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The population of children and adolescents encompasses a remarkable range of physiological, developmental, and experiential phenomena. Considered from a global perspective, differences may seem to overwhelm similarities. This chapter proposes and explains three distinct but interrelated characteristics that should frame ethical considerations of public health approaches to children and adolescents: (1) lack of political, economic, and social power; (2) status as subject to stewardship by adults; and (3) presumed lack of capacity for decision-making.The impact of these shared characteristics is examined using public health approaches to health information, health promotion and access to confidential services. Public health policies that anticipate the risks related to powerlessness and failures of stewardship, and seek to promote respect for developing capacity can help to create conditions in which children can thrive. more...

Purpose To evaluate whether educational sessions on interpreter use and experience with interpreters are associated with resident self-efficacy in the use of professional interpreters. Method In 2010, the authors surveyed residents from seven pediatric residency programs. Their 29-item survey collected data on training and experience with interpreters and self-efficacy in (1) determining when an interpreter is needed and (2) using a professional interpreter. The authors conducted bivariate and multivariate regression analyses. Results Among the 271 respondents, 82% reported that ≥ 10% of their patients had limited English proficiency (LEP), 53% indicated they had "a lot" of experience with interpreters, and 54% reported never receiving any educational sessions on interpreter use. The majority reported high self-efficacy in knowing when an interpreter is needed (69%) and in using an interpreter (68%). Residents reporting a high experience level with interpreters were more likely to report high self-efficacy in knowing when an interpreter is needed (odds ratio [OR] = 1.85; 95% confidence interval[CI] = 1.03-3.32) and in using an interpreter (OR = 3.97; 95% CI = 1.19-13.31). Formal training on using interpreters was also associated with high self-efficacy in interpreter use(OR = 1.62; 95% CI = 1.22-2.14). Conclusions Many residents who care for patients with LEP have never received educational sessions on interpreter use. Such training is associated with high self-efficacy and may enhance patient-provider communication. Incorporating this training into residency programs is necessary to equip providers with skills to communicate with patients and families with LEP. more...

The persistent mismatch between the supply of and need for transplantable organs has led to efforts to increase the supply, including controlled donation after circulatory death (DCD). Controlled DCD involves organ recovery after the planned withdrawal of life-sustaining treatment and the declaration of death according to the cardiorespiratory criteria. Two central ethical issues in DCD are when organ recovery can begin and how to manage conflicts of interests. The “dead donor rule” should be maintained, and donors in cases of DCD should only be declared dead after the permanent cessation of circulatory function. Permanence is generally established by a 2- to 5-minute waiting period. Given ongoing controversy over whether the cessation must also be irreversible, physicians should not be required to participate in DCD. Because the preparation for organ recovery in DCD begins before the declaration of death, there are potential conflicts between the donor’s and recipient’s interests. These conflicts can be managed in a variety of ways, including informed consent and separating the various participants’ roles. For example, informed consent should be sought for premortem interventions to improve organ viability, and organ procurement organization personnel and members of the transplant team should not be involved in the discontinuation of life-sustaining treatment or the declaration of death. It is also important to emphasize that potential donors in cases of DCD should receive integrated interdisciplinary palliative care, including sedation and analgesia. more...

Having adolescents make independent choices about reproductive and mental health reflects our society's pragmatism, willing to seek a balance among fairness, respect for families, and critical public health and safety goals. more...

