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Handling Ethical Conflicts in the Clinical Setting
Handling Ethical Conflicts in the Clinical Setting By Holly L. Hedrick and Robert M. Nelson Philadelphia, Pennsylvania Ethical conflict in the clinical setting generally arises in situation of uncertainty, ambiguity, and complexity. This report discusses 4 cases of conflict between clinicians, between clinicians and patient, and between clinicians and family. Presented in enough detail for the reader to appreciate the extent and nature of the conflict, these cases are difficult and in many ways unresolved. Some conflicts may be inevitable and would not be prevented by even the most conscientious clinician. The authors discuss various approaches and resources that may prevent or ameliorate conflict. However, no easy answers are offered, but the importance of open communication of differing viewpoints in an atmosphere of trust and respect are emphasized. Copyright © 2001 by W.B. Saunders Company
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THICAL CONFLICTS in the clinical setting are inevitable. 1 Conflict is more likely to arise in situations fraught with uncertainty, ambiguity, complexity, stress, and change. Frequently, conflict may arise when individuals perceive different facts, hold different values, or experience different emotions. 2 In pediatrics and pediatric surgery, caregivers often are faced with complex medical circumstances when the "right" strategy is untested and unpublished. In addition, the social and family situation may be equally as challenging in determining who speaks for the child when that child is incapable of participating in a difficult decision about the child's "best interest." Conflict appears in many forms. Medical conflicts may occur between physicians or consultants over treatment decisions, the need for surgery, or the use of extraordinary measures such as extracorporeal membrane oxygenation (ECMO). Physicians may disagree about the flow of information to patients and their families. The fear of legal consequences also may fuel conflicts among consultants. In addition to physicians, there may be similar conflicts among and between nurses, respiratory therapists, ECMO personnel, social workers, or state-run agencies. Conflict also may occur among family members or between the patient and his or her family. The adolescent patient may have concerns about autonomy and confidentiality. Conflict may occur between memFrom the Department of Pediatric, General, and Thoracic Surgery and the Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. Address reprint requests to Robert M. Nelson, MD, PhD, The Children 's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, 9th floor, 34th St and Civic Center Blvd, Philadelphia, PA 19104-4399. Copyright © 2001 by w.E. Saunders Company 1055-858610111004-0005$35.0010 doi: 10.1 0531spsu.200 1.26840 192
bers of the health care team and parents over treatment course, the need for surgery or the use of blood products. The health care team can be splintered by these differences of opinion. Selective members may be "fired" as the parent seeks like-minded care providers. Finally, the accusation that someone is not acting in the child's best interest, as in the evaluation of child abuse and neglect, makes it difficult for the health care team and parents to communicate and prevent conflict. This report presents 4 cases involving conflict among physicians, nurses, parents, and others about the appropriate care of a child who is critically ill. All the cases involve surgeons, but are not limited to the surgical experience. We present the cases in depth, because there are no easy solutions in situations of real conflict. We also offer no easy answers, but rather a few landmarks (such as communication, trust, and respect) that may not solve existing conflict but certainly will prevent most differences from escalating into conflict. CASE 1 A 15-year-old girl sustained a single gunshot wound to the chest and abdomen, requiring emergent abdominal exploration for extensive injuries to her liver, pancreas, stomach, duodenum, and colon. She required multiple enterotomies and subsequently underwent 7 more laparotomies with multiple bowel resections for ongoing bowel necrosis. She was left with a short segment of duodenum connected to the distal transverse colon. As a result, she is dependent on intravenous hyperalimentation and is able to eat only small volumes, which are almost immediately expelled. The adolescent's mother was murdered at the same shooting. Surviving family members include her father who resides in a courtmandated rehabilitation facility and was not involved previously in her life. a brother who is also in a court-mandated rehabilitation facility, 2 siblings under psychiatric care, and a maternal aunt. The patient has history of severe truancy, testing at the third grade level in reading and math. The hospital Ethics Committee was convened in the first month of hospitalization to discuss her resuscitation status and appropriate disclosure to the patient. Multiple meetings were held over the 5-month hospitalization period and involved family members, the health care team, and the county children' s services. In addition to discussing the girl's poor prognosis and resuscitation status, all agreed that she should be informed about her mother's death, her own prognosis, and that returning to her previous environment was not in her best interest. Over her objection, she was made a ward of the state and placed in a group home 20 miles from her old neighborhood. For 2 months before discharge, she became increasingly noncompliant with the treatment plan. Over the ensuing 4 years, she has been admitted to the hospital over 40 times and has undergone over 40 surgical procedures. She has been on suicide precautions during at least 3 of her hospitalizations.
