of pediatric acute myeloid leukemia patients requiring intensive care. DESIGN Retrospective cohort study of children hospitalized between 1999 and 2010. Use of intensive care was defined by utilization of specific procedures and resources. The primary endpoint was hospital mortality. SETTING Forty-three children's hospitals contributing data to the Pediatric Health Information System database. PATIENTS Patients who are newly diagnosed with acute myeloid leukemia and who are 28 days through 18 years old (n = 1,673) hospitalized any time from initial diagnosis through 9 months following diagnosis or until stem cell transplant. A reference cohort of all nononcology pediatric admissions using the same intensive care resources in the same time period (n = 242,192 admissions) was also studied. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One-third of pediatric patients with acute myeloid leukemia (553 of 1,673) required intensive care during a hospitalization within 9 months of diagnosis. Among intensive care admissions, mortality was higher in the acute myeloid leukemia cohort compared with the nononcology cohort (18.6% vs 6.5%; odds ratio, 3.23; 95% CI, 2.64-3.94). However, when sepsis was present, mortality was not significantly different between cohorts (21.9% vs 19.5%; odds ratio, 1.17; 95% CI, 0.89-1.53). Mortality was consistently higher for each type of organ failure in the acute myeloid leukemia cohort versus the nononcology cohort; however, mortality did not exceed 40% unless there were four or more organ failures in the admission. Mortality for admissions requiring intensive care decreased over time for both cohorts (23.7% in 1999-2003 vs 16.4% in 2004-2010 in the acute myeloid leukemia cohort, p = 0.0367; and 7.5% in 1999-2003 vs 6.5% in 2004-2010 in the nononcology cohort, p < 0.0001). CONCLUSIONS Pediatric patients with acute myeloid leukemia frequently required intensive care resources, with mortality rates substantially lower than previously reported. Mortality also decreased over the time studied. Pediatric acute myeloid leukemia patients with sepsis who required intensive care had a mortality comparable to children without oncologic diagnoses; however, overall mortality and mortality for each category of organ failure studied was higher for the acute myeloid leukemia cohort compared with the nononcology cohort.
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Affiliation(s)
- Shannon L Maude
- 1Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA. 2Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 3Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 4Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 5Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA. 6Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA. 7Bristol-Myers Squibb, Hopewell, NJ. 8Division of Haematology/Oncology and Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada. 9Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 10Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Sciences, Penn State Hershey Milton S. Hershey Medical Center, Hershey, PA
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Determination of neurologic prognosis and clinical decision making in adult patients with severe traumatic brain injury: a survey of Canadian intensivists, neurosurgeons, and neurologists. Crit Care Med 2013; 41:1086-93. [PMID: 23385104 DOI: 10.1097/ccm.0b013e318275d046] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Accurate prognostic information in patients with severe traumatic brain injury remains limited, but mortality following the withdrawal of life-sustaining therapies is high and variable across centers. We designed a survey to understand attitudes of physicians caring for patients with severe traumatic brain injury toward the determination of prognosis and clinical decision making on the level of care. DESIGN, SETTING, AND PARTICIPANTS We conducted a cross-sectional study of intensivists, neurosurgeons, and neurologists that participate in the care of patients with severe traumatic brain injury at all Canadian level 1 and level 2 trauma centers. INTERVENTION None. MEASUREMENTS The main outcome measure was physicians' perceptions of prognosis and recommendations on the level of care. MAIN RESULTS Our response rate was 64% (455/712). Most respondents (65%) reported that an accurate prediction of prognosis would be most helpful during the first 7 days. Most respondents (>80%) identified bedside monitoring, clinical exam, and imaging to be useful for evaluating prognosis, whereas fewer considered electrophysiology tests (<60%) and biomarkers (<15%). In a case-based scenario, approximately one-third of respondents agreed, one-third were neutral, and one-third disagreed that the patient prognosis would be unfavorable at one year. About 10% were comfortable recommending withdrawal of life-sustaining therapies. CONCLUSIONS A significant variation in perceptions of neurologic prognosis and in clinical decision making on the level of care was found among Canadian intensivists, neurosurgeons, and neurologists. Improved understanding of the factors that can accurately predict prognosis for patients with traumatic brain injury is urgently needed.
