The Suffering Child: Claims of Suffering in Seminal Cases and What To Do About Them

Exploring how claims of 'suffering' are operationalized in pediatric critical care

CONTEXT

Identifying when a child is suffering can be incredibly challenging. Understanding how the term 'suffering' is used in pediatric critical care - and specifically end of life care - is critical for clinical decision-making, communication, and goal-setting between healthcare providers and families. To gain insight into this complex question, we employed ethnographic methods to explore the underlying meanings and goals associated with the use of this term by clinicians, patients, and families in the Pediatric Intensive Care Unit (PICU).

OBJECTIVES

To explore how the term 'suffering' is operationalized by clinicians and families in Pediatric Intensive Care Units (PICUs) and its implications for decision-making.

METHODS

This study was conducted in three specialized PICUs within a large tertiary children's hospital. This exploratory qualitative study used ethnographic methods, including narrative literature review, analysis of verbatim transcripts of 30 care conferences and 50 ethnographic observations involving physicians, nurses, and families. Analyses employed an iterative, interpretive approach to identify key themes across data sources.

RESULTS

This study identified three main themes: 1) 'Suffering' was rarely defined, 2) Discussions of patient 'suffering' included collateral impacts on providers and families, in addition to impacts on patient experience; and 3) Physicians used 'suffering' to pivot goals of care, while parents used it variably.

CONCLUSION

These findings suggest that 'suffering' is often invoked in the PICU with little specificity, is used to signal provider or caregiver distress, and is used with the intention to shift goals of care in a manner not always consistent with family values or interpretations. Recognizing the implicit messages conveyed through language may support families and healthcare providers to better communicate their goals and preferences, fostering collaborative decision-making and enhancing patient outcomes in the PICU and during end-of-life care.

How to "Do Ethics" in Pediatrics Practice: A Framework for Addressing Everyday Ethics Issues

Pediatricians have a fiduciary responsibility to advocate for the best interests of their patients. They accomplish this through the therapeutic alliance with the patient and their parent. In everyday clinical medicine, the pediatrician may be faced with challenging situations. When a case raises concerns, the pediatrician needs to determine if the issues relate to ethical obligations and whether they are in conflict. To resolve the concerns, a systematic process for gathering, organizing, and analyzing the facts of a case is needed to discern morally permissible options. This article presents a framework for performing an ethics case analysis.

Influence of Genetic Information on Neonatologists' Decisions: A Psychological Experiment

BACKGROUND AND OBJECTIVES

Genetic testing is expanding among ill neonates, yet the influence of genetic results on medical decision-making is not clear. With this study, we sought to determine how different types of genetic information with uncertain implications for prognosis influence clinicians' decisions to recommend intensive versus palliative care.

METHODS

We conducted a national study of neonatologists using a split sample experimental design. The questionnaire contained 4 clinical vignettes. Participants were randomly assigned to see one of 2 versions that varied only regarding whether they included the following genetic findings: (1) a variant of uncertain significance; (2) a genetic diagnosis that affects neurodevelopment but not acute survival; (3) a genetic versus nongenetic etiology of equally severe pathology; (4) a pending genetic testing result. Physicians answered questions about recommendations they would make for the patient described in each vignette.

RESULTS

Vignette versions that included a variant of uncertain significance, a diagnosis foreshadowing neurodevelopmental impairment, or a genetic etiology of disease were all associated with an increased likelihood of recommending palliative rather than intensive care. A pending genetic test result did not have a significant effect on care recommendations.

CONCLUSIONS

Findings from this study of hypothetical cases suggest neonatologists apply uncertain genetic findings or those that herald neurodevelopmental disability in problematic ways. As genetic testing expands, understanding how it is used in decision-making and educating clinicians regarding appropriate use are paramount.