DISCUSSION OF CASE 1
The ethics committee consultation was requested to resolve an emerging conflict between the surgical and
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critical care teams. The severity of her intestinal injury was not fully appreciated until 10 days into her hospitalization after all but 20 cm of her small intestine had been removed over 3 operations. The surgeons who had operated on the patient became increasingly pessimistic about her overall prognosis, and obtained permission for a "Do Not Resuscitate" order from the girl's incarcerated (and previously uninvolved) father. The critical care team, however, disagreed with the order to limit resuscitation attempts as she became increasingly more alert and was recovering from her multiple organ injury. In effect, the 2 teams differed in their assessment of what technical interventions were in the girl's "best interest"-a difference exacerbated by the girl's diminished capacity and the physical (and perceived moral) absence of a parent who could speak for the child. The Ethics Committee was called initially to clarify 2 issues: to mediate the disagreement among clinicians whether to reintubate the patient once extubated, and to review family involvement and inclusion of the adolescent in the decision making. The 2 primary teams, critical care and surgery, were able to communicate their differing positions. The Ethics Committee made 3 recommendations: (1) a conference with all the involved physicians, the father, and patient to establish a clear understanding of the expected quality of life and resuscitation issues; (2) if agreed to by the family, a medically appropriate weaning of ventilator support would be pursued with the question of reintubation left open; and (3) further decision making about the patient's treatment regarding aggressiveness of therapy would depend on the wishes and desires of the patient and her father. The use of the ethics consultation in this circumstance served to mediate the conflict between practitioners. 2 The consultation did not involve a formal assessment of the girl's decision-making capacity, leaving ambiguous whether she should be able to assent or dissent to any treatment options independent of her father's wishes. Over the next several months, she was transitioned into long-term care as she recovered from her multiple medical problems. The management of a chronic enterocutaneous fistula and the inability to take oral feedings were difficult for her to understand, and forced her to live differently than before her trauma. As a result, she increasingly did not adhere to treatment plans by ignoring her "nothing by mouth" orders and suffering central line "mishaps." She lacked an understanding and appreciation of her medical condition, and after the acute phase of treatment, her father was no longer involved to help her. Nevertheless, the clinicians continued to involve her in any treatment decisions to the extent of her capacity.3 The adolescent girl was informed of the extent and implications of her injuries, and her assent was solicited in pursuing each further treatment. Conflict resolution
between the adolescent girl, her family, and the health care team was handled partially by psychiatric services. In the long months of recovery that followed, she seemed to adapt to the initial choices. However, with repeated admissions or unexpected complications, conflict again arises and her needs and wishes must be reassessed. She continues to be intermittently responsive to her ongoing health needs and to the help provided by psychiatry. Overall, as she has matured into adulthood (now 19 years old), the rebellious and self-destructive episodes have decreased. CASE 2 A l-year-old boy was admitted to the Pediatric Intensive Care Unit with pneumonia, progressing to respiratory failure and ventilator dependence. Born prematurely at 32 weeks gestational age, he suffered from prolonged QT syndrome with 2 subsequent cardiac arrests, hypercoagulation with multiple thromboses, and stroke leading to a chronic seizure disorder, and severe gastrointestinal dysmotility after undergoing an ileal resection and Ladd's procedure for necrotizing enterocolitis and intestinal malrotation. The surgeon previously involved in the child's care performed central line placement and tracheostomy. A new diagnosis of glycerol kinase deficiency was established, along with a grave neurologic prognosis based on a magnetic resonance imaging (MRI) finding of cerebral atrophy. In light of the poor prognosis, discussions ensued with his mother about the child's death, issues of organ donation, and burial. As the hospitalization continued, the child's mother increasingly complained to nursing leadership regarding the experience and conduct of some nurses caring for her son. She began to direct the medical and surgical care of her son. When the initial surgeon recommended against open jejunostomy tube placement in favor of an endoscopic or fluoroscopic procedure, the mother requested a surgical opinion from a second surgeon who then performed the open jejunostomy. The child's prognosis for neurologic recovery further diminished over the next 2 months, confirmed by further cerebral edema and atrophy on imaging studies and 2 neurology consultations. The child's family, however, was not prepared to decrease the level of medical care, stating that "my son proved them wrong" in the past. The working relationship with the family deteriorated further, with the mother arguing over ventilator setting changes, medications, and diagnostic testing and refusing to allow some nurses and doctors (specifically neurologists) to care for her son. After a 5-month hospitalization, the child was transferred to another facility at the request of the family.
DISCUSSION OF CASE 2
The evolution of this case is one of escalating conflict between the family and the health care team-conflict that ultimately was resolved only by transferring the child to another facility. On previous hospital admissions, the family had demanded continued neonatal intensive care even after the child had surpassed the usual age for neonatal care. When the relationship between the neonatal staff and family deteriorated, the family requested transfer to the pediatric intensive care unit. The family asked for another surgical opinion in spite of an existing relationship with the primary surgeon who did not agree to the family's request for an open jejunostomy. The decision to perform the operation by the
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second surgeon was to avoid conflict with the mother, rather than a principled difference of opinion about the range of justified surgical approaches. After several months of building conflict and miscommunication, all the medical and surgical consultants and other health care team members agreed that further treatment was futile. At this point, the family sought and obtained transfer to another facility. Although the possibility of transfer in the face of conflict between a patient and clinician usually reflects a difference of opinion about the range of justified clinical approaches, the impression in this case was that the desire to avoid conflict with the child's mother was the primary motivation. Why did this conflict with the family get out of hand? The child had survived extraordinary circumstances as a neonate. In spite of the child's grave neurologic prognosis, the discussion about the child's death, organ donation, and burial before any agreement about limiting resuscitation efforts or before the child actually died was premature in retrospect. The fact that the child continued to survive, coupled with the family's prior neonatal experience, contributed to the mother's opinion that "my son proved them wrong." In spite of the continued involvement of the child's primary care physician in directing the overall plan of care, conflict arose between members of the health care team. Once an untreatable metabolic disorder was diagnosed, several nurses and physicians felt uncomfortable with the level of continued support. Other clinicians felt that the family's wishes should be respected. The child's mother frequently would ask for a change in nursing or physician coverage if she perceived that a clinician believed further treatment was futile. The clinicians' ability to work with the family in making treatment decisions spun out of control as the mother was able to set one member of the health care team against another. The fundamental obligation of the pediatrician or pediatric surgeon is to act for the good of the child. 4 Although parents have a primary role in determining what is in their child's best interest, the claim that parents' wishes for treatment should always prevail improperly restricts physicians to determining empirical fact and issuing technical advice. Parents alone should not dictate the moral values of pediatric practice. Physicians (and other pediatric clinicians) also are morally involved in a child's care and may, in certain cases, refuse to provide treatment as inconsistent with their professional ethical obligations. 5 Such refusal, however, should not be idiosyncratic but should generally reflect a shared professional commitment to a child's best interest. In this complex diagnostic case, it took several months and a number of different consultants to finally establish a consensus professional opinion. Even so, it is essential to maintain a working relationship with a family based on
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trust, and not to unilaterally impose an opinion of futility without an appropriate process of conflict resolution. Earlier consultation with a well-trained and experienced hospital ethics committee may have been useful to help the parents understand the complexity of the case or assist in a resolution of conflict between the health care team and the parents. 5 •6 Unfortunately, by the time the health care team reached consensus about the futility of ongoing treatment, a great deal of mistrust existed between the family and the medical staff. CASE 3 A l4-year-old boy with pentalogy of Cantrell was admitted to the intensive care unit witb severe cardiomyopathy. After repair of his ventricular septal defect at 19 months of age, he was discharged from cardiology follow-up at age 3. Ten years later. dilated cardiomyopatby was diagnosed, and he was maintained on oral medication. His symptoms progressed; however, and he underwent a cardiac catbeterization, which showed severe right heart failure and increased pulmonary vascular resistance. Rejecting tbe suggestion of a trial of intravenous medication, tbe family sought alternative magnetic tberapy at anotber facility. The treatment had to be interrupted after 6 hours when he experienced worsening shortness of breath requiring stabilization on intravenous medications and transfer to tbe intensive care unit at tbe regional children's hospital. During the first week of hospitalization, tbe boy's fatber continued to express the desire to complete the magnetic therapy (100 hours) and to pursue otber alternative treatments such as human growtb hormone or stem cell transplantation. The family finally agreed to cardiac catheterization and listing for transplantation in the face of daily requests given the boy's need for multiple cardioversions. Remaining intubated on mechanical ventilation after tbe catheterization, tbe patient's cardiac function continued to deteriorate to where he was placed on extracorporeal membrane oxygenation (ECMO). The clinical course on ECMO was complicated, and ultimately lasted 62 days. Throughout tbis time, the palliative care team, psychologist, and chaplain met with the patient and family on a consistent basis. The transplant team spent from I to 5 hours with tbe family on a daily basis detailing his progress and medical issues. Eventually, on day 50 of ECMO, the healtb care team recommended withdrawal of support. The patient was removed from the transplant list, a "Do Not Attempt Resuscitation" order was initiated, and no more interventions were done including blood draws. The following day, the fatber expressed his desire to have tbe patient transported by air on ECMO to Mexico for alternate care tberapy along with the administration of a metabolic solution to reverse the patient's condition. The healtb care teams expressed tbeir unwillingness to continue "inhumane care in a child who is suffering." On day 55 of ECMO, the father requested an etbics committee consultation, which resulted in reinitiating nutritional support and daily laboratory testing. After trying to independently arrange transport to Mexico, the family flew in a consulting physician from Mexico who asked to see the patient and his medical records. The request was granted after review by hospital legal counsel and risk management. Citing a 1% chance of benefit, the consultant recommended a metabolic solution to treat cardiomyopathy. The patient continued to deteriorate in spite of tbe solution, and on tbe 62nd day of ECMO support the family agreed to witbdraw support.
