Nudging During Pediatric Intensive Care Conferences With Family Members: Retrospective Analysis of Transcripts From a Single-Center, 2015-2019.

OBJECTIVES: Nudging, a behavioral economics concept, subtly influences decision-making without coercion or limiting choice. Despite its frequent use, the specific application of nudging techniques by clinicians in shared decision-making (SDM) is understudied. Our aim was to analyze clinicians' use of nudging in a curated dataset of family care conferences in the PICU. DESIGN: Between 2019 and 2020, we retrospectively studied and coded 70 previously recorded care conference transcripts that involved physicians and families from 2015 to 2019. We focused on decision-making discussions examining instances of nudging, namely salience, framing, options, default, endowment, commission, omission, recommend, expert opinion, certainty, and social norms. Nudging instances were categorized by decision type, including tracheostomy, goals of care, or procedures. SETTING: Single-center quaternary pediatric facility with general and cardiac ICUs. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS: We assessed the pattern and frequency of nudges in each transcript. MAIN RESULTS: Sixty-three of the 70 transcripts contained SDM episodes. These episodes represented a total of 11 decision categories based on the subject matter of nudging instances, with 308 decision episodes across all transcripts (median [interquartile range] 5 [4-6] per conference). Tracheostomy was the most frequently discussed decision. A total of 1096 nudging instances were identified across the conferences, with 8 (6-10) nudge types per conference. The most frequent nudging strategy used was gain frame (203/1096 [18.5%]), followed by loss frame (150/1096 [13.7%]). CONCLUSIONS: Nudging is routinely employed by clinicians to guide decision-making, primarily through gain or loss framing. This retrospective analysis aids in understanding nudging in care conferences: it offers insight into potential risks and benefits of these techniques; it highlights ways in which their application has been used by caregivers; and it may be a resource for future trainee curriculum development.

Nonresuscitation Fluid Accumulation and Outcomes After Pediatric Cardiac Surgery: Single-Center Retrospective Cohort Study.

OBJECTIVES: Postoperative patients after congenital cardiac surgery are at high risk of fluid overload (FO), which is known to be associated with poor outcomes. "Fluid creep," or nonresuscitation IV fluid in excess of maintenance requirement, is recognized as a modifiable factor associated with FO in the general PICU population, but has not been studied in congenital cardiac surgery patients. Our objective was to characterize fluid administration after congenital cardiac surgery, quantify fluid creep, and the association between fluid creep, FO, and outcome. DESIGN: Retrospective, observational cohort study. SETTING: Single-center urban mixed-medical and cardiac PICU. PATIENTS: Patients admitted to the PICU after cardiac surgery between January 2010 and December 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1,459 postoperative encounters with 1,224 unique patients. Total fluid intake was greater than maintenance requirements on 3,103 of 4,661 patient days (67%), with fluid creep present on 2,624 patient days (56%). Total nonresuscitation intake was higher in patients with FO (defined as cumulative fluid balance 10% above body weight) versus those without. Fluid creep was higher among patients with FO than those without for each of the first 5 days postoperatively. Each 10 mL/kg of fluid creep in the first 24 hours postoperatively was associated with 26% greater odds of developing FO (odds ratio [OR] 1.26; 95% CI, 1.17-1.35) and 17% greater odds of mortality (OR 1.17; 95% CI, 1.05-1.30) after adjusting for risk of mortality based on surgical procedure, age, and day 1 resuscitation volume. Increasing fluid creep in the first 24 hours postoperatively was associated with increased postoperative duration of mechanical ventilation and PICU length of stay. CONCLUSIONS: Fluid creep is present on most postoperative days for pediatric congenital cardiac surgery patients, and fluid creep is associated with higher-risk procedures. Fluid creep early in the postoperative PICU stay is associated with greater odds of FO, mortality, length of mechanical ventilation, and PICU length of stay. Fluid creep may be under-recognized in this population and thus present a modifiable target for intervention.

Cardiac critical care of the post-operative congenital heart disease patient.

Cardiac critical care has become an increasingly complex subspecialty, involving multiple subspecialists to support patients with congenital heart disease. This requires understanding of their physiology and the impact of medical interventions. The purpose of this article is to provide a concise review of the current strategies utilized by cardiac intensivists to optimize outcomes for this vulnerable patient population, with the goal of broadening the knowledge of other members of the multi-disciplinary team.

The True Abuse of Futility.

Futility has wrongly been applied over the past decades to clinical scenarios where treatment disputes exist, but where true physiological futility is not certain. This particularly applies to the pediatric critical care arena, where a major source of ethical debate and moral concern surrounds decisions about appropriateness of treatment, and not necessarily futility. In the pediatric intensive care unit, Schneiderman and colleagues' (2017) definitions of quantitative and qualitative futility are rarely applicable. Attempted alterations to the definition of futility have failed to encapsulate the complex and complicated clinical scenarios encountered, as well as the difficulty of balancing the provision of best medical advice with parental values and authority. The Multiorganization Policy Statement recognizes the difference between futile and potentially inappropriate treatments and puts forth communication strategies to reconcile disputes about the latter. This approach is of value to the greater medical community, including pediatric critical care, and also restores an important and specific meaning to the term futile-a word whose meaning should be unambiguously clear.

Grief and Burnout in the PICU.

Doctors and nurses who work in PICUs often deal with emotionally difficult events. These events take a toll. They can cause long-term psychological problems that, if not addressed, can impair the ability of doctors and nurses to care for patients in a competent and compassionate manner. Furthermore, effective treatment is available. But there is a paradox. To get treatment, one must acknowledge the problem. Acknowledgment of the problem may not be encouraged, or may be discouraged and stigmatized, in the intensive care culture. This article describes a case in which a physician has classic signs of overwhelming grief and burnout, and it discusses the appropriate response.

Are we allowed to discontinue medical treatment in this child?

One of the most difficult ethical dilemmas in pediatrics today arises when a child has complex chronic conditions that are not curable and cause discomfort with no prospect of any improvement on quality of life. In the context of medical futility, it is harmful to prolong medical treatment. The question is: How can medical treatment be discontinued when the child is not dependent on mechanical ventilation or ICU treatment? What is the appropriate palliative care and does it justify the use of sedatives or analgesics if this also might shorten life?