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Ruppe MD, Feudtner C, Hexem KR, Morrison WE. Family factors affect clinician attitudes in pediatric end-of-life decision making: a randomized vignette study. J Pain Symptom Manage 2013; 45:832-40. [PMID: 23017620 DOI: 10.1016/j.jpainsymman.2012.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/08/2012] [Accepted: 05/14/2012] [Indexed: 11/23/2022]
Abstract
CONTEXT Conflicts between families and clinicians in pediatric end-of-life (EOL) care cause distress for providers, dissatisfaction for patients' families, and potential suffering for terminally ill children. OBJECTIVES We hypothesized that family factors might influence clinician decision making in these circumstances. METHODS We presented vignettes concerning difficult EOL decision making, randomized for religious objection to therapy withdrawal and perceived level of family involvement, to clinicians working in three Children's Hospital intensive care units. Additionally, attitudes about EOL care were assessed. RESULTS Three hundred sixty-four respondents completed the questionnaire, for an overall response rate of 54%. Respondents receiving the "involved family" vignette were more likely to agree to continue medical care indefinitely (P<0.0005). Respondents were marginally more likely to pursue a court-appointed guardian for those patients whose families had nonreligious objections to withdrawal (P=0.05). Respondents who thought that a fear of being sued affected decisions were less likely to pursue unilateral withdrawal (odds ratio 0.8, 95% CI=0.6-0.9). Those who felt personal distress as a result of difficult EOL decision making, thought they often provided "futile" care, or those who felt EOL care was effectively addressed at the institution were less likely to want to defer to the parents' wishes (range of odds ratios 0.7-1). CONCLUSION In this randomized vignette study, we have shown that family factors, particularly how involved a family seems to be in a child's life, affect what clinicians think is ethically appropriate in challenging EOL cases. Knowledge of how a family's degree of involvement may affect clinicians should be helpful to the clinical ethics consultants and offer some degree of insight to the clinicians themselves.
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Affiliation(s)
- Michael D Ruppe
- Division of Critical Care Medicine, University of Louisville, Louisville, Kentucky, USA
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The luck of the draw: physician-related variability in end-of-life decision-making in intensive care. Intensive Care Med 2013; 39:1128-32. [DOI: 10.1007/s00134-013-2871-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 02/02/2013] [Indexed: 10/27/2022]
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20
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Influence of personal preferences for life-sustaining treatment on medical decision making among pediatric intensivists*. Crit Care Med 2012; 40:2464-9. [DOI: 10.1097/ccm.0b013e318255d85b] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Carnevale FA, Farrell C, Cremer R, Canoui P, Séguret S, Gaudreault J, de Bérail B, Lacroix J, Leclerc F, Hubert P. Struggling to do what is right for the child: pediatric life-support decisions among physicians and nurses in France and Quebec. J Child Health Care 2012; 16:109-23. [PMID: 22247181 DOI: 10.1177/1367493511420184] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study examined (a) how physicians and nurses in France and Quebec make decisions about life-sustaining therapies (LSTs) for critically ill children and (b) corresponding ethical challenges. A focus groups design was used. A total of 21 physicians and 24 nurses participated (plus 9 physicians and 13 nurses from a prior secondary analysis). Principal differences related to roles: French participants regarded physicians as responsible for LST decisions, whereas Quebec participants recognized parents as formal decision-makers. Physicians stated they welcomed nurses' input but found they often did not participate, while nurses said they wanted to contribute but felt excluded. The LST limitations were based on conditions resulting in long-term consequences, irreversibility, continued deterioration, inability to engage in relationships and loss of autonomy. Ethical challenges related to: the fear of making errors in the face of uncertainty; struggling with patient/family consequences of one's actions; questioning the parental role and dealing with relational difficulties between physicians and nurses.