DISCUSSION OF CASE 3
Clearly, the family did not trust traditional medical interventions and favored various alternative treatments.
HANDLING ETHICAL CONFLICTS
During the 10 years since being discharged from cardiology follow-up, the boy led an active life, attending school and successfully participating in several sports. The sudden change in his exercise tolerance caused by the cardiomyopathy was felt to be secondary to a viral illness, rather than the patient's underlying heart defect, which had been corrected surgically. Initially, recommended treatment options were rejected by the parents in favor of alternative treatments. However, when faced with the real possibility of their child's death, the parents accepted the recommendations for intravenous medications, listing for heart/lung transplantation, and even 2 months of ECMO support. Because the patient's heart disease was deemed irreversible, the use of ECMO required consent for transplantation. Nevertheless, it took 8 days and 5 cardiac arrests before the family agreed to listing for transplantation and the ECMO support. Sixty-two days of ECMO support for a patient awaiting heart/lung transplant is unprecedented. Over the course of this patient's treatment, conflict between the intensive care unit physicians, cardiologists, transplant surgeon, nursing staff, and ECMO team regarding the appropriateness of this extraordinary care intensified. There were many heated discussions regarding continuation of support and long-term plans. The early involvement of the palliative care team, psychologist, and chaplain signaled that the family was being prepared for possible withdrawal of support. This interpretation of the meaning of palliative care involvement may reflect the historical tendency to consult palliative care late in the process of dying, rather than at the onset of a lifethreatening disease.? As a result, an appropriate consultation to palliative care had unfortunate repercussions among the health care team. Moreover, when the patient was removed from the transplant list, the health care team understood this to mean the withdrawal of ECMO support given the futility of the underlying cardiac condition. The father, however, was not willing to accept the withdrawal of ECMO support and the child's consequent death. The health care team was sensitive to the family's beliefs in alternative care. The transplant physician explored each of the family's requests with proponents of these therapies, and had allowed initiation of one such therapy. Nevertheless, the father's rejection of the recommended withdrawal of ECMO support and his request for the use of alternative treatments led to an ethics committee consultation and the subsequent arrival of a consultant from Mexico. The ethics committee tried to mediate the dispute, attempting to reach a middle ground based on an institutional desire to decrease any risk exposure and set limits on the continuation of treatment. The ethics committee recommended reinitiating once-aday laboratory testing (well below the medical standard
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of care on ECMO) and nutrition, and agreed with the recommendation for a trial of a metabolic solution (also not standard of care on ECMO because of high potassium content), which the father thought could change the patient's course. As the health care team justified withdrawing ECMO based on futility, such a negotiated compromise was judged unethical by some clinicians. s However, others may argue that the imposition of a judgement of futility should not occur without due consideration of the father's desires for treatment. Once the metabolic solution was given and failed to change the patient's status, the father agreed to withdrawal of ECMO support. CASE 4 A 9-week-old former 33-week premature baby girl was at home for 1 month on a monitor when she was found by her father to be limp and unresponsive after an apnea alarm. After an estimated time of 20 minutes without a pulse, she was resuscitated and transferred to a children's hospital. The diagnostic evaluation showed extensive intracranial and bilateral retinal hemorrhages and an old rib fracture. Accordingly, the police, social services, and family were notified of the diagnosis of child abuse. The father was the primary suspect. Given the infant's severe neurologic injury (with intermittent gasping as the only visible evidence of brain activity), the health care team recommended withdrawal of ventilator support. This advice was rejected by the family in favor of a tracheostomy, gastrostomy, and transfer to a chronic care facility. However, the infant continued to require a significant level of support, including intermittent resuscitation with chest compressions. By the third week of hospitalization the health care team became concerned that the parents had an inappropriate conflict of interest in pursuing aggressive care because the father was the suspected perpetrator, and the mother continued to support him. The Ethics Committee was consulted and found no legal basis for removing maternal/paternal rights from the family. At one point, the parents were not available for 19 days despite multiple phone messages and attempts to reach them. Social services and the police were notified of possible abandonment. The mother finally returned to the hospital after a 20-day absence to sign the transfer forms. After 3 months in the intensive care unit, the infant was transferred to a chronic care facility. Three months later the infant was readmitted with life-threatening respiratory distress to the same intensive care unit. The heathcare team again addressed the infant's resuscitation status and the need for a court-appointed guardian given the mother's conflict of interest. The father had been arrested for the child's beating and was out on bail with a restraining order to have no contact with the child. Several attempts were made to meet with the mother without success. The hospital ethics committee was again consulted and questioned whether adequate attempts had been made to reach the mother. A federal express letter was sent to the mother indicating a specific meeting time and agenda. If the mother failed to respond 3 times, then third party advocacy would be sought. On the day of planned transfer back to the chronic care facility, the mother called to consent to transfer. She never returned to the hospital. The child had 3 more intensive care unit admissions in the next six months. Each time the mother continues to request aggressive measures. The criminal case has not progressed.
