Background
Inclusion of BMI as criterion in the determination of heart transplant candidacy in children is a clinical and ethical challenge. Childhood obesity is increasing and children with heart ...disease are not spared. Currently, many adult heart transplant centers consider class II obesity and higher (BMI > 35 kg/m2) to be a relative contraindication for transplantation due to risk of poor outcome after transplant. No national guidelines exist regarding consideration of BMI in pediatric heart transplant and outcomes data are limited. This leaves decisions about transplant candidacy in obese pediatric patients to individual institutions or on a case‐by‐case basis, allowing for bias and inequity.
Methods
We review (a) the prevalence of childhood obesity, including among heart transplant candidates, (b) the lack of existing BMI guidelines, and (c) relevant literature on BMI and pediatric heart transplant outcomes. We discuss the ethical considerations of using obesity as a criterion using the principles of utility, justice, and respect for persons.
Results
Existing transplant outcomes data do not show that obese children have different or poor enough outcomes compared to non‐obese children to warrant exclusion. Moreover, obesity in the United States is unequally distributed by race and socioeconomic status. Children already suffering from health disparities are therefore doubly penalized if obesity denies them access to life‐saving transplant.
Conclusion
Insufficient data exist to support using any BMI cutoff as an absolute contraindication for heart transplant in children. Attention should be paid to health equity issues when considering excluding a patient for transplant based on obesity.
To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU.
We used the Council of Medical Specialty Societies principles for the ...development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development.
The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.
These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.
Background
Preliminary evidence suggests that non‐lung organ donation from resolved, asymptomatic or mildly symptomatic SARS‐CoV‐2 infected adults may be safe. However, several biological aspects of ...SARS‐CoV‐2 infection differ in children and the risk for transmission and outcomes of recipients from pediatric donors with SARS‐CoV‐2 infection are not well described.
Methods
We report two unvaccinated asymptomatic pediatric non‐lung organ deceased donors who tested positive for SARS‐CoV‐2 RNA by RT‐PCR. Donor One unexpectedly had SARS‐CoV‐2 RNA detected in nasopharyngeal swab and plasma specimens at autopsy despite several negative tests (upper and lower respiratory tract) in the days prior to organ recovery. Donor Two had SARS‐CoV‐ 2 RNA detected in multiple nasopharyngeal swabs but not lower respiratory tract specimens (endotracheal aspirate and bronchoalveolar lavage) during routine surveillance prior to organ recovery and was managed with remdesivir and monoclonal antibodies prior to organ recovery.
Results
Two hearts, two livers and four kidneys were successfully transplanted into seven recipients. No donor to recipient transmission of SARS‐CoV‐2 was observed and graft function of all organs has remained excellent for up to 7 months of followup.
Conclusions
Due to the persistent gap between organ availability and the number of children waiting for transplants, deceased pediatric patients with non‐disseminated SARS‐CoV‐2 infection, isolated to upper and/or lower respiratory tract, should be considered as potential non‐lung organ donors.
OBJECTIVE:To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States.
DESIGN:Prospective case series.
SETTING:Five U.S. teaching ...hospitals.
SUBJECTS:We concurrently identified 192 consecutive patients who died prior to discharge from the PICU. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:The overall mortality rate was 2.39% (range, 1.85–3.38%). One hundred thirty-three patients (70%) died following the withholding or withdrawal of life-sustaining treatments, 30 (16%) were diagnosed as brain dead, and 26 (14%) died following an unsuccessful resuscitation attempt. Fifty-seven percent of all deaths occurred within the first week of admission; these patients, who were more likely to have new onset illnesses or injuries, included the majority of those who died following unsuccessful cardiopulmonary resuscitation attempts or brain death diagnoses. Patients who died beyond 1-week length of stay in the PICU were more likely to have preexisting diagnoses, to be technology dependent prior to admission, and to have died following the withdrawal of life-sustaining treatment. Only 64% of the patients who died following the withholding or withdrawing of life support had a formal do-not-resuscitate order in place at the time of their death.
CONCLUSIONS:The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved. Death is largely characterized by two fairly distinct profiles that are associated with whether death occurs within or beyond 1-week length of stay. Decisions not to resuscitate are often made in the absence of a formal do-not-resuscitate order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.
Critically insufficient pediatric hospital capacity may develop during a disaster or surge event. Research is lacking on the creation of pediatric surge capacity. A system of "reverse triage," with ...early discharge of hospitalized patients, has been developed for adults and shows great potential but is unexplored in pediatrics.
We conducted an evidence-based modified-Delphi consensus process with 25 expert panelists to derive a disposition classification system for pediatric inpatients on the basis of risk tolerance for a consequential medical event (CME). For potential validation, critical interventions (CIs) were derived and ranked by using a Likert scale to indicate CME risk should the CI be withdrawn or withheld for early disposition.
