How clinicians discuss patients' donor registrations of consent and presumed consent in donor conversations in an opt-out system: a qualitative embedded multiple-case study.

BACKGROUND: The Netherlands introduced an opt-out donor system in 2020. While the default in (presumed) consent cases is donation, family involvement adds a crucial layer of influence when applying this default in clinical practice. We explored how clinicians discuss patients' donor registrations of (presumed) consent in donor conversations in the first years of the opt-out system. METHODS: A qualitative embedded multiple-case study in eight Dutch hospitals. We performed a thematic analysis based on audio recordings and direct observations of donor conversations (n = 15, 7 consent and 8 presumed consent) and interviews with the clinicians involved (n = 16). RESULTS: Clinicians' personal considerations, their prior experiences with the family and contextual factors in the clinicians' profession defined their points of departure for the conversations. Four routes to discuss patients' donor registrations were constructed. In the Consent route (A), clinicians followed patients' explicit donation wishes. With presumed consent, increased uncertainty in interpreting the donation wish appeared and prompted clinicians to refer to "the law" as a conversation starter and verify patients' wishes multiple times with the family. In the Presumed consent route (B), clinicians followed the law intending to effectuate donation, which was more easily achieved when families recognised and agreed with the registration. In the Consensus route (C), clinicians provided families some participation in decision-making, while in the Family consent route (D), families were given full decisional capacity to pursue optimal grief processing. CONCLUSION: Donor conversations in an opt-out system are a complex interplay between seemingly straightforward donor registrations and clinician-family interactions. When clinicians are left with concerns regarding patients' consent or families' coping, families are given a larger role in the decision. A strict uniform application of the opt-out system is unfeasible. We suggest incorporating the four previously described routes in clinical training, stimulating discussions across cases, and encouraging public conversations about donation.

Where medical education meets artificial intelligence: 'Does technology care?'

'COLD' TECHNOLOGIES AND 'WARM' HANDS-ON MEDICINE NEED TO WALK HAND-IN-HAND: Technologies, such as deep learning artificial intelligence (AI), promise benign solutions to thorny, complex problems; but this view is misguided. Though AI has revolutionised aspects of technical medicine, it has brought in its wake practical, conceptual, pedagogical and ethical conundrums. For example, widespread adoption of technologies threatens to shift emphasis from 'hands-on' embodied clinical work to disembodied 'technology enhanced' fuzzy scenarios muddying ethical responsibilities. Where AI can offer a powerful sharpening of diagnostic accuracy and treatment options, 'cold' technologies and 'warm' hands-on medicine need to walk hand-in-hand. This presents a pedagogical challenge grounded in historical precedent: in the wake of Vesalian anatomy introducing the dominant metaphor of 'body as machine,' a medicine of qualities was devalued through the rise of instrumental scientific medicine. The AI age in medicine promises to redouble the machine metaphor, reducing complex patient experiences to linear problem-solving interventions promising 'solutionism.' As an instrumental intervention, AI can objectify patients, frustrating the benefits of dialogue, as patients' complex and often unpredictable fleshly experiences of illness are recalculated in solution-focused computational terms. SUSPICIONS ABOUT SOLUTIONS: The rate of change in numbers and sophistication of new technologies is daunting; they include surgical robotics, implants, computer programming and genetic interventions such as clustered regularly interspaced short palindromic repeats (CRISPR). Contributing to the focus of this issue on 'solutionism,' we explore how AI is often promoted as an all-encompassing answer to complex problems, including the pedagogical, where learning 'hands-on' bedside medicine has proven benefits beyond the technical. Where AI and embodied medicine have differing epistemological, ontological and axiological roots, we must not imagine that they will readily walk hand-in-hand down the aisle towards a happy marriage. Their union will be fractious, requiring lifelong guidance provided by a perceptive medical education suspicious of 'smart' solutions to complex problems.

Effects of a Cognitively Demanding Aerobic Intervention During Recess on Children's Physical Fitness and Executive Functioning.