DISCUSSION OF CASE 4
The issue raised by this case is the mother's apparent conflict of interest in making a decision to withdraw
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support. Initially, both the mother and father were involved in all decisions regarding the ongoing treatment for this child whose outcome was deemed grim. Subsequently, the father was charged with child abuse and not allowed to participate in health care decisions or visit the child. The question of whether a guardian ad litem should be appointed was raised on at least 2 of the child's admissions. The first ethics consultation cited "no legal basis" to remove the mother's decision-making authority. The ethics committee was consulted as negotiator in this case, but acted as mediator.2 Some of the clinicians argued that the committee was more concerned for law and institutional protection than the ethics of what was in the child's best interest. The second ethics consultation simply raised issues of process. The committee concentrated on the effort put forth by the health care team to involve the mother (who never visited and could not be reached by phone). The ethics committee recommended 3 attempts to communicate with the mother by certified mail if necessary and then if unsuccessful to initiate court proceedings. Again, the ethics committee appeared to act on a desire to minimize institutional risk exposure. The resolution of this case is unsatisfying given the ongoing suffering of a child whose outcome is disproportionately burdensome. S The mother has a conflict of interest in deciding to forgo life-sustaining medical treatment because of the risk of changing the legal charge faced by her husband from assault to manslaughter or homicide. Arguing that the primary consideration should be the child's best interest, the Committee on Bioethics of the American Academy of Pediatrics advocates for the appointment of a guardian ad litem in such cases.s Further, decisions to forgo life-sustaining medical treatment of severe brain injury should not be limited to children in a persistent vegetative state. S•9•1O In this case, the health care team has had increasing difficulty involving the mother in decision making for her child. She no longer visits and has been unreachable by telephone. Appropriately, the critical care team has asked for ethics committee consultation yet without any resolution. The complex legal issues ultimately may force this conflict into court. 11 SOME APPROACHES TO CONFLICT RESOLUTION
Early and adequate communication is the first (and often the only necessary) step toward resolution of a conflict. Communication and trust likely will prevent disagreements from escalating into conflict. The source must be understood to begin to resolve any conflict. 12 Short-term and long-term patient care goals must be communicated between the physician in charge, consultants, nurses, therapists, social workers, families, and the child whenever possible. Prognosis and plans should be coordinated and discussed on a regular and frequent
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basis. Mixed signals and inconsistent messages fuel conflict. Families often do not hear distressing news of a poor outcome the first time. It is unwise and unrealistic for a physician to expect that a parent will agree to every recommendation the first time it is presented. This is especially true regarding decisions to forgo treatment. Nevertheless, simply presenting all technically feasible options and then offering to do whatever the parents want is inconsistent with good medical practice. 14 Parents should receive the benefit of their physicians' clinical judgement and ethical wisdom, not just their technical expertise. s At times, differences in education or experience may be the source of conflict. If so, helping a parent to understand and appreciate the medical facts may be all that is needed to resolve conflict. Religion also may play a role in both health care workers and parents' opinions. If religion is a factor, it often is useful to involve an experienced hospital chaplain or one's own religious leader in exploring the conflicts that may occur. s The involvement of an ethics consultation may be requested by physicians, other members of the health care team, parents, or the patient. The opinions of ethics consultants may be useful in clarifying problems in communication or in providing a different perspective. s Orr and de Leon 2 recently suggested that the traditional roles of negotiator, mediator, or arbitrator may not accurately describe the role of the clinical ethicist in any particular situation. One of the primary goals of an ethics consultation should be to provide a forum for discussion among the physicians, nurses, consultants, family members and others involved in a child' s care. Although often such discussion leads to consensus, consensus should not necessarily be the goal. The perceived necessity of reaching consensus, when combined with the inevitable power differentials that exist within an ethics committee and clinical setting, may lead to an apparent consensus based on the silencing of divergent viewpoints rather than substantive agreement. The ethics committee must foster open and uncoerced discussion that respects the diversity of moral and religious values found within our society. II Some conflict may not be resolved. If efforts to reach agreement fail, the physician may look for another physician who is willing to assume responsibility for the patient's management and who can abide by the parents' wishes. If this approach fails, then the physician may look for a physician at another institution who is willing to accept the patient in transfer. 14 CONCLUSION
Differences of opinion always will exist. The key to preventing these difference from escalating into conflict is the open communication of differing viewpoints in an atmosphere of trust and mutual respect. Mistrust usually is the
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seed of conflict. The moral focus always should remain on our commitment to the best interests of the child, tempered by the recognition that others may share this focus but see the situation differently. Consultation with other trusted clinicians or advisors may help clarify the issues, with ethics consultation reserved for those times when our shared judgements about the pertinent facts and values become uncertain. A pediatric ethics consultation should
remain committed to the child's best interest, and be willing to grapple realistically with the political, legal, and institutional barriers that often prevent us from acting with integrity consistent with this commitment. Finally, conflict arises in situations in which the correct course of medical or moral action is unclear. As such, we need to remember our own fallibility and vulnerability, and seek a solution that respects others.