Sometimes, parents refuse medical intervention for philosophical reasons. Pediatricians have an obligation to protect children from medical neglect on the part of their parents. Often, it is not clear where exactly to draw the line between parental rights and the best interest of the child. The law is clear, however. If the doctor suspects medical neglect, he or she has an obligation to notify child protective services (CPS). CPS, and eventually a judge, will then determine if the parental behavior is or is not legally acceptable. For doctors, however, there is often a trade-off between protecting the child and preserving a therapeutic alliance with the parents. We present here a case of a newborn at risk for sepsis whose parents do not want standard medical evaluation and treatment. Two general pediatricians, Elizabeth Simpson, MD, director of the general care nursery at Truman Medical Center, and Margaret Moon, MD, MPH, a bioethicist and pediatrician at Johns Hopkins School of Medicine, offer their responses to the case. A 30-year-old woman presented to labor/delivery at term gestation after a failed home delivery with a lay midwife. Her membranes had ruptured 38 hours before delivery. One hour before presentation, she had developed a temperature to 102°F. The pregnancy had been uncomplicated. She had early prenatal care and a negative screen result for group B streptococcal infection 1 week before delivery. Her white blood cell count was 49 000/μL with 18% bands. The woman and her husband refused fetal monitoring. They insisted on carrying out their plan for a natural birth and said that, right after delivery, they wanted to be discharged and take the child home. The obstetrician recommended that the mother receive intravenous antibiotics. She agreed to this treatment. The pediatric service was consulted 1 hour before delivery. The parents were informed that … Address correspondence to John D. Lantos, MD, Children's Mercy Bioethics Center, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jlantos{at}cmh.edu more...

OBJECTIVES Being a good doctor requires competency in ethics. Accordingly, ethics education during residency training is important. We studied the everyday ethics-related issues (i.e. ordinary ethics issues commonly faced) that internal medical residents encounter in their out-patient clinic and determined whether teaching about these issues occurred during faculty preceptor–resident interactions. more...

When physician and parents disagree about treatment, a powerful therapeutic alliance between them is the best way to work toward their shared goal of the child’s well-being. Virtual Mentor is a monthly bioethics journal published by the American Medical Association. more...

Institutional review boards (IRBs) play a role in approving research that involves human subjects. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Objectives To determine the frequency, prescriber, and type of prescribing errors in written in-house orders and ambulatory prescriptions in a pediatric emergency department (PED). Methods A 17-day retrospective chart review and a 6-month retrospective ambulatory prescription review in a PED for medications with weight-based dosing. Orders and prescriptions were checked for prescriber identification number, route, weight-based target dose in milligrams per kilogram, frequency, correct dosing, and drug allergies. Narcotics were excluded from the prescription analysis. Results Forty-seven (12.5%) of 377 in-house orders and 37 (19.4%) of 191 individual charts contained at least 1 error: 4 (1.1%) orders contained an incorrect dose, 41 (10.8%) were written incorrectly, and 2 (0.5%) contained an incorrect dose and were written incorrectly. Thirty (4.3%) of 696 ambulatory prescriptions contained 1 error: 14 (2.0%) contained an incorrect dose, and 16 (2.3%) were written incorrectly. Pediatric postgraduate year-3 residents had the highest in-house order incorrect dose error rate (1 of 29 orders or 3.5%), and ED pediatric postgraduate year-2 residents had the highest ambulatory prescription incorrect dose error rate (6 of 66 prescriptions or 9.1%). Pediatric ED attending physicians had the highest error rates for writing orders and prescriptions incorrectly, 25% (3 of 12) and 9.7% (3 of 31), respectively. Antibiotics, analgesics, and narcotics were most often involved in errors. Conclusions Prescribing errors are common in both written in-house orders and ambulatory prescriptions in a PED. Targeting safety interventions toward groups with less practice in prescribing pediatric doses and reeducating groups on safe medication writing techniques could decrease this error rate. more...

This study aimed to investigate the optimal degree of weight gain across the gestational spectrum in 1971 children enrolled at birth and followed up to age 7 years. Weight gain in infancy was categorized into four groups based on weight gain z-scores: slow (1.28). Underweight and overweight or obesity (OWO) were defined as a body mass index ≤5th and ≥85th percentile, respectively, for age and gender. In our population, OWO was far more common than underweight (39.7% vs. 3.6%). Weight gain tracked strongly from age 4 to 24 months, and was positively associated with OWO and an unfavorable pattern of metabolic biomarkers, although the degree of weight gain for the risk was different across gestational categories. Extremely rapid weight gain led to a particularly high risk of OWO among children born early term and late preterm: odds ratio: 3.3 (95% confidence interval: 1.9 to 5.5) and 3.7 (1.8 to 7.5), respectively, as compared to those with on track weight gain. Our findings suggest that monitoring and ensuring optimal weight gain across the entire gestational spectrum beginning from birth represents a first step towards primary prevention of childhood obesity. more...

