OBJECTIVE: To conduct a national survey of pediatricians' access to and experience with clinical ethics consultation.

STUDY DESIGN: We surveyed a randomly selected sample of 3687 physician members of the American Academy of Pediatrics. We asked about their experiences with ethics consultation, the helpfulness of and barriers to consultation, and ethics education. Using a discrete choice experiment with maximum difference scaling, we evaluated which traits of ethics consultants were most valuable.

RESULTS: Of the total sample of 3687 physicians, 659 (18%) responded to the survey. One-third of the respondents had no experience with clinical ethics consultation, and 16% reported no access to consultation. General pediatricians were less likely to have access. The vast majority (90%) who had experience with consultation had found it helpful. Those with fewer years in practice were more likely to have training in ethics. The most frequently reported issues leading to consultation concerned end-of-life care and conflicts with patients/families or among the team. Intensive care unit physicians were more likely to have requested consultation. Mediation skills and ethics knowledge were the most highly valued consultant characteristics, and representing the official position of the hospital was the least-valued characteristic.

CONCLUSION: There is variability in pediatricians' access to ethics consultation. Most respondents reported that consultation had been helpful in the past. Determining ethically appropriate end-of-life care and mediation of disagreements are common reasons that pediatricians request consultation.

<p><strong>CONTEXT: </strong>Pediatric oncology patients often receive prolonged courses of opioids, which can result in constipation.</p>

<p><strong>OBJECTIVES: </strong>Comparing patients who received senna matched with similar patients who received other oral bowel medications, determine the subsequent risk of "problematic constipation," assessed as the occurrence of the surrogate markers of receiving an enema, escalation of oral bowel medications, and abdominal radiographic imaging.</p>

<p><strong>METHODS: </strong>This was a retrospective cohort study of hospitalized pediatric oncology patients less than 21&nbsp;years of age in 78 children's and adult hospitals between 2006 and 2011 who were started on seven consecutive days or more of opioid therapy and were started on an oral bowel medication within the first two days of opioid therapy. Clinically detailed administrative data were used from the Pediatric Health Information System and the Premier Perspective Database. After performing propensity score matching of similar patients who started senna and who started a different oral bowel medication, Cox regression modeling was used to compare the subsequent hazard of the surrogate markers.</p>

<p><strong>RESULTS: </strong>The final matched sample of 586 patients averaged 11.5&nbsp;years of age (range 0-20&nbsp;years); 41.8% (n&nbsp;=&nbsp;245) had blood cancer, 50.3% (n&nbsp;=&nbsp;295) had solid tumor cancer, and 7.9% (n&nbsp;=&nbsp;46) had brain cancer. Initiating senna therapy within two days of starting the prolonged opioid course, compared with initiating another oral bowel medication, was significantly associated with a lower hazard during the ensuing five days for receipt of an enema (hazard ratio [HR], 0.31; 95% CI, 0.11-0.91) or undergoing abdominal radiographic imaging (HR, 0.74; 95% CI, 0.55-0.98), was marginally associated with a lower hazard of oral bowel medicine escalation (HR, 0.78; 95% CI, 0.59-1.03), and overall was significantly associated with a lower hazard of the composite end point of problematic constipation (HR, 0.70; 95% CI, 0.56-0.88).</p>

<p><strong>CONCLUSION: </strong>Initiating senna therapy, compared with other oral bowel medications, diminishes the subsequent risk of surrogate markers of problematic constipation in this population.</p>

<p><strong>CONTEXT: </strong>Appropriate use of opioids is essential to manage moderate-to-severe pain in children safely and effectively, yet published guidance regarding opioid treatment for pediatric patients is limited, potentially resulting in excessive variation in opioid use in pediatric patients across hospitals in the U.S.</p>

<p><strong>OBJECTIVES: </strong>The aim was to evaluate hospital variation in opioid use in pediatric inpatients.</p>

<p><strong>METHODS: </strong>Using data from the Pediatric Health Information System and the Premier Perspective Database regarding all pediatric inpatients in 626 hospitals, we examined hospital variation in opioid use and the length of opioid use, adjusting for patient demographic and clinical characteristics and for hospital type (children's vs. general) and hospital patient volume, using multilevel generalized linear regression modeling.</p>