REFERENCES I. Marcus U: Renegotiating Health Care. San Francisco, CA, Jossey-Bass, 1995 2. Orr RD, de Leon DM: The role of the clinical ethicist in conflict resolution. J Clin Ethics 11:21-30, 2001 3. Bartholome WG: A new understanding of consent in pediatric practice: Consent, parental permission, and child assent. Pediatric Annals 18:262-265, 1989 4. Pellegrino ED, Thomasma D: For the Patient's Good. New York, NY, Oxford University Press, 1988, pp 73-91 5. Nelson U , Nelson RM: Ethics and the provision of futile, harmful , or burdensome treatment to children. Crit Care Med 20:427-433, 1992 6. Committee on Bioethics, American Academy of Pediatrics, AAP: Institutional Ethics Committees. Pediatrics 107:205-209, 2001 7. Committee on Bioethics and Committee on Hospital Care, AAP: Palliative Care for Children. Pediatrics 106:351-357, 2000
8. Committee on Child Abuse and Neglect and Committee on BiGethics, AAP: Foregoing life-sustaining medical treatment in abused children. Pediatrics 106:1151-1153, 2000 9. Committee on Bioethics, AAP: Guidelines on forgoing life-sustaining medical treatment. Pediatrics 93:532-536, 1994 10. Committee on Bioethics, AAP: Ethics and the care of critically ill infants and children. Pediatrics 98:149-152,1996 II. Nelson RM, Shapiro RS: The role of an ethics committee in resolving conflict in the neonatal intensive care unit. J Law Med Ethics 23:27-32, 1995 12. Goold SD, Brent W, Arnold RM: Conflicts regarding decisions to limit treatment: A differential diagnosis. JAMA 283:909-914,
2000 13. Ingelfinger FJ: Arrogance. N Engl J Med 303:1507-1511, 1980 14. Paris JJ, Crone RK: Physicians' refusal of requested treatment. N Engl J Med 322:1012-1015, 1990
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THICAL CONFLICTS in the clinical setting are inevitable. 1 Conflict is more likely to arise in situations fraught with uncertainty, ambiguity, complexity, stress, and change. Frequently, conflict may arise when individuals perceive different facts, hold different values, or experience different emotions. 2 In pediatrics and pediatric surgery, caregivers often are faced with complex medical circumstances when the "right" strategy is untested and unpublished. In addition, the social and family situation may be equally as challenging in determining who speaks for the child when that child is incapable of participating in a difficult decision about the child's "best interest." Conflict appears in many forms. Medical conflicts may occur between physicians or consultants over treatment decisions, the need for surgery, or the use of extraordinary measures such as extracorporeal membrane oxygenation (ECMO). Physicians may disagree about the flow of information to patients and their families. The fear of legal consequences also may fuel conflicts among consultants. In addition to physicians, there may be similar conflicts among and between nurses, respiratory therapists, ECMO personnel, social workers, or state-run agencies. Conflict also may occur among family members or between the patient and his or her family. The adolescent patient may have concerns about autonomy and confidentiality. Conflict may occur between memFrom the Department of Pediatric, General, and Thoracic Surgery and the Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. Address reprint requests to Robert M. Nelson, MD, PhD, The Children 's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, 9th floor, 34th St and Civic Center Blvd, Philadelphia, PA 19104-4399. Copyright © 2001 by w.E. Saunders Company 1055-858610111004-0005$35.0010 doi: 10.1 0531spsu.200 1.26840 192
bers of the health care team and parents over treatment course, the need for surgery or the use of blood products. The health care team can be splintered by these differences of opinion. Selective members may be "fired" as the parent seeks like-minded care providers. Finally, the accusation that someone is not acting in the child's best interest, as in the evaluation of child abuse and neglect, makes it difficult for the health care team and parents to communicate and prevent conflict. This report presents 4 cases involving conflict among physicians, nurses, parents, and others about the appropriate care of a child who is critically ill. All the cases involve surgeons, but are not limited to the surgical experience. We present the cases in depth, because there are no easy solutions in situations of real conflict. We also offer no easy answers, but rather a few landmarks (such as communication, trust, and respect) that may not solve existing conflict but certainly will prevent most differences from escalating into conflict. CASE 1 A 15-year-old girl sustained a single gunshot wound to the chest and abdomen, requiring emergent abdominal exploration for extensive injuries to her liver, pancreas, stomach, duodenum, and colon. She required multiple enterotomies and subsequently underwent 7 more laparotomies with multiple bowel resections for ongoing bowel necrosis. She was left with a short segment of duodenum connected to the distal transverse colon. As a result, she is dependent on intravenous hyperalimentation and is able to eat only small volumes, which are almost immediately expelled. The adolescent's mother was murdered at the same shooting. Surviving family members include her father who resides in a courtmandated rehabilitation facility and was not involved previously in her life. a brother who is also in a court-mandated rehabilitation facility, 2 siblings under psychiatric care, and a maternal aunt. The patient has history of severe truancy, testing at the third grade level in reading and math. The hospital Ethics Committee was convened in the first month of hospitalization to discuss her resuscitation status and appropriate disclosure to the patient. Multiple meetings were held over the 5-month hospitalization period and involved family members, the health care team, and the county children' s services. In addition to discussing the girl's poor prognosis and resuscitation status, all agreed that she should be informed about her mother's death, her own prognosis, and that returning to her previous environment was not in her best interest. Over her objection, she was made a ward of the state and placed in a group home 20 miles from her old neighborhood. For 2 months before discharge, she became increasingly noncompliant with the treatment plan. Over the ensuing 4 years, she has been admitted to the hospital over 40 times and has undergone over 40 surgical procedures. She has been on suicide precautions during at least 3 of her hospitalizations.
DISCUSSION OF CASE 1
The ethics committee consultation was requested to resolve an emerging conflict between the surgical and
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critical care teams. The severity of her intestinal injury was not fully appreciated until 10 days into her hospitalization after all but 20 cm of her small intestine had been removed over 3 operations. The surgeons who had operated on the patient became increasingly pessimistic about her overall prognosis, and obtained permission for a "Do Not Resuscitate" order from the girl's incarcerated (and previously uninvolved) father. The critical care team, however, disagreed with the order to limit resuscitation attempts as she became increasingly more alert and was recovering from her multiple organ injury. In effect, the 2 teams differed in their assessment of what technical interventions were in the girl's "best interest"-a difference exacerbated by the girl's diminished capacity and the physical (and perceived moral) absence of a parent who could speak for the child. The Ethics Committee was called initially to clarify 2 issues: to mediate the disagreement among clinicians whether to reintubate the patient once extubated, and to review family involvement and inclusion of the adolescent in the decision making. The 2 primary teams, critical care and surgery, were able to communicate their differing positions. The Ethics Committee made 3 recommendations: (1) a conference with all the involved physicians, the father, and patient to establish a clear understanding of the expected quality of life and resuscitation issues; (2) if agreed to by the family, a medically appropriate weaning of ventilator support would be pursued with the question of reintubation left open; and (3) further decision making about the patient's treatment regarding aggressiveness of therapy would depend on the wishes and desires of the patient and her father. The use of the ethics consultation in this circumstance served to mediate the conflict between practitioners. 2 The consultation did not involve a formal assessment of the girl's decision-making capacity, leaving ambiguous whether she should be able to assent or dissent to any treatment options independent of her father's wishes. Over the next several months, she was transitioned into long-term care as she recovered from her multiple medical problems. The management of a chronic enterocutaneous fistula and the inability to take oral feedings were difficult for her to understand, and forced her to live differently than before her trauma. As a result, she increasingly did not adhere to treatment plans by ignoring her "nothing by mouth" orders and suffering central line "mishaps." She lacked an understanding and appreciation of her medical condition, and after the acute phase of treatment, her father was no longer involved to help her. Nevertheless, the clinicians continued to involve her in any treatment decisions to the extent of her capacity.3 The adolescent girl was informed of the extent and implications of her injuries, and her assent was solicited in pursuing each further treatment. Conflict resolution
