RESUMO
Disagreements, including those between residents and attending physicians, are common in medicine. In this Ethics Rounds article, we present a case in which an intern and attending disagree about discharging the patient; the attending recommends that the patient be hospitalized longer without providing evidence to support his recommendation. Commentators address different aspects of the case. The first group, including a resident, focus on the intern's potential moral distress and the importance of providing trainees with communication and conflict resolution skills to address inevitable conflicts. The second commentator, a hospitalist and residency program director, highlights the difference between residents' decision ownership and attending physicians' responsibilities and the way in which attending physicians' responsibilities for patients can conflict with their roles as teachers. She also highlights a number of ways training programs can support both trainees and attending physicians in addressing conflict, including cultivating a learning environment in which questioning is encouraged and celebrated. The third commentator, a hospitalist, notes the importance of shared decision-making with patients and their parents when decisions involve risk and uncertainty. Family-centered rounds can facilitate shared decision-making.
Assuntos
Dissidências e Disputas , Médicos Hospitalares , Internato e Residência , Alta do Paciente , Infecções por Adenoviridae/complicações , Infecções por Adenoviridae/diagnóstico , Criança , Competência Clínica , Tomada de Decisão Clínica , Febre/virologia , Médicos Hospitalares/psicologia , Humanos , Masculino , Angústia PsicológicaRESUMO
Although pediatric donation of hematopoietic stem cells (HSCs) for allogeneic transplants is common in the clinical setting, the question of when children may donate HSCs in research has received little attention. Our analysis reveals that institutional review boards (IRBs) may approve children's participation as HSC donors in transplant research when it poses no more than minimal risk to them. The risks that IRBs should consider are those that result specifically from the research, as opposed to risks donors would have faced regardless of the research. Transplant protocols that expose pediatric donors to more than minimal risk can be approved by the Secretary of U.S. Department of Health and Human Services in a special category of pediatric research.
Assuntos
Pesquisa Biomédica/ética , Pesquisa Biomédica/legislação & jurisprudência , Comitês de Ética em Pesquisa/legislação & jurisprudência , Transplante de Células-Tronco Hematopoéticas/métodos , Doadores de Tecidos/legislação & jurisprudência , Fatores Etários , Criança , Transplante de Células-Tronco Hematopoéticas/ética , Humanos , Fatores de Risco , Doadores de Tecidos/ética , Estados Unidos , United States Dept. of Health and Human ServicesRESUMO
OBJECTIVE: To assess neonatologists' attitudes and practices regarding treatment of extremely preterm infants in the delivery room, particularly in response to parental wishes. STUDY DESIGN: Cross-sectional survey of all neonatologists in Sweden registered with the Swedish Pediatric Society. RESULTS: The response rate was 71% (88 of 124 neonatologists). At 24[1/7] to 24[6/7] weeks of gestation, 68% of neonatologists considered treatment clearly beneficial; at 25[1/7] to 25[6/7] weeks of gestation, 93% considered it clearly beneficial. When respondents consider treatment clearly beneficial, 97% reported that they would resuscitate in the delivery room despite parental requests to withhold treatment. At or below 23[0/7] weeks of gestation, 94% of neonatologists considered treatment futile. Nineteen percent reported that they would provide what they consider futile treatment at parental request. When respondents consider treatment to be of uncertain benefit, 99% reported that they would resuscitate when parents request it, 99% reported that they would resuscitate when parents are unsure, and 25% reported that they would follow parental requests to withhold treatment. CONCLUSION: Although neonatologists' attitudes and practices varied, respondents to our survey in general envisioned little parental role in delivery room decision-making for extremely preterm infants.
Assuntos
Atitude do Pessoal de Saúde , Tomada de Decisões , Recém-Nascido Prematuro , Neonatologia/normas , Padrões de Prática Médica , Ressuscitação/estatística & dados numéricos , Adulto , Estudos Transversais , Salas de Parto , Feminino , Humanos , Recém-Nascido , Pessoa de Meia-Idade , Gravidez , Suécia , Suspensão de TratamentoRESUMO
OBJECTIVES: To assess attitudes of neonatologists toward parental wishes in delivery room resuscitation decisions at the threshold of viability. STUDY DESIGN: Cross-sectional survey of the 175 practicing level II/III neonatologists in six New England states. RESULTS: Response rate was 85% (149/175). At 24 1/7-6/7 weeks' gestation, 41% of neonatologists considered treatment clearly beneficial, and at 25 1/7-6/7 weeks' gestation, 84% considered treatment clearly beneficial. When respondents consider treatment clearly beneficial, 91% reported that they would resuscitate in the delivery room despite parental requests to withhold. At or below 23 0/7 weeks' gestation, 93% of neonatologists considered treatment futile. Thirty-three percent reported that they would provide what they consider futile treatment at parental request. When respondents consider treatment to be of uncertain benefit, all reported that they would resuscitate when parents request it, 98% reported that they would resuscitate when parents are unsure, and 76% reported that they would follow parental requests to withhold. CONCLUSIONS: Variation in neonatologists' beliefs about the gestational age bounds of clearly beneficial treatment and attitudes toward parental wishes in the context of uncertainty is likely to impact the manner in which they discuss options with parents before delivery. This supports the importance of transparency in neonatal decision-making.