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Durall A, Zurakowski D, Wolfe J. Barriers to conducting advance care discussions for children with life-threatening conditions. Pediatrics 2012; 129:e975-82. [PMID: 22392177 DOI: 10.1542/peds.2011-2695] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Advance care discussions (ACD) occur infrequently or are initiated late in the course of illness. Although data exist regarding barriers to ACD among the care of adult patients, few pediatric data exist. The goal of this study was to identify barriers to conducting ACD for children with life-threatening conditions. METHODS Physicians and nurses from practice settings where advance care planning typically takes place were surveyed to collect data regarding their attitudes and behaviors regarding ACD. RESULTS A total of 266 providers responded to the survey: 107 physicians and 159 nurses (54% response rate). The top 3 barriers were: unrealistic parent expectations, differences between clinician and patient/parent understanding of prognosis, and lack of parent readiness to have the discussion. Nurses identified lack of importance to clinicians (P = .006) and ethical considerations (P < .001) as impediments more often than physicians. Conversely, physicians believed that not knowing the right thing to say (P = .006) was more often a barrier. There are also perceived differences among specialties. Cardiac ICU providers were more likely to report unrealistic clinician expectations (P < .001) and differences between clinician and patient/parent understanding of prognosis (P = .014) as common barriers to conducting ACD. Finally, 71% of all clinicians believed that ACD happen too late in the patient's clinical course. CONCLUSIONS Clinicians perceive parent prognostic understanding and attitudes as the most common barriers to conducting ACD. Educational interventions aimed at improving clinician knowledge, attitudes, and skills in addressing these barriers may help health care providers overcome perceived barriers.
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Affiliation(s)
- Amy Durall
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Boston, Massachusetts 02115, USA.
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Joffe AR, Carcillo J, Anton N, deCaen A, Han YY, Bell MJ, Maffei FA, Sullivan J, Thomas J, Garcia-Guerra G. Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent. Philos Ethics Humanit Med 2011; 6:17. [PMID: 22206616 PMCID: PMC3313846 DOI: 10.1186/1747-5341-6-17] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 12/29/2011] [Indexed: 05/20/2023] Open
Abstract
Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD.
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Affiliation(s)
- Ari R Joffe
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital; Edmonton Clinic Health Academy 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
- John Dossetor Health Ethics Center, University of Alberta, Edmonton, Alberta, Canada
| | - Joe Carcillo
- Department of Pediatrics and Critical Care Medicine, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, 400 45th Street, Pittsburgh, PA, 15201, USA
| | - Natalie Anton
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital; Edmonton Clinic Health Academy 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Allan deCaen
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital; Edmonton Clinic Health Academy 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Yong Y Han
- Department of Pediatrics & Communicable Diseases, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Michael J Bell
- Department of Pediatrics and Critical Care Medicine, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, 400 45th Street, Pittsburgh, PA, 15201, USA
| | - Frank A Maffei
- Department of Pediatrics, Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
| | - John Sullivan
- Department of Pediatrics, Pediatric Critical Care Medicine, Janet Weis Children's Hospital, Geisinger Medical Center, 100 N. Academy Ave, Danville, PA, 17822, USA
- Golisano Children's Hospital at Strong, University of Rochester School of Medicine, 601 Elmwood Avenue, Rochester, NY 15642, USA
| | - James Thomas
- Department of Pediatrics, University of Texas, Southwestern Medical Center; 5323 Harry Hines Blvd, Dallas, Texas, 75390-9063, USA
| | - Gonzalo Garcia-Guerra
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital; Edmonton Clinic Health Academy 11405-87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
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Bodensteiner JB, Ng YT. Ethical considerations in paediatric neurology: neuromuscular disease and epilepsy. J Paediatr Child Health 2011; 47:599-602. [PMID: 21951440 DOI: 10.1111/j.1440-1754.2011.02159.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The pace of developing technology with respect to many diagnostic tests, as well as available treatments including artificial ventilation, may have progressed at a faster rate than our ethical, humane ability to decide on the optimal choices for our patients. In fact, who should make these choices; physicians or patients and families? Certain ethical aspects of neuromuscular disorders and epilepsy are reviewed. For neuromuscular disease, the example of Duchenne muscular dystrophy (DMD) with regards to genetic testing, relatively early wheelchair placement and individualised invasive ventilation is discussed. In epilepsy, performing neurosurgery in severely impaired children is probably appropriate in some cases if desired by the family. Financial and human costs restrict therapies and testing for epilepsy as well as other neurological and medical diseases. Whether it is ethical to consider costs in medical treatment or not, it is certainly a reality.