between the adolescent girl, her family, and the health care team was handled partially by psychiatric services. In the long months of recovery that followed, she seemed to adapt to the initial choices. However, with repeated admissions or unexpected complications, conflict again arises and her needs and wishes must be reassessed. She continues to be intermittently responsive to her ongoing health needs and to the help provided by psychiatry. Overall, as she has matured into adulthood (now 19 years old), the rebellious and self-destructive episodes have decreased. CASE 2 A l-year-old boy was admitted to the Pediatric Intensive Care Unit with pneumonia, progressing to respiratory failure and ventilator dependence. Born prematurely at 32 weeks gestational age, he suffered from prolonged QT syndrome with 2 subsequent cardiac arrests, hypercoagulation with multiple thromboses, and stroke leading to a chronic seizure disorder, and severe gastrointestinal dysmotility after undergoing an ileal resection and Ladd's procedure for necrotizing enterocolitis and intestinal malrotation. The surgeon previously involved in the child's care performed central line placement and tracheostomy. A new diagnosis of glycerol kinase deficiency was established, along with a grave neurologic prognosis based on a magnetic resonance imaging (MRI) finding of cerebral atrophy. In light of the poor prognosis, discussions ensued with his mother about the child's death, issues of organ donation, and burial. As the hospitalization continued, the child's mother increasingly complained to nursing leadership regarding the experience and conduct of some nurses caring for her son. She began to direct the medical and surgical care of her son. When the initial surgeon recommended against open jejunostomy tube placement in favor of an endoscopic or fluoroscopic procedure, the mother requested a surgical opinion from a second surgeon who then performed the open jejunostomy. The child's prognosis for neurologic recovery further diminished over the next 2 months, confirmed by further cerebral edema and atrophy on imaging studies and 2 neurology consultations. The child's family, however, was not prepared to decrease the level of medical care, stating that "my son proved them wrong" in the past. The working relationship with the family deteriorated further, with the mother arguing over ventilator setting changes, medications, and diagnostic testing and refusing to allow some nurses and doctors (specifically neurologists) to care for her son. After a 5-month hospitalization, the child was transferred to another facility at the request of the family.
DISCUSSION OF CASE 2
The evolution of this case is one of escalating conflict between the family and the health care team-conflict that ultimately was resolved only by transferring the child to another facility. On previous hospital admissions, the family had demanded continued neonatal intensive care even after the child had surpassed the usual age for neonatal care. When the relationship between the neonatal staff and family deteriorated, the family requested transfer to the pediatric intensive care unit. The family asked for another surgical opinion in spite of an existing relationship with the primary surgeon who did not agree to the family's request for an open jejunostomy. The decision to perform the operation by the
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second surgeon was to avoid conflict with the mother, rather than a principled difference of opinion about the range of justified surgical approaches. After several months of building conflict and miscommunication, all the medical and surgical consultants and other health care team members agreed that further treatment was futile. At this point, the family sought and obtained transfer to another facility. Although the possibility of transfer in the face of conflict between a patient and clinician usually reflects a difference of opinion about the range of justified clinical approaches, the impression in this case was that the desire to avoid conflict with the child's mother was the primary motivation. Why did this conflict with the family get out of hand? The child had survived extraordinary circumstances as a neonate. In spite of the child's grave neurologic prognosis, the discussion about the child's death, organ donation, and burial before any agreement about limiting resuscitation efforts or before the child actually died was premature in retrospect. The fact that the child continued to survive, coupled with the family's prior neonatal experience, contributed to the mother's opinion that "my son proved them wrong." In spite of the continued involvement of the child's primary care physician in directing the overall plan of care, conflict arose between members of the health care team. Once an untreatable metabolic disorder was diagnosed, several nurses and physicians felt uncomfortable with the level of continued support. Other clinicians felt that the family's wishes should be respected. The child's mother frequently would ask for a change in nursing or physician coverage if she perceived that a clinician believed further treatment was futile. The clinicians' ability to work with the family in making treatment decisions spun out of control as the mother was able to set one member of the health care team against another. The fundamental obligation of the pediatrician or pediatric surgeon is to act for the good of the child. 4 Although parents have a primary role in determining what is in their child's best interest, the claim that parents' wishes for treatment should always prevail improperly restricts physicians to determining empirical fact and issuing technical advice. Parents alone should not dictate the moral values of pediatric practice. Physicians (and other pediatric clinicians) also are morally involved in a child's care and may, in certain cases, refuse to provide treatment as inconsistent with their professional ethical obligations. 5 Such refusal, however, should not be idiosyncratic but should generally reflect a shared professional commitment to a child's best interest. In this complex diagnostic case, it took several months and a number of different consultants to finally establish a consensus professional opinion. Even so, it is essential to maintain a working relationship with a family based on
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trust, and not to unilaterally impose an opinion of futility without an appropriate process of conflict resolution. Earlier consultation with a well-trained and experienced hospital ethics committee may have been useful to help the parents understand the complexity of the case or assist in a resolution of conflict between the health care team and the parents. 5 •6 Unfortunately, by the time the health care team reached consensus about the futility of ongoing treatment, a great deal of mistrust existed between the family and the medical staff. CASE 3 A l4-year-old boy with pentalogy of Cantrell was admitted to the intensive care unit witb severe cardiomyopathy. After repair of his ventricular septal defect at 19 months of age, he was discharged from cardiology follow-up at age 3. Ten years later. dilated cardiomyopatby was diagnosed, and he was maintained on oral medication. His symptoms progressed; however, and he underwent a cardiac catbeterization, which showed severe right heart failure and increased pulmonary vascular resistance. Rejecting tbe suggestion of a trial of intravenous medication, tbe family sought alternative magnetic tberapy at anotber facility. The treatment had to be interrupted after 6 hours when he experienced worsening shortness of breath requiring stabilization on intravenous medications and transfer to tbe intensive care unit at tbe regional children's hospital. During the first week of hospitalization, tbe boy's fatber continued to express the desire to complete the magnetic therapy (100 hours) and to pursue otber alternative treatments such as human growtb hormone or stem cell transplantation. The family finally agreed to cardiac catheterization and listing for transplantation in the face of daily requests given the boy's need for multiple cardioversions. Remaining intubated on mechanical ventilation after tbe catheterization, tbe patient's cardiac function continued to deteriorate to where he was placed on extracorporeal membrane oxygenation (ECMO). The clinical course on ECMO was complicated, and ultimately lasted 62 days. Throughout tbis time, the palliative care team, psychologist, and chaplain met with the patient and family on a consistent basis. The transplant team spent from I to 5 hours with tbe family on a daily basis detailing his progress and medical issues. Eventually, on day 50 of ECMO, the healtb care team recommended withdrawal of support. The patient was removed from the transplant list, a "Do Not Attempt Resuscitation" order was initiated, and no more interventions were done including blood draws. The following day, the fatber expressed his desire to have tbe patient transported by air on ECMO to Mexico for alternate care tberapy along with the administration of a metabolic solution to reverse the patient's condition. The healtb care teams expressed tbeir unwillingness to continue "inhumane care in a child who is suffering." On day 55 of ECMO, the father requested an etbics committee consultation, which resulted in reinitiating nutritional support and daily laboratory testing. After trying to independently arrange transport to Mexico, the family flew in a consulting physician from Mexico who asked to see the patient and his medical records. The request was granted after review by hospital legal counsel and risk management. Citing a 1% chance of benefit, the consultant recommended a metabolic solution to treat cardiomyopathy. The patient continued to deteriorate in spite of tbe solution, and on tbe 62nd day of ECMO support the family agreed to witbdraw support.