Ethics curricula are nearly universal in residency training programs, but the content and delivery methods are not well described, and there is still a relative paucity of literature evaluating the effect of ethics curricula. Several commentators have called for more ethics curriculum development at the postgraduate level, and specifically in surgery training. We detail our development and implementation of a clinical ethics curriculum for surgery interns.We developed curricula and simulated patient cases for 2 core clinical ethics skills--breaking bad news and obtaining informed consent. Educational sessions for each topic included (1) framework development (discussion of interns' current experience, development of a consensus framework for ethical practice, and comparison with established frameworks) and (2) practice with simulated patient followed by peer and faculty feedback. At the beginning and end of each session, we administered a test of confidence and knowledge about the topics to assess the effect of the sessions.A total of 98 surgical interns participated in the ethics skills laboratory from Spring 2008 to Spring 2011. We identified significant improvement in confidence regarding the appropriate content of informed consent (0.001) and capacity to break bad news (0.001). We also identified significant improvement in overall knowledge regarding informed consent (0.01), capacity assessment (0.05), and breaking bad news (0.001). Regarding specific components of informed consent, capacity assessment, and breaking bad news, significant improvement was shown in some areas, while we failed to improve knowledge in others.Through faculty-facilitated small group discussion, surgery interns were able to develop frameworks for ethical practice that paralleled established frameworks. Skills-based training in clinical ethics resulted in an increase in knowledge scores and self-reported confidence. Evaluation of 4 annual cohorts of surgery interns demonstrates significant successes and some areas for improvement in this educational intervention. more...

Objective To assess residents' self-efficacy, satisfaction and frustration in the care of limited English proficient (LEP) families and to identify individual and programmatic factors associated with the above outcomes. Methods A multisite cross-sectional survey of pediatric residents currently in training and caring for LEP families was conducted. Resident self-efficacy scores in specific skill domains were assessed. Clustered multivariate logistic regression analyses were used to identify individual and programmatic factors associated with increased satisfaction and frustration. Qualitative analyses were also utilized to identify themes related to frustrating aspects of care. Results A total of 271 of 449 eligible residents representing 7 US pediatric residency programs participated in our study (60% response rate). A majority of residents (51%) rated their self-efficacy in the overall care of LEP families as low. Satisfaction was associated with a high self-efficacy score (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.8–12.6), increasing year in training (OR 3.2, 95% CI 1.01–10.2), frequent non-English language use (OR 3.1, 95% CI 1.1–8.8), and instruction on the use of interpreters (OR 1.9, 95% CI 1.02–3.64). Satisfaction was inversely associated with increased LEP patient volumes (OR 0.40, 95% CI 0.18–0.91). Clinical inefficiency related to interpreter use and distrust of interpreter skills were frequently cited as aspects that contribute to overall frustration. Conclusions A majority of residents reported lacking self-efficacy in their ability to deliver care to LEP patients, which may influence overall satisfaction with such encounters. Strategies that promote resident self-efficacy and assess non-English language proficiency should be included in future training curricula. Exposing trainees to best practices in interpreter-based encounters may further promote resident satisfaction. more...