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Affiliation(s)
- John B Bodensteiner
- Division of Pediatric Neurology, Barrow Neurological Institute/St. Joseph's Children's Health Center, Phoenix, Arizona, United States
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Gresiuk CS, Joffe AR. Variability in the pediatric intensivists' threshold for withdrawal/limitation of life support as perceived by bedside nurses: a multicenter survey study. Ann Intensive Care 2011; 1:31. [PMID: 21906385 PMCID: PMC3224498 DOI: 10.1186/2110-5820-1-31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 08/08/2011] [Indexed: 11/11/2022] Open
Abstract
Background We hypothesized that bedside nurses perceive significant variability in the pediatric intensivist thresholds for approaching a family about withdrawal/limitation of life-sustaining therapy. Methods All nurses working in four university-affiliated medical-surgical pediatric intensive care units staffed by 11, 7, 6, and 5 intensivists with 36, 18, 10, and 8 beds were sent three mailings of a survey asking questions about intensivist decisions for withdrawal/limitation of life-sustaining therapy. Responses were tabulated; chi-square compared results among centers; a p < 0.05 after Bonferroni correction was significant. Results The response rate was 205 of 415 (49%); 152 of 205 (74%) disagreed with the statement that each of the intensivists had the same threshold for approaching a family to suggest withdrawal/limitation of life-sustaining therapy, with no significant difference between centers. Also, 110 of 205 (54%) and 119 of 205 (58%) disagreed with the statement that each intensivist has the same threshold of the patient's chance for survival or projected quality of life when making a decision to withdraw/limit life-sustaining therapy with no significant difference between centers. The threshold to suggest withdraw/limit life-sustaining therapy based on chance of survival or projected quality of life differs between intensivists by at least 10% according to 113 of 184 (61%) and 121 of 184 (66%) nurses; the two larger centers had significantly higher difference among intensivists for projected quality of life. Fifty-five of 200 (27%) disagreed with the statement that they would have equal confidence in each intensivist accepting a recommendation for withdrawal/limitation of life-sustaining therapy for their own child, with no difference between centers. Conclusions Bedside pediatric intensive care unit nurses in this multicenter Canadian study perceive wide variability in intensivist thresholds for approaching a family to suggest withdrawal/limitation of life-sustaining therapy.
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Affiliation(s)
- Colleen S Gresiuk
- University of Alberta, Stollery Children's Hospital, 8440 112 Street, Edmonton, Alberta, T6G 2B7, Canada.
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Abstract
BACKGROUND Research in medicine has shown that physicians have difficulty estimating the probability that a patient has a condition on the basis of available diagnostic evidence. They consistently undervalue baseline information about the patient relative to test information and are poor intuitive calculators of probability. The authors could not locate in the literature any studies of diagnostic probability estimates from baseline information and test data for dentists. METHODS Using two vignettes that contained different baseline information, dental students and clinical faculty members estimated the probability that the described hypothetical patient had the condition in question. Respondents also commented on the project. CONCLUSIONS Both groups of respondents overemphasized the importance of test evidence relative to baseline information, although experienced practitioners did so to a lesser extent than did students. Respondents, especially practitioners, expressed resistance to performing a diagnostic task that required precise estimates of probability. CLINICAL IMPLICATIONS Dentists appear to estimate diagnostic probabilities in an intuitive fashion, but they do so imprecisely. Clinical experience provides some protection against the bias of overestimating test evidence compared with baseline information. These findings raise questions about how practitioners use probability estimates and whether other models also may play a role. The incorporation of information from evidence-based dentistry into practice requires better understanding.
