Showing posts with label ethics. Show all posts
Showing posts with label ethics. Show all posts

Wednesday, July 15, 2015

What Do You Do When Someone Asks For A White Doctor?

By:  Terrill Bravender  MD, MPH; Editorial Board Member   

Department of Foreign Affairs 
     In clinical practice, we don’t think twice when an adolescent girl asks for a female physician, or when a Hispanic parent requests a Spanish-speaking provider. We accommodate requests like those regularly without even giving them a second thought. After all, it seems self-evident that requests such as this will help patients and families feel more comfortable, and help ensure a better clinical outcome.
       The Institute of Medicine’s landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century, stated that medical care should be more patient-centered. In order to achieve this, the committee recommended that physicians should become more responsive to patient needs and perspectives, and that patient values should guide medical decision making. For the most part this also is intuitive and self-evident. Of course we will help the patient who requests it to find a female (or male, or Spanish-speaking) physician.
      What happens though, when a patient or family makes a request for a provider that we find particularly odious? For example, what if the father of a small child will not allow a Black provider to touch his daughter and requests a white physician?
     The Ethics Rounds case presented in this issue of Pediatrics, from Reynolds et al. (doi: 10.1542/peds.2014-2092) describes such a case in the context of the historical discrimination faced by black medical providers in the United States, as well as identifying our current expectations for non-discrimination in employment and education.
      The thoughtful discussion helped me come to a better understanding as to why I had such a negative visceral response to the father’s request, why I would accommodate a request in other cases, and what I might do if faced with such a request. Have you had similar requests from parents? How were you able to address such requests while still assuring appropriate care for the child? 

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Wednesday, April 8, 2015

A Fork In The Road: Two Cases, Two Families, and Divergent Paths

By: Joann Schulte  DO, MPH; Editorial Board Member

      “It depends.” That's an answer you've probably heard from your parents growing up and is a phrase you've used with your own children. The circumstances of what you got to do as an adolescent or what you permit your children to do figure into the decisions made.
      “It depends” applies in medical ethical dilemmas as well. How the impact of family circumstances can shape medical decision making is well illustrated in the Ethics Rounds article “
Two babies, same prognosis, different parental choices” presented this month in Pediatrics. Antommaria et al. (doi: 10.1542/peds.2013-4044) described different decisions in the same NICU concerning two different families and their respective infants with the same medical problem. Both families had premature infants born with esophageal atresia with tracheoesophageal fistula. Each infant failed extubation and would have been maintained on long-term mechanical ventilation for months or years. In both cases, the NICU staff recommended long-term mechanical ventilation. One infant was born at 33 weeks to an Amish family who declined additional care and requested only comfort care. The other infant was a twin born at 31 weeks whose postoperative repair was complicated by cardiac tamponade and an unclear neuro-developmental future. That family agreed with the NICU staff and accepted the recommendation for long-term ventilation.
      The authors describe the NICU staff as being troubled by the different decisions made by parents in two different babies and reviewed the circumstances of the two families. The ethics experts discussed circumstances of the Amish family in detail, including the fact that the members of the religion rely on community support for care of such children and live in circumstances where electricity for a ventilator is not available. The other family decided to accept the recommendation of the NICU and agreed to the mechanical ventilation of their child for a prolonged period with no guaranteed outcome. 
       This Ethics Rounds article deals with the issues from the perspectives of the NICU staff.  Ethics issues and decision making are increasingly becoming a joint venture between the families involved and the NICU staff.   I’d like to know more about how families cope with the long-term, chronic consequences they face in caring for a child who is heavily dependent on medical technology.  What’s the impact on a marriage or on other children?  The issues of medical technology raise ethical issues about care that have to be re-evaluated periodically.  This ethics article  about two preterm infants with the same condition is an important  step in thinking about this  issue.

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Wednesday, April 30, 2014

Sibling Donors for Pediatric Stem Cell Transplant: Do (or Should) They Have a Say?

Photo by Andrew Nourse via Flickr
It is common to consider a sibling a possible donor for
a pediatric hematopoietic stem cell transplant, even when that sibling is a child or adolescent.

Yet how often are these potential donors informed about the risks and benefits of being a donor, and should parents insist they be told? Better yet, do parents feel siblings should even be given a choice in the decision to be a donor for their sibling?

Pentz et al. (doi:10.1542/peds.2013-3067) tackle this ethically challenging topic by sharing the results of qualitative interviews with more than 30 families (and over a hundred family members) who were interviewed pre- and post-transplant, regarding siblings being given a choice or concerns that parents and siblings had about being worked up as donors for transplant.

Clearly, this is a controversial area, so we also enlisted two medical ethicists Drs. Lainie Ross and Armand Antommaria (doi: 10.1542/peds.2014-0375) to reflect on the findings in this study in an accompanying commentary.

Whether or not you have had one of your patients undergo a bone marrow transplant from a sibling donor, you will find these two articles well-worth your consideration and reflection as to your role in making sure siblings are fully informed before they are evaluated as prospective donors.

Related Reading:

Wednesday, November 13, 2013

Low or Traditional Oxygen Strategies for Preterm Neonates—Which Do You SUPPORT?

There has been much in the news about the SUPPORT trial, which involved enrolling babies in a prospective randomized trial to evaluate different approaches to the provision of supplemental oxygen.

Photo by minder via Pixabay
Kapadia et al. (doi: peds.10.1542/2013-0978) share some results of this trial in an early release study made available this week prior to official publication next month. While the results are certainly well-worth learning about, there is also the ethical issue of whether or not infants should have been entered into this trial in the first place given the uncertainty of the benefits versus the risks of different oxygen strategies prior to learning from this study.

Our own journal Ethics Rounds editor Dr. John Lantos (doi: peds.10.1542/2013-1292) offers a unique and important viewpoint on the controversy surrounding this study also being released this week. Read both this important study and commentary so you can breathe more easily when it comes to understanding what the issues are or are not in this controversial area of newborn resuscitation.