Context Previous research on ethical issues encountered by medical professionals in training and practice have presented the thematic content of the cases they encounter rather than the activities in which clinicians engage and in which they most often encounter ethical issues. We conducted a direct observation study of paediatrics residents and their preceptors seeing patients in an out-patient general paediatrics clinic. Our objectives were to describe the everyday ethics-related issues paediatrics residents encounter as they interact with patients. Our ultimate goal is to use this knowledge to enhance current efforts to teach ethics to paediatrics residents. Methods The study team directly observed paediatrics residents discussing patients with their faculty preceptors (19 half-day sessions, 76 hours) in an out-patient general paediatrics clinic located in an urban academic medical centre. Each interaction between resident and preceptor about a single patient was considered a case for further analysis. Results A total of 247 cases were recorded. Forty-one of the cases were coded as having ethics-related content. A constant comparative method of qualitative data analysis revealed that residents were most likely to encounter ethical issues when engaged in the following activities: (i) maintaining a therapeutic alliance with the caregiver (e.g. the parent); (ii) prioritising patient or family needs; (iii) adjusting to the power embodied by the role of doctors, and (iv) distinguishing suboptimal care from abuse or neglect. In addition, our findings indicate that it is through their efforts to maintain the therapeutic alliance with the caregivers of their patients that residents engage in and integrate three processes: developing their medical knowledge; adhering to professional norms, and balancing the power inherent in the doctor’s role with their responsibility to serve the patient’s interests. Conclusions Medical faculty tasked with teaching ethics to paediatrics residents can utilise the results of this project to better target and enhance their ethics education efforts directed at residents in the out-patient setting. Future research could further examine and test these findings in other clinical settings (e.g. adult general medicine). more...

Objective To describe the ethics issues that pediatric residents encounter during routine care in an outpatient teaching clinic. Design Qualitative study including in-depth interviews with pediatric residents and direct observation of interactions between preceptors and residents in a pediatric teaching clinic. Setting The Johns Hopkins Harriet Lane Pediatric Primary Care Clinic, March 20 through April 11, 2006. Participants A convenience sample including all pediatric faculty preceptors supervising at the clinic during the 19 half-day sessions that occurred during the observation period (N = 15) and the pediatric residents seeing patients during these clinic sessions (N = 50). Main Outcome Measure Field notes of preceptor-resident discussions about patient care were made and transcribed for qualitative analysis. Results Qualitative analysis of the ethics content of cases presented by residents in this pediatric teaching clinic identified 5 themes for categorizing ethics challenges: (1) promoting the child's best interests in complex and resource-poor home and social settings; (2) managing the therapeutic alliance with parents and caregivers; (3) protecting patient privacy and confidentiality; (4) balancing the dual roles of learner and health care provider; and (5) using professional authority appropriately. Conclusions Qualitative analysis of the ethics content of directly observed preceptor-resident case discussions yielded a set of themes describing the ethics challenges facing pediatric residents. The themes are somewhat different from the lists of residents' ethics experiences developed using recall or survey methods and may be very different from the ideas usually included in hospital-based ethics discussions. This may have implications for improving ethics education during residency training. more...

IMPACT OF PARTICIPATING IN QUALITATIVE RESEARCH ON YOUNG BLACK MEN WHO HAVE SEX WITH MEN Renata Arrington-Sanders, MD, MPH , Thu (Ann) Dao, BS , Jessica Oidtman, BS , Anthony Morgan , Margaret Moon, MD, MPH , J. Dennis Fortenberry, MD , Mary Ott, MD . Johns Hopkins School of Medicine; Philadelphia College of Pharmacy; Indiana University; Section of Adolescent Medicine Indiana University School of Medicine. more...

Clinwa genetics is an integral part of pediatrics. Genetic diseases are common in childhood: as many as 53 per 1000 children and young adults can be expected to have diseases with an important genetic component. 1 This rate increases to 79 per 1000 if congenital anomalies are included. 1 In addition, 12% to 40% of all pediatric hospitalizations are for genetic diseases and birth defects. 2-4 Despite its importance in primary care pediatrics, genetics has maintained its subspecialty status. Newborn screening for genetic diseases is the only aspect of genetics that has been incorporated as routine pediatric practice. more...