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Gresiuk C, Joffe A. Variability in the Pediatric Intensivists’ Threshold for Withdrawal/Limitation of Life Support as Perceived by Bedside Nurses. THE JOURNAL OF CLINICAL ETHICS 2009. [DOI: 10.1086/jce200920404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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The Practice of and Documentation on Withholding and Withdrawing Life Support: A Retrospective Study in Two Dutch Intensive Care Units. Anesth Analg 2009; 109:841-6. [DOI: 10.1213/ane.0b013e3181acc64a] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Extracorporeal life support for support of children with malignancy and respiratory or cardiac failure: The extracorporeal life support experience*. Crit Care Med 2009; 37:1308-16. [DOI: 10.1097/ccm.0b013e31819cf01a] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
O estudo teve por objetivo descrever os antecedentes, atributos e conseqüências do conceito de morte digna da criança. Utilizou-se a estratégia de análise de conceito para avaliar os 40 artigos, tendo como foco publicações nas áreas médica e de enfermagem, que estudaram ou focalizaram a morte digna da criança. Os atributos do conceito de morte digna da criança incluem: qualidade de vida, cuidado centrado na criança e na família, conhecimento específico sobre cuidados paliativos, decisão compartilhada, alívio do sofrimento da criança, comunicação clara, relacionamento de ajuda e ambiente acolhedor. Poucos artigos trazem a definição de morte digna da criança e, quando isso ocorre, essa definição é vaga e, muitas vezes, ambígua entre os vários autores. Esse aspecto indica que o conceito ainda não é consistentemente definido, demandando estudos de sua manifestação na prática clínica, contribuindo com os cuidados no final da vida em pediatria.
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Baverstock A, Finlay F. What can we learn from the experiences of consultants around the time of a child's death? Child Care Health Dev 2008; 34:732-9. [PMID: 18959570 DOI: 10.1111/j.1365-2214.2008.00875.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To describe how paediatric consultants report dealing with child and neonatal deaths as part of their daily work. BACKGROUND Paediatric consultants are involved with children and their families facing death through illness. This study focused on consultant's involvement around the time of death including: decision making and its associated difficulties, talking to parents and the use of coping strategies. Consultants with more than 5 years experience were asked what experience has taught them and consultants with less that 5 years experience were asked what they felt was the biggest change from being a registrar. METHODS Following Multicentre Research Ethics Committee (MREC) approval a pre-piloted self-administered questionnaire (with one reminder) was sent to 100 of the paediatric consultants within the South West Region. RESULTS There was a 61% response rate. Most consultants had experienced a variety of opinions when talking to parents about when to withdraw or withhold life sustaining treatment. Uncertainty (39%) and disagreement (44%) made decision making difficult. Discussion with colleagues (41%), 'honesty and time with parents' (28%) and planning or 'stage managing' talking with parents (38%) were well used strategies to deal with this. New consultants find responsibility and decision making the biggest change from being a registrar. CONCLUSIONS We can learn much from the experiences of consultants around the time of a child's death. Their approach during resuscitation and withdrawal or withholding life sustaining treatment describes many strategies that have been developed to ease the often complex decision-making process. Although consultants have built up personal support networks and individual coping strategies many recognize that these are not all encompassing and some harbour unresolved feelings of grief. Enabling health professionals to genuinely care, 'giving oneself totally yet preserving oneself totally' remains a challenge.
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Affiliation(s)
- A Baverstock
- Community Child Health Department, Newbridge Hill, Bath, UK.
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Devictor D, Latour JM, Tissières P. Forgoing life-sustaining or death-prolonging therapy in the pediatric ICU. Pediatr Clin North Am 2008; 55:791-804, xiii. [PMID: 18501766 DOI: 10.1016/j.pcl.2008.02.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Most deaths in the pediatric intensive care unit occur after a decision to withhold or withdraw life-sustaining treatments. The management of children at the end of life can be divided into three steps. The first concerns the decision-making process. The second concerns the actions taken once a decision has been made to forego life-sustaining treatments. The third regards the evaluation of the decision and its implementation. The mission of pediatric intensive care has expanded to provide the best possible care to dying children and their families. Improving the quality of care received by dying children remains an ongoing challenge for every pediatric intensive care unit team member.
