Disposition Decisions in Cases of Medical Complexity and Health Inequity
Adult; Covid-19; Child; Ethics; Clinical; Health; Inequities; Humans; Palliative Care; Pandemics
The question of optimal disposition for children with complex medical and social circumstances has long challenged the well-intentioned clinician. The coronavirus disease 2019 pandemic created unique difficulties for patients, families, and health care providers, in addition to highlighting long-standing racial and socioeconomic inequities in health care. In pediatric hospitals, necessary public health measures such as visitor restrictions shifted many shared decision-making processes such as discharge planning from complicated to impossible. Here, we present the case of a medically complex adult (with a long-standing pediatric condition) whose surrogate decision-maker objected to discharge to a long-term care facility because of restrictions and risks associated with the coronavirus disease 2019 pandemic. We offer the commentary of experts in clinical ethics, intensive care, inpatient subacute care, and palliative care. Our discussion includes analysis of the ethical considerations involved in the case, concrete guidance on steps toward an ethically permissible discharge, and suggestions for how a health equity lens can improve communication and decision-making for families who are victims of systemic racism and economic discrimination.
Shapiro J P; Anspacher M; Madrigal V; Lantos JD
Pediatrics
2022
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1542/peds.2021-055558">10.1542/peds.2021-055558</a>
Teaching Pediatric Intensive Care Physicians Communication Skills: The Enduring Effects
Objectives
Determine feasibility of a communication skills
training (CST) to prepare pediatric intensivists
for communicating bad news and assessing goals
of care in the pediatric intensive care unit
(PICU).
Describe the impact of CST on intensivist skill in
communication.
Original Research Background. Families of seriously
ill children describe unmet needs for honest information
presented empathetically, while intensivists
report inadequate training in having difficult
conversations.
Research Objectives. 1. To determine feasibility of
communication skills training (CST) to prepare pediatric
intensivists for communicating bad news and assessing
goals of care in the pediatric intensive care
unit (PICU). 2. To describe the impact of CST on intensivist
skill in communication.
Methods. Intensivists volunteered to undergo CST
with didactics, discussions with simulated parents,
and a videotaped OSCE exam. Surveys prior to the
intervention and one month after were tabulated for
descriptive statistics. Wilcoxon signed-rank tests
compared outcomes at 2 time points. 2 independent
trained reviewers scored the OSCE using a validated
tool.
Results. Twelve participants completed training. In
the post-CST survey, all participants agreed the
Vol. 51 No. 2 February 2016 Poster Abstracts 431
training gave them skills to communicate in challenging
situations, and they would recommend it to
peers. When comparing pre- and post-CST self-assessment
measures of intensivists’ information-seeking
from families, there was a significant increase 1 month
after training (p¼0.03), with intensivists more likely to
ask what kinds of information families need and what
their understanding of their child’s disease is, but no
significant changes in information seeking or giving,
which was not covered in the training. Finally, 11 of
the 12 intensivists received passing scores on the
OSCE as measured by a validated tool, with the
average score being 48.5 (SD 5.92) compared to 38.6
(SD 9.93) after training that was reported in the
literature.
Conclusion. This study provides evidence that intensivists
are willing to participate in CST and an OSCE
exam, and they find it worthwhile. There is also evidence
that they perceive an improvement in their skill
set as a result of having participated.
Implications for Research, Policy or
Practice. Offering realistic, simulation-based CST is
feasible and effective for training intensivists.
Walter J; Shah P; Odeniyi F; Madrigal V; Feudtner C
Journal Of Pain And Symptom Management
2016
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
DOI: http://dx.doi.org/10.1016/j.jpainsymman.2015.12.048