Assuntos
Atitude do Pessoal de Saúde , Recém-Nascido Prematuro , Consentimento dos Pais/psicologia , Médicos/psicologia , Ordens quanto à Conduta (Ética Médica)/psicologia , Viabilidade Fetal , Idade Gestacional , Humanos , Recém-Nascido , New England , PrognósticoRESUMO
OBJECTIVE: Existing studies present conflicting evidence for the role of cigarette smoking as a risk factor in the development of systemic lupus erythematosus (SLE). We performed an extensive search of the medical literature for all studies examining this relationship, and performed a meta-analysis to arrive at a more precise estimate of effect. METHODS: We performed a computerized literature search for all studies (in all languages), using Medline and EMBASE (1966 to present) and the Cochrane Collaboration database, and completed hand searches of relevant bibliographies and abstracts of conference proceedings. Several investigators systematically extracted data from the relevant studies. Unpublished data were obtained from the author of one abstract. Studies were examined in aggregate for heterogeneity and publication bias. The relationships of current smoking and past smoking (prior to the onset of SLE) to development of SLE were analyzed separately. RESULTS: Fifty-two studies were identified and chosen for detailed review. Of these, 9 (7 case-control and 2 cohort studies) were appropriate for inclusion in our meta-analyses. For current smokers compared with nonsmokers, the odds ratio (OR) for development of SLE was significantly elevated (OR 1.50, 95% confidence interval [95% CI] 1.09-2.08). Former smokers, compared with nonsmokers, did not demonstrate an increased risk of SLE (OR 0.98, 95% CI 0.75-1.27). Several subgroups were also analyzed. CONCLUSION: Our meta-analysis of the 7 existing case-control and 2 cohort studies revealed a small but statistically significant association between current smoking and development of SLE. However, no association between past smoking and development of SLE was observed.
Assuntos
Lúpus Eritematoso Sistêmico/etiologia , Fumar/efeitos adversos , Estudos de Casos e Controles , Estudos de Coortes , Humanos , Razão de ChancesRESUMO
BACKGROUND: Viral respiratory tract infections and atopy are associated with attacks of wheezing during childhood. However, information about the relationship between viral infections and atopy among children whose attacks of wheezing lead to hospitalization is unclear. OBJECTIVE: To evaluate the prevalence of viral respiratory tract pathogens among infants and children hospitalized for wheezing and to analyze the results in relation to the patient's age, atopic characteristics, and season of admission. METHODS: This was a case-control study of children (age 2 months to 18 years) admitted for wheezing to the University of Virginia Medical Center over a period of 12 months. Children without wheezing were enrolled as controls. Nasal secretions were evaluated for viral pathogens by using cultures, PCR tests, and antigen detection. Total IgE and specific IgE antibody to common aeroallergens was measured in serum. RESULTS: Seventy percent of children hospitalized for wheezing before age 3 years (n=79) were admitted between December and March, whereas 46% of children age 3 to 18 years (n=54) were hospitalized between September and November. Among children younger than 3 years, viral pathogens were detected in 84% (66/79) of wheezing children and 55% (42/77) of controls (P <.001). Respiratory syncytial virus was the dominant pathogen during the winter months, but rhinovirus was more common during other months. Total serum IgE levels were generally low, and values from wheezing and control subjects overlapped considerably. Among children 3 years and older, 61% (33/54) of subjects admitted for wheezing tested positive for virus (predominantly rhinovirus), compared with 21% (12/56) of controls (P <.001). The total serum IgE values among wheezing children (geometric mean, 386 IU/mL; 95% CI, 259-573) were substantially elevated compared with those of controls (geometric mean, 38 IU/mL; 95% CI, 26-56; P <.001). A significantly higher percentage of wheezing children compared with controls was sensitized to at least 1 of the inhaled allergens tested: 84% (36/43) compared with 33% (15/45; P <.001). The atopic characteristics of wheezing children who tested positive or negative for virus were similar. CONCLUSIONS: Viral infections were the dominant risk factor for wheezing among children hospitalized before 3 years of age. By comparison, a large majority of the wheezing children age 3 to 18 years had striking atopic characteristics that may be critical as a risk factor for hospitalization and an adverse response to viral infections, especially infections caused by rhinovirus.