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Affiliation(s)
- Denis Devictor
- Pediatric Intensive Care, Hôpital de Bicêtre, AP-HP, Department of Research on Ethics, Paris-Sud 11 University, Bicêtre 94275, France.
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Byrne CM, Solomon MJ, Young JM, Selby W, Harrison JD. Patient preferences between surgical and medical treatment in Crohn's disease. Dis Colon Rectum 2007; 50:586-97. [PMID: 17380368 DOI: 10.1007/s10350-006-0847-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Crohn's disease poses difficult choices in which the most appropriate treatment option is not always obvious. When this state of uncertainty exists, patients' preferences should have an increasingly important part of clinical decision making. The purpose of this study was to compare patients' preferences for surgical intervention in Crohn's disease with the preferences of surgeons and gastroenterologists. METHODS Outpatients with Crohn's disease were interviewed to quantify their preferences for six scenarios by using the prospective preference measure. An identical questionnaire was mailed to all Australian and New Zealand colorectal surgeons and a random sample of 300 Australian gastroenterologists. RESULTS Forty-one of 123 patients with Crohn's disease (33 percent), 92 of 127 colorectal surgeons (72 percent), and 74 of 272 gastroenterologists (27 percent) participated. There were significant differences between patients and gastroenterologists for three of six scenarios and between surgeons and gastroenterologists in four of six scenarios. Seventy-six percent of gastroenterologists were willing to gamble to avoid an ileocolic resection compared with 37 percent of surgeons (chi-squared = 25.44; P < 0.0001) and 39 percent of patients (chi-squared = 15.44; P < 0.001). CONCLUSIONS Patients and clinicians were able to trade and gamble life expectancy as a measure of preference for varying hypothetical surgical treatments, even though these treatment options impacted on quality of life rather than survival. Patients' preferences did not align with clinicians. For most scenarios, colorectal surgeons' preferences were significantly different to those of gastroenterologists.
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Affiliation(s)
- Christopher M Byrne
- Surgical Outcomes Research Centre (SOuRCe), Sydney South West Area Health Service & University of Sydney, P.O. Box M157, Missenden Road, NSW, 2050, Sydney, Australia
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Truog RD, Meyer EC, Burns JP. Toward interventions to improve end-of-life care in the pediatric intensive care unit. Crit Care Med 2007; 34:S373-9. [PMID: 17057601 DOI: 10.1097/01.ccm.0000237043.70264.87] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although children account for only about 3% of all deaths that occur in the United States each year, these patients and their families have needs that are uniquely different from those of adult patients. To date, however, no research on interventions to improve end-of-life care in the pediatric intensive care unit (PICU) has been performed. This review seeks to facilitate and inform future interventional studies by summarizing existing descriptive data about end-of-life care in this setting. These data are organized around six domains that have been identified as critical to high-quality, family-centered care: 1) support of the family unit; 2) communication with the child and family about treatment goals and plans; 3) ethics and shared decision making; 4) relief of pain and other symptoms; 5) continuity of care; and 6) grief and bereavement support. These data are integrated and used to develop evidence-based suggestions for a variety of interventions that could be implemented and then evaluated for their potential contribution to improving the care of children dying in the PICU.