DISCUSSION OF CASE 3
Clearly, the family did not trust traditional medical interventions and favored various alternative treatments.
HANDLING ETHICAL CONFLICTS
During the 10 years since being discharged from cardiology follow-up, the boy led an active life, attending school and successfully participating in several sports. The sudden change in his exercise tolerance caused by the cardiomyopathy was felt to be secondary to a viral illness, rather than the patient's underlying heart defect, which had been corrected surgically. Initially, recommended treatment options were rejected by the parents in favor of alternative treatments. However, when faced with the real possibility of their child's death, the parents accepted the recommendations for intravenous medications, listing for heart/lung transplantation, and even 2 months of ECMO support. Because the patient's heart disease was deemed irreversible, the use of ECMO required consent for transplantation. Nevertheless, it took 8 days and 5 cardiac arrests before the family agreed to listing for transplantation and the ECMO support. Sixty-two days of ECMO support for a patient awaiting heart/lung transplant is unprecedented. Over the course of this patient's treatment, conflict between the intensive care unit physicians, cardiologists, transplant surgeon, nursing staff, and ECMO team regarding the appropriateness of this extraordinary care intensified. There were many heated discussions regarding continuation of support and long-term plans. The early involvement of the palliative care team, psychologist, and chaplain signaled that the family was being prepared for possible withdrawal of support. This interpretation of the meaning of palliative care involvement may reflect the historical tendency to consult palliative care late in the process of dying, rather than at the onset of a lifethreatening disease.? As a result, an appropriate consultation to palliative care had unfortunate repercussions among the health care team. Moreover, when the patient was removed from the transplant list, the health care team understood this to mean the withdrawal of ECMO support given the futility of the underlying cardiac condition. The father, however, was not willing to accept the withdrawal of ECMO support and the child's consequent death. The health care team was sensitive to the family's beliefs in alternative care. The transplant physician explored each of the family's requests with proponents of these therapies, and had allowed initiation of one such therapy. Nevertheless, the father's rejection of the recommended withdrawal of ECMO support and his request for the use of alternative treatments led to an ethics committee consultation and the subsequent arrival of a consultant from Mexico. The ethics committee tried to mediate the dispute, attempting to reach a middle ground based on an institutional desire to decrease any risk exposure and set limits on the continuation of treatment. The ethics committee recommended reinitiating once-aday laboratory testing (well below the medical standard
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of care on ECMO) and nutrition, and agreed with the recommendation for a trial of a metabolic solution (also not standard of care on ECMO because of high potassium content), which the father thought could change the patient's course. As the health care team justified withdrawing ECMO based on futility, such a negotiated compromise was judged unethical by some clinicians. s However, others may argue that the imposition of a judgement of futility should not occur without due consideration of the father's desires for treatment. Once the metabolic solution was given and failed to change the patient's status, the father agreed to withdrawal of ECMO support. CASE 4 A 9-week-old former 33-week premature baby girl was at home for 1 month on a monitor when she was found by her father to be limp and unresponsive after an apnea alarm. After an estimated time of 20 minutes without a pulse, she was resuscitated and transferred to a children's hospital. The diagnostic evaluation showed extensive intracranial and bilateral retinal hemorrhages and an old rib fracture. Accordingly, the police, social services, and family were notified of the diagnosis of child abuse. The father was the primary suspect. Given the infant's severe neurologic injury (with intermittent gasping as the only visible evidence of brain activity), the health care team recommended withdrawal of ventilator support. This advice was rejected by the family in favor of a tracheostomy, gastrostomy, and transfer to a chronic care facility. However, the infant continued to require a significant level of support, including intermittent resuscitation with chest compressions. By the third week of hospitalization the health care team became concerned that the parents had an inappropriate conflict of interest in pursuing aggressive care because the father was the suspected perpetrator, and the mother continued to support him. The Ethics Committee was consulted and found no legal basis for removing maternal/paternal rights from the family. At one point, the parents were not available for 19 days despite multiple phone messages and attempts to reach them. Social services and the police were notified of possible abandonment. The mother finally returned to the hospital after a 20-day absence to sign the transfer forms. After 3 months in the intensive care unit, the infant was transferred to a chronic care facility. Three months later the infant was readmitted with life-threatening respiratory distress to the same intensive care unit. The heathcare team again addressed the infant's resuscitation status and the need for a court-appointed guardian given the mother's conflict of interest. The father had been arrested for the child's beating and was out on bail with a restraining order to have no contact with the child. Several attempts were made to meet with the mother without success. The hospital ethics committee was again consulted and questioned whether adequate attempts had been made to reach the mother. A federal express letter was sent to the mother indicating a specific meeting time and agenda. If the mother failed to respond 3 times, then third party advocacy would be sought. On the day of planned transfer back to the chronic care facility, the mother called to consent to transfer. She never returned to the hospital. The child had 3 more intensive care unit admissions in the next six months. Each time the mother continues to request aggressive measures. The criminal case has not progressed.
