Highlight doc Day 1
#ir #peds
- BIOETHICS:
- Informed Consent (c.f. assent): 1) appropriate info 2) decision-making capacity 3) voluntariness (←the 3 hallmarks of informed consent)
- Confidentiality
- Age not a factor
- Unless teen is
- Suicidal, homicidal, has thoughts of self-harm/harming others
- <16yo w/ hx of current/past abuse
- Disclosure of abuse & children <16yo in home
- Capacity & consent
- Capable if
- Able to UNDERSTAND info relevant to making decision re: tx
- Eg I’ll lose my leg if I don’t manage my DM
- And able to APPRECIATE consequences of a decision
- Eg of no appreciation: That’s in the future so I don’t care if I’ll lose my leg, I want to live my life now
- Assume everyone’s capable.
- Don’t assume incapability b/c
- Age, Refusal/Disagreement w/ tx, Request for alt tx, Psych/neuro dx, Disability
- Healthcare decisions for ped pts should be made jointly by health care team, parents, & child/adoles to varying deg
- Assent = children given info they understand & some appropriate choice in tx
- Sexual consent (Ontario): 12-13yo ± 2, 14-15yo ± 5, 16yo (no porn, prostitution, authority)
- ETHICAL PRINCIPLES
- Mother doesn’t want her child to be vaccinated. Which ethical principle would you apply to give the vaccine to the child who doesn’t have capacity? Why would you honour mom’s wishes – 2 reasons?
- Capacity (assumed, each decision): 1) understand relevant info (risks, benefits) 2) appreciate consequences
- Disagree: 1) best interests of the child (non-maleficence, beneficence), 2) justice
- Agree: 1) best interests of the child (non-maleficence, beneficence), 2) family centred-care
- Best interests of child: looking at their interests broadly & not focusing exclusively on biomed facts; value judgment; harm-benefit balance
- Family centered-care: triadic model of therapeutic relationship; child’s best interest trumps FCC
- 9yo with HIV, parents do not want child to know Dx. Give 2 reasons to support parents, 2 reasons to support informing the child. How would this change if he was 12yo?
- Agree: 1) best interests of the child (non-maleficence, beneficence), 2) family centred-care
- Disagree: 1) best interests of the child (non-maleficence, beneficence), 2) child autonomy
- ↑age: makes it more likely that child has capacity (developing child autonomy)
- Child’s need for info should be paramount vs parents’ wishes
- Developing autonomy of child: fluctuating autonomy, stability of values, dependence on & influence of fam
- 6yo ♂ comes to you sick. You do some blood tests on him and learn that he as HIV. What are arguments for and against disclosure?
- 2wk has fever, irritability and appears sick (standard, run-of-the-mill, staple ethics question which is always good to have on any mind-exhausting end-of-rotation exams ;-). You want to do LP, but mom refuses, saying her mother, herbalist, will treat the child. Give an advantage of doing the LP (1 mark), a disadvantage of doing the LP (1 mark), 2 strategies of dealing with the situation (assuming LP indicated) and 2 rationales (picked from list of 6 principles that the professor asked us to memorize for the exam) (4 marks), and give 2 resources that the clinician may rely upon during times of dilemma (2 marks).
- PROs: better-informed clinical decision CONs: AEs (HA, back pain, hemorrhage)
- Strategies: 1) go along, 2) do it, 3) better understand decision/share rationale
- BEST INTERESTS OF THE CHILD: survival, harms/benefits, Tx, QoL
- DEVELOPING CHILD AUTONOMY
- FAMILY CENTRED CARE
- TRUTH TELLING/DISCLOSURE
- CONFIDENTIALITY: exceptions (harm, self-harm, abuse <16y)
- Resources: hospital ethicist, CCB (if concern over best interests)
- 14yo ♂ comes to you with whom it took time for you to develop trusting relationship. He confides in you that he’s being picked on at school and feeling depressed. He hasn’t told parents and doesn’t want you to either. Give 2 reasons why you would respect his request, 2 reasons why you would not follow his request, and your plan.
- Agree: 1) child autonomy, 2) legal duty (confidentiality)
- Disagree: 1) best interests of the child (non-maleficence, beneficence), 2) family centred-care, 3) legal duty (confidentiality exceptions)
Plan: better understand decision/share rationale of involving parents
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