<p><strong>RESULTS: </strong>Overall, 41.2% of all pediatric hospitalizations were exposed to opioids. Among the exposed patients, the mean length of exposure was 4.6 days. Exposure proportion and exposure length varied substantially across hospitals, even after accounting for patient demographic and clinical characteristics, hospital type and hospital patient volume, especially among terminal hospitalizations. For patients discharged alive vs. died, the adjusted exposure percentage for each hospital ranged from 0.7% to 99.1% (interquartile range [IQR]: 35.3%-59.9%) vs. 0.1% to 100.0% (IQR: 29.2%-66.2%), respectively, and the adjusted exposure length ranged from 1.0 to 8.4 days (IQR: 2.2-2.7 days) vs. 0.9 to 35.2 days (IQR: 4.0-7.4 days).</p>

<p><strong>CONCLUSION: </strong>The substantial hospital-level variation in opioid use in pediatric inpatients suggests room for improvement in clinical practice.</p>

<p><strong>BACKGROUND: </strong>Physician empathy is both theoretically and empirically critical to patient health, but research indicates that empathy declines throughout medical school and is lower than ideal among physicians. In this paper, we synthesize the published literature regarding interventions that were quantitatively evaluated to detect changes in empathy among medical students, residents, fellows and physicians.</p>

<p><strong>METHODS: </strong>We systematically searched PubMed, EMBASE, Web of Science and PsychINFO in June of 2014 to identify articles that quantitatively assessed changes in empathy due to interventions among medical students, residents, fellows and physicians.</p>

<p><strong>RESULTS: </strong>Of the 1,415 articles identified, 64 met inclusion criteria. We qualitatively synthesized the findings of qualified studies by extracting data for ten study metrics: 1) source population, 2) sample size, 3) control group, 4) random assignment, 5) intervention type, 6) intervention duration, 7) assessment strategy, 8) type of outcome measure, 9) outcome assessment time frame, and 10) whether a statistically significant increase in empathy was reported. Overall, the 64 included studies were characterized by relatively poor research designs, insufficient reporting of intervention procedures, low incidence of patient-report empathy assessment measures, and inadequate evaluations of long-term efficacy. 8 of 10 studies with highly rigorous designs, however, found that targeted interventions did increase empathy.</p>

<p><strong>CONCLUSIONS: </strong>Physician empathy appears to be an important aspect of patient and physician well-being. Although the current empathy intervention literature is limited by a variety of methodological weaknesses, a sample of high-quality study designs provides initial support for the notion that physician empathy can be enhanced through interventions. Future research should strive to increase the sample of high-quality designs through more randomized, controlled studies with valid measures, explicit reporting of intervention strategies and procedures, and long-term efficacy assessments.</p>

<p><strong>BACKGROUND: </strong>Pediatric medical experiences are potentially traumatic but may lead to psychological growth.</p>

<p><strong>OBJECTIVE: </strong>The study objective was to synthesize the published literature regarding posttraumatic growth (PTG) in parents and patients with serious pediatric illness (SPI) into a conceptual model.</p>

<p><strong>METHODS: </strong>We systematically searched MEDLINE, CINAHL, PsychInfo, and Sociological Abstracts in December 2012 to identify articles on stress or trauma caused by medical events with PTG as an outcome, reviewing articles pertaining to the pediatric population. We additionally reviewed articles outside pediatric medicine that described a model of PTG.</p>

<p><strong>RESULTS: </strong>Of the 605 articles identified, 55 met inclusion criteria, 26 of which examined parents or pediatric patients. Parents and children may experience PTG following medical trauma through a combination of cognitive and affective processing of their subjective experience. Components of SPI-PTG are unclear, but may include greater appreciation of life, improved interpersonal relationships, greater personal strength, recognition of new possibilities in one's life course, spiritual or religious growth, and reconstruction of a positive body image. Individual characteristics, and the level of social support, may affect the likelihood that SPI-PTG will occur. SPI-PTG in siblings and other family members has not been well studied.</p>

<p><strong>CONCLUSIONS: </strong>SPI-PTG is an important but understudied and inadequately understood phenomenon affecting children with SPI and their family members. Research should focus on clarifying SPI-PTG domains, creating measurement instruments, assessing SPI-PTG across the pediatric age range and among family members, and improving our understanding of and ability to positively intervene regarding the cognitive processes of rumination, sense making, and benefit finding.</p>

<p><strong>BACKGROUND: </strong>Operation Smile is a non-profit organization that provides free cleft lip and cleft palate repair to impoverished children worldwide. To date, no longitudinal studies of satisfaction among these patients or their families have been published.</p>

