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Ethics and law

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G/TUES/LAW1 ETHICAL DECISION-MAKING IN PAEDIATRIC INTENSIVE CARE: WHOSE “BEST INTERESTS” ARE WE SERVING?

L. Jackman, J. Brierley, V. Larcher.Great Ormond Street Hospital, London, UK

Background: In making healthcare decisions for children deemed incompetent to make informed choices, parental views carry substantial weight. Despite the desirability of achieving consensus between parents and professionals over what constitutes a child’s best interests, disputes, which may be intransigent, can occur. This is a particular concern in the paediatric intensive care unit (PICU) setting where such decisions may have immense personal significance as well as societal and resource implications. In this context teams have a duty to consider carefully optimal strategies for resolving conflicts between parental opinion and the requirement to balance the burdens and benefits of patient care.

Objectives: To explore the practical application of ethical principles in conflict resolution and in particular the framework in which they are applied.

Cases:Case 1: A 3-year-old admitted to PICU following an episode of near drowning resulting in prolonged cardiac arrest, multi-organ failure, hypoxic brain injury and severe neurological impairment. In this case court involvement was sought by the clinical team to request permission for withdrawal of intensive care support in contrast to the family’s wishes, following a second admission to PICU in the context of a pre-existing DNAR order and failure of other forms of mediation. Case 2: An infant with hypoplastic left heart syndrome with severe cardiac failure and dependence on respiratory support on PICU despite appropriate initial surgery. The dilemma here related to conflicts regarding ongoing management. While the team consensus supported a palliative approach, the parents were in favour of further aggressive intervention. Case 3: A family who elected for termination of pregnancy following a fetal diagnosis of congenital cardiac disease, generally associated with a favourable prognosis with surgical intervention, despite detailed antenatal counselling.

Discussion: These cases highlight the difficulties healthcare …

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