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.

"We're Performing Improvisational Jazz": Interprofessional Pediatric Palliative Care Fellowship Prepares Trainees for Team-Based Collaborative Practice.

CONTEXT: Interprofessional education (IPE) prepares clinicians for collaborative practice, yet little is known about the effectiveness of postgraduate IPE. OBJECTIVES: This is the first study to describe educational outcomes of an interprofessional fellowship in pediatric palliative care. Objectives were to understand the experiences of postgraduate trainees in an interprofessional, clinical environment and to evaluate program effect on interprofessional competencies. METHODS: In this mixed-methodology study, we surveyed former fellows from 2002 to 2018 about their fellowship experience and perceived change in interprofessional skills. We performed qualitative semantic content analysis of fellows' responses about learning in an interprofessional context. We compared fellows' self-rated ability (5-point Likert scale), before and after fellowship, in 10 interprofessional competencies selected from the Interprofessional Education Collaborative's core competencies. RESULTS: Response rate was 87% (41/47). Fifty-one percent of respondents were physicians, 29% were social workers, and 20% were nurse practitioners. Respondents reported significant improvement in all 10 competencies, with summed mean scores of 2.8 ± 0.6 prefellowship ("not very well prepared") and 4.4 ± 0.4 postfellowship ("very well" to "extremely well prepared") (t = 15.6, P< 0.0001). Effect size for each competency was greater than 1.9 (strong positive impact). The fellowship experience was characterized by dynamic educational relationships: peer relationships with interprofessional co-fellows, mentoring relationships with faculty, clinical relationships with patients and families, and collaborative relationships with the healthcare system. Benefits and challenges of IPE were associated with interprofessional roles, teamwork, patient care, and educational needs. CONCLUSION: This study demonstrates the feasibility and effectiveness of an interprofessional postgraduate fellowship in preparing clinicians for collaborative practice.