DISCUSSION OF CASE 4
The issue raised by this case is the mother's apparent conflict of interest in making a decision to withdraw
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support. Initially, both the mother and father were involved in all decisions regarding the ongoing treatment for this child whose outcome was deemed grim. Subsequently, the father was charged with child abuse and not allowed to participate in health care decisions or visit the child. The question of whether a guardian ad litem should be appointed was raised on at least 2 of the child's admissions. The first ethics consultation cited "no legal basis" to remove the mother's decision-making authority. The ethics committee was consulted as negotiator in this case, but acted as mediator.2 Some of the clinicians argued that the committee was more concerned for law and institutional protection than the ethics of what was in the child's best interest. The second ethics consultation simply raised issues of process. The committee concentrated on the effort put forth by the health care team to involve the mother (who never visited and could not be reached by phone). The ethics committee recommended 3 attempts to communicate with the mother by certified mail if necessary and then if unsuccessful to initiate court proceedings. Again, the ethics committee appeared to act on a desire to minimize institutional risk exposure. The resolution of this case is unsatisfying given the ongoing suffering of a child whose outcome is disproportionately burdensome. S The mother has a conflict of interest in deciding to forgo life-sustaining medical treatment because of the risk of changing the legal charge faced by her husband from assault to manslaughter or homicide. Arguing that the primary consideration should be the child's best interest, the Committee on Bioethics of the American Academy of Pediatrics advocates for the appointment of a guardian ad litem in such cases.s Further, decisions to forgo life-sustaining medical treatment of severe brain injury should not be limited to children in a persistent vegetative state. S•9•1O In this case, the health care team has had increasing difficulty involving the mother in decision making for her child. She no longer visits and has been unreachable by telephone. Appropriately, the critical care team has asked for ethics committee consultation yet without any resolution. The complex legal issues ultimately may force this conflict into court. 11 SOME APPROACHES TO CONFLICT RESOLUTION
Early and adequate communication is the first (and often the only necessary) step toward resolution of a conflict. Communication and trust likely will prevent disagreements from escalating into conflict. The source must be understood to begin to resolve any conflict. 12 Short-term and long-term patient care goals must be communicated between the physician in charge, consultants, nurses, therapists, social workers, families, and the child whenever possible. Prognosis and plans should be coordinated and discussed on a regular and frequent
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basis. Mixed signals and inconsistent messages fuel conflict. Families often do not hear distressing news of a poor outcome the first time. It is unwise and unrealistic for a physician to expect that a parent will agree to every recommendation the first time it is presented. This is especially true regarding decisions to forgo treatment. Nevertheless, simply presenting all technically feasible options and then offering to do whatever the parents want is inconsistent with good medical practice. 14 Parents should receive the benefit of their physicians' clinical judgement and ethical wisdom, not just their technical expertise. s At times, differences in education or experience may be the source of conflict. If so, helping a parent to understand and appreciate the medical facts may be all that is needed to resolve conflict. Religion also may play a role in both health care workers and parents' opinions. If religion is a factor, it often is useful to involve an experienced hospital chaplain or one's own religious leader in exploring the conflicts that may occur. s The involvement of an ethics consultation may be requested by physicians, other members of the health care team, parents, or the patient. The opinions of ethics consultants may be useful in clarifying problems in communication or in providing a different perspective. s Orr and de Leon 2 recently suggested that the traditional roles of negotiator, mediator, or arbitrator may not accurately describe the role of the clinical ethicist in any particular situation. One of the primary goals of an ethics consultation should be to provide a forum for discussion among the physicians, nurses, consultants, family members and others involved in a child' s care. Although often such discussion leads to consensus, consensus should not necessarily be the goal. The perceived necessity of reaching consensus, when combined with the inevitable power differentials that exist within an ethics committee and clinical setting, may lead to an apparent consensus based on the silencing of divergent viewpoints rather than substantive agreement. The ethics committee must foster open and uncoerced discussion that respects the diversity of moral and religious values found within our society. II Some conflict may not be resolved. If efforts to reach agreement fail, the physician may look for another physician who is willing to assume responsibility for the patient's management and who can abide by the parents' wishes. If this approach fails, then the physician may look for a physician at another institution who is willing to accept the patient in transfer. 14 CONCLUSION
Differences of opinion always will exist. The key to preventing these difference from escalating into conflict is the open communication of differing viewpoints in an atmosphere of trust and mutual respect. Mistrust usually is the
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seed of conflict. The moral focus always should remain on our commitment to the best interests of the child, tempered by the recognition that others may share this focus but see the situation differently. Consultation with other trusted clinicians or advisors may help clarify the issues, with ethics consultation reserved for those times when our shared judgements about the pertinent facts and values become uncertain. A pediatric ethics consultation should
remain committed to the child's best interest, and be willing to grapple realistically with the political, legal, and institutional barriers that often prevent us from acting with integrity consistent with this commitment. Finally, conflict arises in situations in which the correct course of medical or moral action is unclear. As such, we need to remember our own fallibility and vulnerability, and seek a solution that respects others.
REFERENCES I. Marcus U: Renegotiating Health Care. San Francisco, CA, Jossey-Bass, 1995 2. Orr RD, de Leon DM: The role of the clinical ethicist in conflict resolution. J Clin Ethics 11:21-30, 2001 3. Bartholome WG: A new understanding of consent in pediatric practice: Consent, parental permission, and child assent. Pediatric Annals 18:262-265, 1989 4. Pellegrino ED, Thomasma D: For the Patient's Good. New York, NY, Oxford University Press, 1988, pp 73-91 5. Nelson U , Nelson RM: Ethics and the provision of futile, harmful , or burdensome treatment to children. Crit Care Med 20:427-433, 1992 6. Committee on Bioethics, American Academy of Pediatrics, AAP: Institutional Ethics Committees. Pediatrics 107:205-209, 2001 7. Committee on Bioethics and Committee on Hospital Care, AAP: Palliative Care for Children. Pediatrics 106:351-357, 2000
8. Committee on Child Abuse and Neglect and Committee on BiGethics, AAP: Foregoing life-sustaining medical treatment in abused children. Pediatrics 106:1151-1153, 2000 9. Committee on Bioethics, AAP: Guidelines on forgoing life-sustaining medical treatment. Pediatrics 93:532-536, 1994 10. Committee on Bioethics, AAP: Ethics and the care of critically ill infants and children. Pediatrics 98:149-152,1996 II. Nelson RM, Shapiro RS: The role of an ethics committee in resolving conflict in the neonatal intensive care unit. J Law Med Ethics 23:27-32, 1995 12. Goold SD, Brent W, Arnold RM: Conflicts regarding decisions to limit treatment: A differential diagnosis. JAMA 283:909-914,
2000 13. Ingelfinger FJ: Arrogance. N Engl J Med 303:1507-1511, 1980 14. Paris JJ, Crone RK: Physicians' refusal of requested treatment. N Engl J Med 322:1012-1015, 1990