Achieving consensus advice for paediatricians and other health professionals: on prevention, recognition and management of conflict in paediatric practice
Achieving consensus advice for paediatricians and other health professionals: on prevention, recognition and management of conflict in paediatric practice
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DOI：
10.1136/archdischild-2018-316485
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发表时间：
2019-05-01
影响因子：
5.2
通讯作者：
Arkell, Emily
中科院分区：
文献类型：
--
作者：
Linney, Mike;Hain, Richard D. W.;Arkell, Emily
保健专业人员和儿童的父母之间可能发生冲突，不仅在撤销或停止维持生命治疗方面存在分歧，如最近一些引人注目的病例12，而且在更一般的常规护理中也可能发生冲突。在本文中，我们试图提出一些可以减少不和谐的做法。虽然你们中的许多人已经在日常工作中采用了这些做法，但我们认为整理这份涵盖冲突明显存在时的预防、识别和管理情况的指南是有用的。它不会解决所有的冲突，显然会有其他有用的做法，但这里没有提到，同样，需要对最近的案例进行进一步的反思。在这个领域的研究有限，所以我们在撰写本文件时从临床医生、父母、家长倡导者、伦理学家和冲突调解人那里收集了证据。作为照顾儿童和青少年的医疗保健专业人员，我们所做的每一个决定都将儿童的最大利益放在心上。有关护理的决定，包括尽可能停止治疗，应始终在父母的参与下作出。在大多数情况下，这些决定是由父母和临床医生共同做出的。然而，在儿童和成人的危重疾病背景下，专业人员和家庭之间有时会出现导致冲突的分歧。临终决定和沟通失败是常见的争议领域。冲突在儿童住院病房也很普遍，工作人员报告说，最常见的原因是沟通障碍、对治疗的分歧和不切实际的期望。造成这种情况的一个原因可能是，住院儿童的父母和照料者报告从保健专业人员那里得到相互矛盾的信息。考虑到这一点，该指南虽然主要是在停止维持生命治疗的情况下制定的，但也适用于许多其他情况。在0-19岁的个体中，复杂和限制生命的疾病越来越普遍，维持生命的先进治疗形式越来越多，以及网上关于创新但未经证实的严重疾病治疗方法的大量信息，都是可能增加冲突风险的因素。此外，可能会出现与临床事实有关的分歧，例如，什么样的治疗在技术上是可行的，违反真诚和坚定的信念和价值观，应该给予什么样的治疗。皇家儿科和儿童健康学院（RCPCH）以前已经制定了关于治疗局限性的指导方针，包括关于决策和处理分歧的指导。12 .然而，最近根深蒂固的分歧与媒体的密集报道和儿童医院外的示威活动有关。13这可能对工作人员、儿童及其家庭产生深远影响。所有与儿童和青少年打交道的医疗保健专业人员不时会遇到父母对治疗计划的担忧。经验告诉我们，在医疗保健方面的分歧通常可以通过共同决策的过程来管理，父母早期积极参与，并在可能的情况下与儿童/年轻人一起参与。尽早与家人坦诚交流的重要性是不可低估的。在大多数情况下，即使在持续存在分歧的领域，也可以通过仔细倾听和理解以及在可能的情况下尽早参与调解服务来解决问题。然而，在某些情况下，讨论……
Conflict can arise between health professionals and the parents of children not only where there is disagreement on the withdrawal or withholding of life sustaining treatment, as seen in recent high-profile cases 1 2 but also in more general routine care. In this paper we attempt to suggest practices which may reduce disharmony. Although, many of you will already incorporate such practices in your daily working lives, we felt it useful to collate this guidance covering prevention, recognition and management of situations when conflict clearly exists. It will not resolve all conflicts and clearly there will be other practices which are helpful but are not mentioned here, similarly there are further reflections needed on recent cases 3 There is limited research in this field so we have taken evidence from clinicians, parents, parent advocates, ethicists and mediators of conflict in writing this document. As healthcare professionals involved in the care of children and young people, every decision we take will always have the best interests of the child at heart. Decisions on care, including the withdrawal of treatment, as far as is possible, should always be made with the involvement of parents. In the majority of cases in these decisions are made jointly by parents and clinicians. 4 However, disagreements leading to conflict can sometimes develop between professionals and families in the context of critical illness both in children and adults. 5 6 End-of-life decision making and communication failure are the common areas of dispute. 6 7 Conflict is also prevalent in children’s inpatient wards 8 where staff report communication breakdown, disagreements over treatment and unrealistic expectations as the most common causes. A contributor to this may be the fact that the parents and carers of children in hospital report receiving conflicting information from health professionals. 9 With this in mind, the guidance, although primarily developed with the withdrawal of life-sustaining treatment, will have relevance in many other scenarios. The increasing prevalence of both complex and life-limiting conditions in individuals aged 0–19 years, 10 the increasing availability of advanced forms of life-sustaining treatment and the large amount of information online about innovative but unproven treatments for serious illnesses 11 are factors that may produce increased risks of conflict. Also, disagreements may arise in relation to the clinical facts, for example, what treatment is technically feasible, against sincerely and firmly held beliefs and values as to what treatment should be given. The Royal College of Paediatrics and Child Health (RCPCH) has previously produced guidelines on limitations of treatment, including guidance around decision making and managing disagreement. 12 However, recent cases of entrenched disagreement have been associated with intense media coverage and demonstrations outside children’s hospitals. 13 This can have profound effects on staff, children and their families. All healthcare professionals working with children and young people encounter parental concerns about treatment plans from time to time. Experience teaches us that disagreements in healthcare can usually be managed by a process of shared decision making with active early involvement of parents and whenever possible with the child/young person. The importance of honest and open communication with families as early as possible cannot be understated. In most cases, even in areas of persistent disagreement, resolution can be achieved by careful listening and understanding and where possible early involvement of mediation services. However, in some circumstances, discussion …