Ethical argument for opt-out approach to DNR status in terminally ill children

Feb 10th – Pediatrics – Ethical argument suggests why physicians, not parents, should assume moral responsibility for determining when CPR should be withheld from terminally ill children.

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1. Ethical argument suggests why physicians, not parents, should assume moral responsibility for determining when cardiopulmonary resuscitation (CPR) should be withheld from terminally ill children.

2. Physicians should present the decision to withhold CPR to parents as a strong clinical recommendation.

This article argues physicians should relieve parents of the burden of deciding whether to withhold CPR from their terminally ill children. While physicians making decisions for parents or patients can be considered paternalistic, the opt-out model proposed in this article, by which parents can opt to have CPR administered against the recommendations of physicians, achieves a balance between respecting patient autonomy and promoting familial welfare. Authors argue physicians caring for terminally ill children should adopt palliative care-based discussion techniques whereby physicians elicit parental hopes and goals for their family, then employ a goal-oriented directive approach to end-of-life discussions whereby parental choices are limited to potentially therapeutic options.

Limitations of this article include a lack of empirical research on the impact of the parental role in establishing do not resuscitate orders for children. Such information could support or discredit the key assertions of authors: that an opt-out approach is no worse for children’s well-being and improves family cohesiveness. Strengths of this argument include its grounding in conversational approaches taken from palliative care research as well as the American Academy of Pediatrics’ policy statement that CPR is inappropriate when it is harmful, of no benefit, or futile. Future research could explore the merits of this ethical argument by investigating parent and provider satisfaction with the opt-out conversational and therapeutic approach.

Click to read the study in Pediatrics

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Image: PD

1. Ethical argument suggests why physicians, not parents, should assume moral responsibility for determining when cardiopulmonary resuscitation (CPR) should be withheld from terminally ill children.

2. Physicians should present the decision to withhold CPR to parents as a strong clinical recommendation.

This [ethics] article: addressed who can most appropriately make the decision to withhold CPR from terminally ill children. Authors used data from clinical cases, ethical literature about parent-physician trust and responsibilities, rulings from legal cases that define the limitations of parental rights in resuscitation, and qualitative studies exploring how families experience end-of-life care.

Authors conclude that aspects of the parent-child bond can disallow parents from making objective decisions about forgoing CPR, even when CPR will prolong suffering. Instead, the provider has a duty to decide when to withhold CPR. Providers also have a duty to communicate their decision to the parents as a clinical recommendation. Ideally, this provider-parent conversation would refocus parents’ decision from whether to forgo CPR to how to best promote patient and familial welfare.

In sum: This article argues physicians should relieve parents of the burden of deciding whether to withhold CPR from their terminally ill children. While physicians making decisions for parents or patients can be considered paternalistic, the opt-out model proposed in this article, by which parents can opt to have CPR administered against the recommendations of physicians, achieves a balance between respecting patient autonomy and promoting familial welfare. Authors argue physicians caring for terminally ill children should adopt palliative care-based discussion techniques whereby physicians elicit parental hopes and goals for their family, then employ a goal-oriented directive approach to end-of-life discussions whereby parental choices are limited to potentially therapeutic options.

Limitations of this article include a lack of empirical research on the impact of the parental role in establishing do not resuscitate orders for children. Such information could support or discredit the key assertions of authors: that an opt-out approach is no worse for children’s well-being and improves family cohesiveness. Strengths of this argument include its grounding in conversational approaches taken from palliative care research as well as the American Academy of Pediatrics’ policy statement that CPR is inappropriate when it is harmful, of no benefit, or futile. Future research could explore the merits of this ethical argument by investigating parent and provider satisfaction with the opt-out conversational and therapeutic approach.

Click to read the study in Pediatrics

By Caroline Huang and Leah Hawkins

More from this author: Positive response to alcohol ads in young adolescence associated with alcohol-related problems later, Knowledge of breast cancer overdiagnosis changes attitudes toward treatment, screening, Pediatric providers who completed tobacco education program more likely to educate parental smokers about quitting

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