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ContextOutcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree.ObjectivesDetermine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families.MethodsThis multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness.ResultsOur qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending.ConclusionsIA is a feasible and reasonable approach to CPR discussions in selected patient populations.

Pediatric palliative care teams seek to collaboratively promote the quality of life for children with serious medical illness in the context of the values expressed by the patient and family. Especially for infants with high medical fragility, shared decision making can be a complex task that often requires flexibility to respond to the clinical circumstances at hand, as well as contextualization within the family culture. In this paper, we present the case of an infant with a severe congenital brain malformation who was born in an American hospital to a Rohingya-speaking, Burmese family whose care preferences seemed to oscillate between comfort-focused and life-prolonging without clear acknowledgement of the consequences of shifting between treatment plans. Discussion of this case helps to illustrate the cultural factors, ethical challenges, and systems-level issues that can arise for medical teams in seeking to promote patient-centered care that respects family values while also honoring the principle of nonmaleficience. [ABSTRACT FROM AUTHOR]

1. Utilizing personal reflection and observation, participants will self-report increased appreciation and understanding of the distinct roles of somatic and spiritual care providers. 2. Utilizing a case-based approach, participants will self-report greater facility in addressing spiritual dilemmas. While somatic and spiritual care often take place in parallel, each should inform the other. Three pediatric palliative care physicians also trained in spiritual care reflect on what somatic and spiritual care providers can learn from (and about) each other, in providing optimal care to pediatric patients and families. Palliative care is, by definition, an interdisciplinary specialty, with spiritual care constituting a core component. It is not uncommon for the medical and spiritual components of palliative care to function in parallel—one provided by medical providers and the other by spiritual care professionals—or sometimes seemingly in conflict, as when a family hopes for a "miracle." While the interprofessional team offers the opportunity for dialogue between representatives of these groups, this panel features the perspectives of three pediatric palliative care physicians who each have a foot in both worlds by virtue of their additional training in spiritual care, including seminary degrees, units of Clinical Pastoral Education, and ordained parish ministry. The panel will address three questions, the first being what physicians can learn from (and about) spiritual care professionals. Topics to be covered include coming to peace with not being able to solve problems, the breadth of spiritual beliefs and needs at different developmental stages, and bearing witness to spiritual and emotional pain in the special context of the suffering and death of children and adolescents. The second question is what spiritual care professionals can learn from (and about) physicians, including the fear of imperfection and uncertainty, the tendency to interpret "heart statements" as "head questions," and the self-doubt that often is associated with insoluble dilemmas. The final question is what unique opportunities and challenges face a pediatric palliative care professional who bridges distinct disciplines. While there certainly are risks associated with blurred role delineation—to be sure, there are some things a patient might be willing to share with their physician but not their chaplain—dual training also affords the opportunity to attend to a patient or family's overall needs, while also helping physician colleagues recognize the importance and nuance of spiritual care. Existential / Humanities / Spirituality / Religion Interdisciplinary Teamwork / Professionalism [ABSTRACT FROM AUTHOR]