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Affiliation(s)
- Robert D Truog
- Medical Ethics, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Up to 60% of deaths in pediatric intensive care units occur after placing limits upon life-sustaining treatment. Two-thirds of limitations are made on the last day of life. Our aim was to characterize the timing, indications, and implementation of "do not resuscitate" (DNR) orders and the withdrawal of support from children with severe burns. A retrospective evaluation was conducted of all deaths in a pediatric burn unit over a 7-year period. Values are presented as mean +/- SD; two-tailed t-tests and Fisher's exact tests were used for analysis. Of the 29 deaths (total admissions = 1261; 2.3% death rate), 12 were of patients with DNR status. Active withdrawal of support occurred for 15 patients: 10 with DNR orders, 5 without. There was no difference in age, burn size, inhalation injury, etiology of injury, cause of death, intensive care unit days, or ventilator days between DNR patients and non-DNR patients. Of the 12 patients with DNR status, only five had orders indicating no cardiopulmonary resuscitation (CPR), no vasopressors, and no cardioversion. The mean time from DNR to death was 22.9 +/- 49.6 hours (median, 2.75 hours). Patients without DNR orders before death had more CPR attempts (0.8 +/- 0.6 vs. 0.3 +/- 0.6; P < .05). At the time of death, few patients with DNR orders were receiving vasopressors (two patients) or underwent CPR (1 patient). Of the 17 patients without DNR orders, 12 underwent resuscitative efforts: CPR (11), vasopressors (12), or cardioversion (9). No resuscitative efforts were undertaken for four children, two with DNR orders. For the acutely injured child there is a strong tendency to wait until the last possible hours of life to address limitation of life-sustaining measures. Documentation of limitation of care was not previously addressed in nearly a third of cases in which support was actively withdrawn. Once a decision to limit support was made, the majority of children proceeded rapidly to death. Further evaluation of the indications, timing, and implementation of DNR orders for children with severe burns is warranted.
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Affiliation(s)
- Michael Shay O'Mara
- Shriners Hospital for Children of Northern California, Department of Burns Surgery, Sacramento, California, USA
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de Lemos ML. Defining the clinical improvement in cancer drug therapy: implications for priority setting in healthcare. J Oncol Pharm Pract 2006; 12:91-4. [PMID: 16984747 DOI: 10.1177/1078155206069164] [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: 11/17/2022]
Abstract
An explicit approach to funding decisions has become increasingly important to ensure fairness and consistency in resource allocation in cancer therapy. Funding decisions are often based on whether a treatment is 'medically necessary' and the level of clinical improvement. Currently, there is a lack of consensus on defining different levels of clinical improvement, leading to controversies on the values placed on different outcomes and degrees of clinical improvements during funding evaluation. More information on how clinicians and patients define the levels of clinical improvement can help ensure the evaluation and decision-making processes of funding to become more predictable, consistent, understandable and therefore accountable to providers and consumers of healthcare.
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Affiliation(s)
- Mário L de Lemos
- Provincial Systemic Therapy Program, British Columbia Cancer Agency, Vancouver, B.C., Canada.
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Abstract
OBJECTIVE Decisions to forgo life support from critically ill children are commonly faced by parents and physicians. Previous research regarding parents' perspectives on the decision-making process has been limited by retrospective methods and the use of closed-ended questionnaires. We prospectively identified and described parents' self-reported influences on decisions to forgo life support from their children. Deeper understanding of parents' views will allow physicians to focus end-of-life discussions on factors important to parents and help resolve conflicts. DESIGN Prospective, qualitative pilot study. SETTING Pediatric intensive care unit of a university-affiliated children's hospital. PARTICIPANTS A total of 14 parents of ten children whose pediatric intensive care unit physician had made a recommendation to limit or withdraw life support. INTERVENTIONS : In-depth, semistructured interviews were conducted with parents during their decision-making process. MEASUREMENTS AND MAIN RESULTS Factors influencing the parents in this study in their decision to forgo life support included their previous experience with death and end-of-life decision making for others, their personal observations of their child's suffering, their perceptions of their child's will to survive, their need to protect and advocate for their child, and the family's financial resources and concerns regarding life-long care. Parents in this study expressed the desire to do what is best for their child but struggled with feelings of selfishness, guilt, and the need to avoid agony and sorrow. Physician recommendations, review of options, and joint formulation of a plan helped parents gain a sense of control over their situation. Parents of eight children agreed to forgo life support and parents of two did not. CONCLUSIONS Prospective interviews with open-ended questions identified factors influencing parents' decision making not previously described in the critical care literature such as parents' past experiences with end-of-life decisions and their anticipated emotional adjustments and future resources. Inclusion of these factors into discussions is important to parents and may facilitate decisions regarding the limitation or withdrawal of life support.
