The impact of adverse childhood experiences on adolescent health risk indicators in a community sample.

OBJECTIVE: Despite growing awareness of the high prevalence of adverse childhood experiences (ACEs) in community samples of adolescents, little work has examined the impact of ACEs on adolescence and well-being during this critical period of development. Much research has focused on retrospective reports of ACEs by adults and adult physical and mental health, finding that ACEs contribute to a range of diseases and mental health disorders in adulthood. This study examined differences in self-reported mental health, nonsuicidal self-injury, suicidality, violence, and substance use between adolescents without self-reported history of ACEs, youth with one self-reported ACE, and youth with self-reported multiple (2 or more) ACEs. METHOD: The sample included 1,532 adolescents who completed the Youth Risk Behavior Surveillance Survey in their local high schools. By local consensus, this national survey was augmented with questions exploring prevalence of 11 commonly identified ACEs. RESULTS: After controlling for age, gender, and race, youth with multiple ACEs reported 3 to 15 times the odds of a range of negative health experiences. CONCLUSIONS: Findings indicate a serious burden of ACEs on adolescent social emotional well-being. This study did not include youth in out of school placements or who were not present the day the survey was given, and thus represent youth who may benefit from universal prevention and intervention programs. Universal screening of ACEs and health-related outcomes suggests that reporting multiple ACEs is strongly related to a wide range of mental health, violence, and substance use histories. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies.

PURPOSE: Poor documentation and understanding of the limitations of life-sustaining therapies upon admission to the pediatric intensive care unit (PICU) can result in moral distress for both providers and families. Limitations of life-sustaining treatments are often not documented and/or understood by members of the health care team. METHODS: We performed a quality improvement initiative to improve the care teams' understanding and paper documentation of the limitations of life-sustaining therapies in the PICU of a quaternary children's hospital from January 2018 to March 2019. We implemented a series of plan-do-study-act cycles, including initiation of an updated rounding tool that included limitations of interventions, in-person and electronic information sessions, and implementation of a visual bedside tool to remind providers when limitations were present. Pre- and postintervention surveys were administered. RESULTS: Nursing paper documentation of limitations of life-sustaining therapies increased sequentially from 0% to 88% during plan-do-study-act cycles. Creating a specific area to document limitations on the nursing sheet resulted in the most significant increase in documentation (36.6 points). Nurses reported that they "always" document limitations, which increased from 10% to 38%. The percentage of nurses who understood patients' intervention limitations increased from 28% to 33%. CONCLUSIONS: Limitations of life-sustaining therapies in the PICU are nuanced and involve multiple stakeholders. Nursing education and designation of a section of intervention limitations in nursing daily goal paper documentation can increase comfort with therapeutic limitations in the PICU. Future studies should explore impacts on patient care and serve as a framework for the ultimate goal of improving documentation of care limitations and code status in the electronic medical record.

Communication Skills and Practices Vary by Clinician Type.

OBJECTIVES: Unscheduled admission to the PICU is a stressful experience for families. During the admission process, families communicate with 4 types of clinicians (resident, nurse practitioner, fellow, and attending physician). All clinicians must manage family stress while communicating concise, accurate information. The manner and variability in how different clinicians communicate with families at the time of PICU admission is not yet known. METHODS: We performed a prospective observational study to evaluate communication patterns of various clinician types, including the length of communication encounters and the number of provider interruptions at the time of admission to the PICU during a 3-month period. All nonscheduled admissions to the PICU were eligible for enrollment. The admission intake was audio recorded and directly observed. RESULTS: We observed 45 different family-clinician interactions for a total of 19 unique family encounters (48% of eligible admissions). Residents and nurse practitioners spent the most time communicating with families (14.3 and 19 minutes, respectively) compared with fellows (7.3 minutes) and attending physicians (6.6 minutes). Residents were frequently interrupted by pages and phone calls (64% of interactions) and spoke at a higher reading level than all other clinician types (P = .03; 95% confidence interval 74.6-83.9). Qualitatively, residents had more challenges coping with distractions, acknowledging parental emotions, and aligning with parental goals compared with other clinician types. CONCLUSIONS: Resident trainees spend significantly more time with families and, during this time, are burdened with frequent interruptions. In this stressful communication environment, residents encounter more barriers to communication and may require additional communication skills to manage relaying complex information while simultaneously responding to parental emotions.

