Medical decision-making in paediatrics: Infancy to adolescence.

Medical decision-making in the paediatric population is complicated by the wide variation in physical and psychological development that occurs as children progress from infancy to adolescence. Parents and legal guardians are the de facto decision-makers in early infancy, but thereafter, the roles of parents/legal guardians and paediatric patients become ever more complex. Health care providers (HCPs), while not decision-makers per se, have a significant role in medical decision-making throughout childhood. This statement outlines the ethical principles of medical decision-making for HCPs involved in caring for paediatric patients. This revision focuses on individual decision-making in the context of the patient-provider relationship and provides increased guidance for dealing with disagreements.

Paediatricians, social media and blogs: Ethical considerations.

The use of blogs, Facebook and similar social networking sites is rapidly expanding and, when compared with e-mail, may be having a significantly different impact on the traditional doctor-patient relationship. Characteristics specific to these online platforms have major implications for professional relationships, including the 'Facebook effect' (the relative permanence of postings) and the 'online disinhibition effect'. The present practice point illustrates relevant ethical considerations and provides guidance to paediatricians and others concerning the prudent professional and personal use of social networking media.

L'utilisation des blogues, de Facebook et de sites de réseautage social similaires prend une expansion rapide. Par rapport aux courriels, les réseaux sociaux peuvent avoir des répercussions très différentes sur la relation classique entre le médecin et son patient. Les caractéristiques propres à ces plateformes virtuelles ont des conséquences considérables sur les relations professionnelles, y compris « l'effet Facebook ¼ (la permanence relative des textes affichés) et « l'effet de désinhibition virtuelle ¼. Le présent point de pratique illustre les considérations éthiques pertinentes et oriente les pédiatres et les autres professionnels de la santé quant à l'utilisation professionnelle et personnelle prudente des réseaux sociaux.

Chest compressions and epinephrine during resuscitation of infants born at the border of viability: Yes, no or maybe?

Neonatology, in large part due to its population of babies born at the edge of viability, is rife with bioethical issues. This unique population is at high risk of mortality and considerable neurodevelopmental morbidity. One contentious, ongoing debate concerns whether these extremely low birth weight infants born at the border of viability should, if required by the Neonatal Resuscitation Program guidelines, receive chest compressions and epinephrine as part of their delivery room resuscitation. The present article, through a case presentation and discussion based on the ethical framework of principlism, provides readers with a thoughtful approach to the controversial issue of the provision of chest compressions and epinephrine as part of resuscitation for extremely low birth weight infants born at the border of viability.

Life and death decisions in the extremely preterm infant: What happens in a level III perinatal centre?

OBJECTIVE: To describe resuscitation decisions and withdrawal of treatment practices in live-born infants at the extremes of prematurity at St Joseph's Health Care (London, Ontario). STUDY DESIGN: A retrospective chart review was conducted on all neonatal deaths between 22 weeks, zero days' and 25 weeks, six days' gestational age over an eight-year period. Documentation concerning end-of-life discussions was subjected to thematic review to limit or withhold resuscitation or withdraw treatment. RESULTS: Three hundred eighteen infants were delivered between 22 weeks, zero days' and 25 weeks, six days' gestational age. Of these, 21% of infants (67 of 318) were stillborn, 38% (121 of 318) were alive on discharge from hospital and 41% (130 of 318) died in the neonatal period. Of the live-born infants who did not survive to discharge, 34% (44 of 130) had no initial attempts at resuscitation. Withdrawal of life-sustaining treatment was the immediate cause of death in 84% of cases (61 of 73) in which the infant survived initial resuscitation. Documented parental rationale for withdrawal of treatment included "preventing pain and suffering", "not wanting (their baby) to die on a ventilator" and "poor quality of life". Families in which the mother identified as Catholic were more likely to withhold resuscitation and to withdraw life-sustaining treatment because death was imminent despite ongoing treatment. Non-Catholic families were more likely to withdraw life-sustaining treatment based on prediction of a poor long-term prognosis. CONCLUSIONS: Decisions not to initiate resuscitation remain fairly common practice at the extremes of prematurity. The majority of deaths in those who survive initial resuscitative measures are secondary to withdrawal of treatment decisions made in the neonatal intensive care unit.