Abstract
ObjectivesTo investigate how life-sustaining treatment (LST) decisions are made and identify problematic ethical concerns confronted by physicians and nurses in pediatric intensive care within Italy.MethodsAn 88-question online survey was created, based on a previous qualitative study conducted by this team. The survey was designed to identify how LST decisions were managed; contrasting actual practices with what participants think practices should be. Replies from physicians and nurses were compared, to identify potential inter-professional ethical tensions. The study also identified participants’ principal ethical concerns. Moreover, open-ended questions elicited qualitative perspectives on participants’ views. The survey was pilot-tested and refined before initiation of the study.Results31 physicians and 65 nurses participated in the study. Participants were recruited from pediatric intensive care units across five Italian cities; i.e., Florence, Milan, Padua, Rome, Verona. Statistically significant differences were identified for (a) virtually all questions contrasting actual practices with what participants think practices should be and (b) 14 questions contrasting physician replies with those of nurses. Physicians and nurses identified the absence of legislative standards for LST withdrawal as a highly problematic ethical concern. Physicians also identified bearing responsibility for LST decisions as a major concern. Qualitative descriptions further demonstrated that these Italian pediatric intensive care clinicians encounter significantly distressing ethical problems in their practice.ConclusionsThe results of this study highlight a need for the development of (a) strategies for improving team processes regarding LST decisions, so they can be better aligned with how clinicians think decisions should be made, and (b) Italian LST decision-making standards that can help ensure optimal ethical practices.
Highlights
NB: this study was conducted before the COVID-19 pandemic
A child’s best interests are frequently difficult to determine because it can be unclear which benefits and burdens should carry the greatest weight. It sometimes unclear what decisional authority and responsibility should be borne by different stakeholders when making life-sustaining treatment (LST) decisions with regard for critically ill children; e.g., parents, physicians, nurses and other health care providers (HCPs), as well as childpatients themselves
A statement published by the Italian Society of Neonatal and Pediatric Anesthesia and Intensive Care states that the physician in charge of the patient’s care and the unit head bear the main responsibility for the final decision, the participation of other staff and the parents should be sought [2]
Summary
NB: this study was conducted before the COVID-19 pandemic. pandemic-related ethical concerns are not reflected in this investigation It is widely recognized that critical illness in childhood commonly requires complex health care that frequently gives rise to challenging ethical concerns [1–4]. Best interests is commonly defined as the treatment option that offers the greatest proportion of benefit in relation to burden. These standards recognize that any LST can be withheld or withdrawn depending on the balance of benefits and burdens for the child [1, 6, 7]. A child’s best interests are frequently difficult to determine because it can be unclear which benefits and burdens should carry the greatest weight It sometimes unclear what decisional authority and responsibility should be borne by different stakeholders when making LST decisions with regard for critically ill children; e.g., parents, physicians, nurses and other health care providers (HCPs), as well as childpatients themselves. A statement published by the Italian Society of Neonatal and Pediatric Anesthesia and Intensive Care states that the physician in charge of the patient’s care and the unit head bear the main responsibility for the final decision, the participation of other staff and the parents should be sought [2]
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