Parental Conflict, Regret, and Short-term Impact on Quality of Life in Tracheostomy Decision-Making.

OBJECTIVES: The prevalence of tracheostomy-dependence in critically ill children is increasing in the United States. We do not know the impact of this decision on parental outcomes. We aimed to determine the prevalence of decisional conflict and regret and explore the impact on quality of life among parents considering tracheostomy placement for their child. SUBJECTS: Parents facing tracheostomy decision for their child. DESIGN: Prospective, mixed-methods longitudinal study. SETTING: PICU, cardiac ICU, and neonatal ICU of a single quaternary medical center. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Parents completed a decisional conflict survey at the time of tracheostomy decision and decisional regret and quality of life surveys at 2 weeks and 3 months after the decision regarding tracheostomy placement was made. We enrolled 39 parents, of which 25 completed surveys at all three time points. Thirty-five of 39 (89.7%) reported at least some decisional conflict, most commonly from feeling uninformed and pressured to make a decision. At 2 weeks, 13 of 25 parents (52%) reported regret, which increased to 18 of 25 participants (72%) at 3 months. Regret stemmed from feeling uninformed, ill-chosen timing of placement, and perceptions of inadequate medical care. At 2 weeks, the quality of life score was in the mid-range, 78.8 (SD 13.8) and decreased to 75.5 (SD 14.2) at 3 months. Quality of life was impacted by the overwhelming medical care and complexity of caring for a child with a tracheostomy, financial burden, and effect on parent's psychosocial health. CONCLUSIONS: The decision to pursue tracheostomy among parents of critically ill children is fraught with conflict with worsening regret and quality of life over time. Strategies to reduce contributing factors may improve parental outcomes after this life-changing decision.

Crowdsourced analysis of factors and misconceptions associated with parental willingness to donate their child's organs.

We evaluated factors associated with a parental willingness to donate their child's organs. A twenty-one-question survey was administered to US parents with at least one child to measure organ donation acceptability and brain death beliefs using an online crowdsourcing medium, Amazon's Mechanical Turk Prime. We collected 425 surveys; 76% were willing to donate their own and 65% willing to donate their child's organs. Parents who agreed brain death was synonymous with death (47%) were 2.37 times more willing to donate. Compared with White respondents, Black (OR 5.27, CI 2.81, 9.88) and Hispanic (OR 2.24, CI 1.06-4.75) participants were more likely to believe doctors "steal organs from patients" and "declare someone dead based on their skin color" (OR 4.97, CI 2.65-9.32; OR 2.19, CI 1.01-4.72, respectively). Lower income participants were also more likely to believe doctors "steal organs from patients," OR 0.81 (95% CI 0.68-0.96 for increasing income) and "declare someone dead based on how much money they have," OR 0.80 (95% CI 0.67-0.96 for increasing income). Confusion surrounding brain death and skepticism (particularly among racial and ethnic minorities and lower socioeconomic groups) toward doctors' motivations for donation contribute to lack of parental willingness to donate.

Investigation of Public Perception of Brain Death Using the Internet.

BACKGROUND: Brain death is a difficult concept for the public to comprehend, resulting in a reliance on alternative resources for clarity. This study aims to understand the public's perception of brain death via analysis of information on the Internet, determine the accuracy of that information, and understand how its perception affects the physician-patient relationship. METHODS: We conducted a prospective cross-sectional study to evaluate information available to the public about brain death. The top 10 Google websites were analyzed for language complexity and accuracy in describing brain death. The top 10 YouTube videos were examined for content and the comments qualitatively analyzed for themes. RESULTS: Inaccuracies describing brain death inconsistent with national guidelines were prevalent amongst 4 of 10 Google websites, 6 of 10 YouTube videos, and 80% of YouTube comments. On average, Google websites were written at a 12th grade level and 90% mentioned organ donation. Videos were frequently emotional (78%); 33% included negative comments toward physicians, of which 50% mentioned organ donation. All videos included clarification comments questioning the differences between brain death, death, coma, and persistent vegetative states. CONCLUSIONS: The study revealed a significant amount of inaccurate information about brain death, affecting the public's understanding of the concept of brain death and resulting in negative emotions specifically toward physicians, and the link between brain death and organ donation. The medical community can improve understanding through consistent, simplified language, dissociating brain death from organ donation, and recognizing the emotions tied to discussions of brain death.