<p><strong>OBJECTIVES: </strong>In a cohort of parents of children receiving cleft lip/cleft palate repair, to assess parental satisfaction and fulfillment of expectations.</p>

<p><strong>METHODS: </strong>A prospective cohort study with pre-operative and 6-month post-operative interviews of parents of 45 patients of the Operation Smile mission in Tegucigalpa, Honduras, 2007 was undertaken. Patients were recruited from a total of 96 who underwent surgery, with follow-up data available for 22 of them (49% of participants). Pre-operative interviews concerned expectations regarding surgery, and post-operative interviews addressed surgical outcomes and satisfaction.</p>

<p><strong>RESULTS: </strong>Mean patient age was 4 years (range 3 months to 17 years); 51% underwent isolated cleft lip repair, and 49% cleft palate repair. This was the first surgery for 53%, the remainder having had previous surgery on one to six occasions. Pre-operatively, parents expressed expectations that speech (n = 26), appearance (n = 21) or feeding (n = 17) would improve. Among the 22 re-interviewed 6 months after surgery, two had experienced minor and one major post-operative complications. Only 14 of 22 had all their pre-operative expectations fulfilled. All except one parent reported satisfaction with the surgery.</p>

<p><strong>CONCLUSION: </strong>Despite unmet expectations, parents of children who received medical mission surgery for cleft lip or cleft palate express satisfaction with outcomes. Other factors are likely to influence expressions of satisfaction in this setting.</p>

<p><strong>BACKGROUND: </strong>Pediatric palliative care (PPC) programs facilitate the provision of comprehensive care to seriously ill children. Over the past 10 years many such programs have been initiated by children's hospitals, but little is known about their number, staff composition, services offered, sources of support, or national distribution.</p>

<p><strong>METHODS: </strong>In the summer of 2012, we surveyed 226 hospitals as identified by the National Association of Children's Hospitals and Related Institutions. The survey instrument gathered data about whether their institution had a PPC program, and for hospitals with programs, it asked for a wide range of information including staffing, patient age range, services provided, and financial support.</p>

<p><strong>RESULTS: </strong>Of the 162 hospitals that provided data (71.7% response rate), 69% reported having a PPC program. The rate of new program creation peaked in 2008, with 12 new programs created that year, and 10 new programs in 2011. Most programs offer only inpatient services, and most only during the work week. The number of consults per year varied substantially across programs, and was positively associated with hospital bed size and number of funded staff members. PPC programs report a high level of dependence on hospital funding.</p>

<p><strong>CONCLUSIONS: </strong>PPC programs are becoming common in children's hospitals throughout the United States yet with marked variation in how these programs are staffed, the level of funding for staff effort to provide PPC, and the number of consultations performed annually. Guidelines for PPC team composition, funding, and consultation standards may be warranted to ensure the highest quality of PPC.</p>

<p><strong>OBJECTIVE: </strong>To identify and illustrate common explicit heuristics (decision-making aids or shortcuts expressed verbally as terse rules of thumb, aphorisms, maxims, or mantras and intended to convey a compelling truth or guiding principle) used by parents of children with life-threatening illnesses when confronting and making medical decisions.</p>

<p><strong>METHODS: </strong>Prospective cross-sectional observational study of 69 parents of 46 children who participated in the Decision-making in Pediatric Palliative Care Study between 2006 and 2008 at the Children's Hospital of Philadelphia. Parents were guided individually through a semistructured in-depth interview about their experiences and thoughts regarding making medical decisions on behalf of their ill children, and the transcribed interviews were qualitatively analyzed.</p>

<p><strong>RESULTS: </strong>All parents in our study employed explicit heuristics in interviews about decision-making for their children, with the number of identified explicit heuristics used by an individual parent ranging from tens to hundreds. The heuristics served 5 general functions: (1) to depict or facilitate understanding of a complex situation; (2) to clarify, organize, and focus pertinent information and values; (3) to serve as a decision-making compass; (4) to communicate with others about a complex topic; and (5) to justify a choice.</p>

<p><strong>CONCLUSIONS: </strong>Explicit heuristics played an important role in decision-making and communication about decision-making in our population of parents. Recognizing explicit heuristics in parent interactions and understanding their content and functions can aid clinicians in their efforts to partner with parents in the decision-making process.</p>