The objective of this study was to analyze the effects of a physical activity program including both aerobic exercise and cognitively engaging physical activities on children's physical fitness and executive functions. Children from 3 primary schools (aged 8-12 years) were recruited. A quasi-experimental design was used. Children in the intervention group (n = 53; 19 boys, 34 girls) participated in a 22-week physical activity program for 30 min during lunch recess, twice a week. Children in the control group (n = 52; 32 boys, 20 girls) followed their normal lunch routine. Aerobic fitness, speed and agility, and muscle strength were assessed using the Eurofit test battery. Executive functions were assessed using tasks measuring inhibition (Stroop test), working memory (Visual Memory Span test, Digit Span test), cognitive flexibility (Trailmaking test), and planning (Tower of London). Children in the intervention group showed significantly greater improvement than children in the control group on the Stroop test and Digit Span test, reflecting enhanced inhibition and verbal working memory skills, respectively. No differences were found on any of the physical fitness variables. A physical activity program including aerobic exercise and cognitively engaging physical activities can enhance aspects of executive functioning in primary school children.

Associations between daily physical activity and executive functioning in primary school-aged children.

OBJECTIVES: While there is some evidence that aerobic fitness is positively associated with executive functioning in children, evidence for a relation between children's daily physical activity and their executive functioning is limited. The objective was to examine associations between objectively measured daily physical activity (total volume, sedentary behavior, moderate to vigorous physical activity) and executive functioning in children. DESIGN: Cross-sectional. METHODS: Eighty primary school children (36 boys, 44 girls) aged 8-12 years old participated in the study. Physical activity was measured using accelerometers. Executive functions measured included inhibition (Stroop test), working memory (Visual Memory Span test), cognitive flexibility (Trailmaking test), and planning (Tower of London). Total volume of physical activity, time spent in sedentary behavior and moderate to vigorous physical activity were calculated and related to performance on executive functioning. RESULTS: More time spent in sedentary behavior was related to worse inhibition (r = -0.24). A higher total volume of physical activity was associated with better planning ability, as reflected by both a higher score on the Tower of London (r = 0.24) and a shorter total execution time (r = -0.29). Also, a significant moderate correlation was found between time spent in moderate to vigorous physical activity and the total execution time of the Tower of London (r = -0.29). CONCLUSIONS: Children should limit time spent in sedentary behavior, and increasing their total physical activity. Total volume of physical activity, which consisted mostly of light intensity physical activity, is related to executive functioning. This opens up new possibilities to explore both the quantity and quality of physical activity in relation to cognition in children.

Relationship between physical activity and physical fitness in school-aged children with developmental language disorders.

Children with developmental language disorders (DLD) often experience difficulty in understanding and engaging in interactive behavior with other children, which may lead to reduced daily physical activity and fitness levels. The present study evaluated the physical activity and physical fitness levels of 8-11 year old children with DLD (n = 27) and compared this to typically developing (TD) age and gender matched controls (n = 27). In addition, it was investigated whether interrelationships existed between physical activity and physical fitness in children with DLD and in TD children. Physical activity was measured using accelerometers. Physical fitness was measured using five tests of the Eurofit test battery (standing broad jump (SBJ), sit-ups (SUP), handgrip (HG), 10 × 5 m shuttle run (10 × 5 m SR), and the 20 m shuttle run test (20 m SR)). Physical activity of children with DLD did not significantly differ from TD children. Physical fitness of children with DLD was significantly lower on the SBJ, SUP, HG and 10 × 5 m SR than TD controls, while no significant difference was found on the 20 m SR. Strong significant relationships were found between physical activity variables and sedentary behavior and some physical fitness measures (SBJ and SUP) in children with DLD, while in TD children a strong significant relationship was found between time spent in moderate to vigorous physical activity and performance on the SBJ. This study reveals important differences in fitness between children with DLD and TD children, which should be taken into account when creating physical activity interventions. Special attention has to be paid to children with DLD who show low physical activity and low physical fitness performance.