Panelists unanimously agreed on a 5-category risk-based disposition classification system. The panelists established upper limit (mean) CME risk for each category as <2% (interquartile range IQR: 1-2%); 7% (5-10%), 18% (10-20%), 46% (20-65%), and 72% (50-90%), respectively. Panelists identified 25 CIs with varying degrees of CME likelihood if withdrawn or withheld. Of these, 40% were ranked high risk (Likert scale mean ≥7) and 32% were ranked modest risk (≤3).
The classification system has potential for an ethically acceptable risk-based taxonomy for pediatric inpatient reverse triage, including identification of those deemed safe for early discharge during surge events.
Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to ...important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.
Every year, an increasing number of international patients seek medical care in the United States (U.S.), yet little is known about their impact. Based on single institution experiences, we wanted to ...explore the perceived impact of international pediatric patients on large academic U.S. pediatric intensive care units (PICUs), as they are already taxed systems.
To explore current perceptions, seven geographically diverse institutions who advertise care for international patients on their websites and have ≥24 PICU beds were identified after IRB approval was obtained. We consented and interviewed PICU division chiefs or medical directors from each institution regarding their demographics and international patients. Common themes were identified.
Participating institutions were diverse in geographic location, census, and resource allocation strategies. Five of the seven institutions reported the presence of a formal international patient program. Four of those five reported an increase in international patients receiving PICU care over the past 5 years. International patients sought complex surgeries, advanced cancer treatments and metabolic/genetic evaluations. We identified three primary domains that require further exploration and research: (1) cultural and language differences leading to barriers in providing optimal care to international patients (2) institutional financial considerations, and (3) perceived positive and negative impact on the care of local/domestic patient populations.
The presence of international programs raises a number of important ethical questions, including whether clinicians have a greater duty to serve residents of the local community as opposed to international patients when resources are limited. Further exploration is warranted.
Shared decision-making in pediatrics is based on a trusting partnership between parents, clinicians, and sometimes patients, wherein all stakeholders explore values and weigh options. Within that ...framework, clinicians often have an obligation to provide guidance. We describe a range of ethically justifiable clinician directiveness that could be appropriate in helping families navigate serious pediatric illness. The presentation of "default" options and informed nondissent as potential strategies are discussed. The degree of clinician directiveness may vary even for decisions that are equally "shared." A myriad of factors affect how directive a clinician can or should be. Some of the most important factors are the degree of prognostic certainty and the family's desire for guidance, but others are important as well, such as the urgency of the decision; the relationship between the clinician, patient, and family; the degree of team consensus; and the burdens and benefits of therapy. Directiveness should be considered an important tool in a clinician's armamentarium and is one that can be used to support families in stressful and emotionally difficult situations.
Families and clinicians approaching a child’s death in the paediatric intensive care unit (PICU) frequently encounter questions surrounding medical decision-making at the end of life (EOL), including ...defining what is in the child’s best interest, finding an optimal balance of benefit over harm, and sometimes addressing potential futility and moral distress. The best interest standard (BIS) is often marshalled by clinicians to help navigate these dilemmas and focuses on a clinician’s primary ethical duty to the paediatric patient. This approach does not consider a clinician’s potential duty to the patient’s family. This paper argues that when a child is dying in the PICU, the physician has a duty to serve both the patient and the family, and that in some circumstances, the duty to serve the family becomes as important as that owed to the child. We detail the limitations of the BIS in paediatric EOL care and propose the relational potential standard as an additional ethical framework to guide our decisions.
Following Hurricane Katrina and the 2009 H1N1 epidemic, pediatric critical care clinicians recognized the urgent need for a standardized pediatric triage/allocation system. This study collected ...regional provider opinion on issues of care allocation and pediatric triage in a disaster/pandemic setting.
This study was a cross-sectional survey of United States (US) health care providers and public health workers who demonstrated interest in critical care and/or disaster care medicine by attending a Northwest regional pediatric critical care symposium on disaster preparation, held in 2012 at Seattle Children's Hospital in Seattle, Washington (USA). The survey employed an electronic audience response system and included demographic, ethical, and logistical questions. Differences in opinions between respondents grouped by professions and work locations were evaluated using a chi-square test.
One hundred and twelve (97%) of 116 total attendees responded to at least one question; however, four of these responders failed to answer every question. Sixty-two (55%) responders were nurses, 29 (26%) physicians, and 21 (19%) other occupations. Fifty-five (51%) responders worked in pediatric hospitals vs 53 (49%) in other locations. Sixty-three (58%) of 108 successful responses prioritized children predicted to have a good neuro-cognitive outcome. Seventy-one (68%) agreed that no pediatric age group should be prioritized. Twenty-two (43%) of providers working in non-pediatric hospital locations preferred a triage system based on an objective score alone vs 14 (26%) of those in pediatric hospitals (P = .038).
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