An Ethical Claim for Providing Medical Recommendations in Pediatric Intensive Care.

The Declaration of Geneva was recently revised to emphasize patient autonomy and the importance of clinicians sharing medical knowledge. This reflects the welcome evolution of the doctor-patient relationship from one of paternalism to more informed, shared decision-making. Unfortunately, there is an increasing trend for clinicians to avoid making recommendations, instead providing a "menu" of care options from which patients and families must choose. This seems to be underpinned by the belief that it is unacceptably paternalistic to give guidance as to which course of action may be best to take. In this article, we argue that there is an ethical imperative for doctors to provide medical recommendations. This is discussed with particular emphasis on the pediatric critical care setting, where autonomy and shared decision-making are especially complex. We outline how a failure to provide clinical recommendations represents inadequate shared decision-making and erodes the doctor-patient relationship, leading to suboptimal care, paradoxically decreasing respect for autonomy. We describe an approach through which doctors can avoid paternalism without placing an undue burden of decision-making on families. We assert that patients' interests are best served by clinicians taking an active, relational role in shared decision-making, including exploration of values and giving explicit medical recommendations for care.

Evaluation of a paediatric clinical ethics service.

AIM: To evaluate a paediatric clinical ethics service incorporating both normative and empirical analysis. METHODS: Section 1: Review of consensus guidelines to identify emerging standards for clinical ethics services (CES) and evaluation of the service in relation to these. Section 2: Description of service activity data. Section 3: Feedback from clinical staff involved in clinical ethics consultations was collected using a web-based survey. RESULTS: Four guideline documents were reviewed, and clear emerging consensus standards were identified. Our service fulfils identified knowledge and skill core competencies and at least partially fulfils all of the identified service-level standards. Clinicians report that clinical ethics consultation decreases their moral distress. CONCLUSIONS: There is emerging consensus for staff competencies and service-level standards for CES. The role of CES in staff well-being needs to be explored. Collaborative, multi-modal research to develop standards and evaluate CES is needed.