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Affiliation(s)
- Mahesh Sharman
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI 48201, USA
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Hinds PS, Oakes L, Furman W, Quargnenti A, Olson MS, Foppiano P, Srivastava DK. End-of-life decision making by adolescents, parents, and healthcare providers in pediatric oncology: research to evidence-based practice guidelines. Cancer Nurs 2001; 24:122-34; quiz 135-6. [PMID: 11318260 DOI: 10.1097/00002820-200104000-00007] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Participating in end-of-life decisions is life altering for adolescents with incurable cancer, their families, and their healthcare providers. However, no empirically developed and validated guidelines to assist patients, parents, and healthcare providers in making these decisions exist. The purpose of the work reported here was to use three sources (the findings of three studies on decision making in pediatric oncology, published literature, and recommendations from professional associations) to develop guidelines for end-of-life decision making in pediatric oncology. The study designs include a retrospective, descriptive design (Study 1); a prospective, descriptive design (Study 2); and a cross-sectional, descriptive design (Study 3). Settings for the pediatric oncology studies included a pediatric catastrophic illness research hospital located in the Midsouth (Studies 1 and 2); and that setting plus a children's hospital in Australia and one in Hong Kong (Study 3). Study samples included 39 guardians and 21 healthcare providers (Study 1); 52 parents, 10 adolescents, and 22 physicians (Study 2); and 43 parents (Study 3). All participants in the studies responded to six open-ended questions. A semantic content analysis technique was used to analyze all interview data. Four nurses independently coded each interview; interrater reliability per code ranged from 68% to 100% across studies. The most frequently reported influencing factors were "information on the health and disease status of the patient," "all curative options having been attempted," "trusting the healthcare team," and "feeling support from the healthcare provider." The agreement across studies regarding influencing factors provides the basis for the research-based guidelines for end-of-life decision making in pediatric oncology. The guidelines offer assistance with end-of-life decision making in a structured manner that can be formally evaluated and individualized to meet patient and family needs.
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Affiliation(s)
- P S Hinds
- St. Jude Children's Research Hospital, Memphis, Tennessee 38105-2794, USA
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Burns JP, Mitchell C, Griffith JL, Truog RD. End-of-life care in the pediatric intensive care unit: Attitudes and practices of pediatric critical care physicians and nurses. Crit Care Med 2001; 29:658-64. [PMID: 11373439 DOI: 10.1097/00003246-200103000-00036] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care. DESIGN Cross-sectional survey. SETTING A random sample of clinicians at 31 pediatric hospitals in the United States. MEASUREMENTS AND MAIN RESULTS The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%; p < .003); that ethical issues are discussed well within the team (92% vs. 59%; p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%; p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care. CONCLUSIONS Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.
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MESH Headings
- Adult
- Analysis of Variance
- Attitude of Health Personnel
- Attitude to Death
- Child
- Child Advocacy
- Critical Care/organization & administration
- Critical Care/psychology
- Cross-Sectional Studies
- Decision Making
- Ethics, Medical
- Ethics, Nursing
- Health Knowledge, Attitudes, Practice
- Hospitals, Pediatric
- Humans
- Intensive Care Units, Pediatric
- Medical Staff, Hospital/education
- Medical Staff, Hospital/psychology
- Middle Aged
- Multivariate Analysis
- Nursing Staff, Hospital/education
- Nursing Staff, Hospital/psychology
- Pediatrics/methods
- Practice Patterns, Physicians'/organization & administration
- Surveys and Questionnaires
- Terminal Care/organization & administration
- Terminal Care/psychology
- United States
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Affiliation(s)
- J P Burns
- Department of Anesthesia, Harvard Medical School, Children's Hospital, USA
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Danis M. Deciding whether to withdraw life-support in critically ill children: insightful data on hard choices. Crit Care Med 2000; 28:1685-6. [PMID: 10834753 DOI: 10.1097/00003246-200005000-00091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vose LA, Nelson RM. Ethical Issues Surrounding Limitation and Withdrawal of Support in the Pediatric Intensive Care Unit. J Intensive Care Med 1999. [DOI: 10.1046/j.1525-1489.1999.00220.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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