EXECUTIVE SUMMARY

A unilateral do not attempt resuscitation order only is appropriate in very limited circumstances in pediatric care, concludes a recent paper. Some ethical approaches include the following:

• holding an open discussion between parents and members of the clinical team;

• using a shared decision-making process;

• supporting clinicians who express discomfort with parental decisions.


A unilateral “do not attempt resuscitation” (DNAR) order only is appropriate in very limited circumstances in pediatric care, according to a recent paper.1

“It is always challenging when patients and the medical team disagree about care plans, particularly so at or near the end of life,” says lead author Jonathan M. Marron, MD, MPH, a clinical ethicist at Boston Children’s Hospital. Marron also is a postdoctoral research scholar at Harvard Medical School’s Center for Bioethics.

Shared decision-making encourages the medical team and patient or surrogate to work collaboratively to decide on an appropriate treatment plan, in light of the medical facts and the patient’s preferences and values. “But what happens when there is disagreement about what is ‘appropriate?’” asks Marron. “And how does the added layer of complexity of a parent making choices for her child change this decision-making calculus?”

The researchers became acutely aware of these challenges when caring for a patient with end-stage liver disease for whom liver transplant was not possible. The mother wished to provide CPR if her infant son were to have a cardiopulmonary arrest. The medical team was unsure if performing CPR was medically appropriate, given that there were no curative options. “We wanted to explore the role of the unilateral DNAR order in pediatrics, using this case as a jumping-off point,” says Marron.

The fact that everyone involved in the care for children is “incredibly emotionally invested” can lead to disagreements that can be particularly entrenched and even contentious, says Marron.

Parents wish to do what is best for their children. The medical team wishes to do the same: They feel it is their professional responsibility and moral obligation. “The challenge lies in these rare cases in which stakeholders view ‘what is best’ to be different, sometimes diametrically so,” says Marron.

There is an increasing focus on how to ethically manage requests for futile or potentially harmful interventions. “We have begun to recognize that providing care that is believed to be inappropriate can cause medical providers great moral distress, and the feeling of not meeting one’s professional responsibilities,” says Marron.

Several societies have put forth professional guidelines as a process-based means to address such challenges.2,3 “But parents are not like other surrogates. Their role, and their relationship with their children, is unique and quite hallowed,” says Marron.

A previous study showed that a majority of neonatologists (76%) believed unilateral DNAR decisions are ethically permissible if survival is felt to be impossible. A minority (25%) responded that the unilateral DNAR order would be permissible based solely on poor neurological prognosis.4

“In pediatrics, we have great deference to parents’ preferences regarding the medical care for their children. Should care at the end of life be any different?” asks Marron.

Ultimately, the authors concluded that with very few exceptions, maintaining an open dialogue is preferable to unilaterally placing a DNAR order for a child.

“This strategy is not without its own challenges,” notes Marron. “But we feel it to be ethically preferable to the potentially great harm to the parent-provider alliance that could be caused by placing a unilateral DNAR order.”

Instead, the authors say, focus should be placed on open discussion between parents and members of the clinical team, shared decision-making, and maintenance of the clinician-parent relationship while simultaneously supporting members of the clinical team who express discomfort with parental decisions.

The parent-provider relationship is “incredibly important, particularly so at the end of life,” says Marron. “It is not ethically defensible to put that relationship in jeopardy when other options are available.”

REFERENCES

1. Marron JM, Jones E, Wolfe J. Is there ever a role for the unilateral do not attempt resuscitation order in pediatric care? J Pain Symptom Manage 2018; 55(1):164-171.

2. Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015; 191(11):1318-1330.

3. Kon AA, Shepard EK, Sederstrom NO, et al. Defining futile and potentially inappropriate interventions: A policy statement from the Society of Critical Care medicine ethics committee. Crit Care Med 2016; 44(9):1769-1774.

4. Murray PD, Esserman D, Mercurio MR. In what circumstances will a neonatologist decide a patient is not a resuscitation candidate? J Med Ethics 2016; 42(7):429-434.

SOURCE

• Jonathan M. Marron, MD, MPH, Clinical Ethicist, Boston Children’s Hospital. Phone: (617) 632-3453. Email: Jonathan_Marron@dfci.harvard.edu.