Living bioethics, theories and children's consent to heart surgery.

Background: This analysis is about practical living bioethics and how law, ethics and sociology understand and respect children's consent to, or refusal of, elective heart surgery. Analysis of underlying theories and influences will contrast legalistic bioethics with living bioethics. In-depth philosophical analysis compares social science traditions of positivism, interpretivism, critical theory and functionalism and applies them to bioethics and childhood, to examine how living bioethics may be encouraged or discouraged. Illustrative examples are drawn from research interviews and observations in two London paediatric cardiac units. This paper is one of a series on how the multidisciplinary cardiac team members all contribute to the complex mosaic of care when preparing and supporting families' informed consent to surgery. Results: The living bioethics of justice, care and respect for children and their consent depends on theories and practices, contexts and relationships. These can all be undermined by unseen influences: the history of adult-centric ethics; developmental psychology theories; legal and financial pressures that require consent to be defined as an adult contract; management systems and daily routines in healthcare that can intimidate families and staff; social inequalities. Mainstream theories in the clinical ethics literature markedly differ from the living bioethics in clinical practices. Conclusion: We aim to contribute to raising standards of respectful paediatric bioethics and to showing the relevance of virtue and feminist ethics, childhood studies and children's rights.

Living bioethics, clinical ethics committees and children's consent to heart surgery.

This discussion paper considers how seldom recognised theories influence clinical ethics committees. A companion paper examined four major theories in social science: positivism, interpretivism, critical theory and functionalism, which can encourage legalistic ethics theories or practical living bioethics, which aims for theory-practice congruence. This paper develops the legalistic or living bioethics themes by relating the four theories to clinical ethics committee members' reported aims and practices and approaches towards efficiency, power, intimidation, justice, equality and children's interests and rights. Different approaches to framing ethical questions are also considered. Being aware of the four theories' influence can help when seeking to understand and possibly change clinical ethics committee routines. The paper is not a research report but is informed by a recent study in two London paediatric cardiac units. Forty-five practitioners and related experts were interviewed, including eight members of ethics committees, about the work of informing, preparing and supporting families during the extended process of consent to children's elective heart surgery. The mosaic of multidisciplinary teamwork is reported in a series of papers about each profession, including this one on bioethics and law and clinical ethics committees' influence on clinical practice. The qualitative social research was funded by the British Heart Foundation, in order that more may be known about the perioperative views and needs of all concerned. Questions included how disputes can be avoided, how high ethical standards and respectful cooperation between staff and families can be encouraged, and how minors' consent or refusal may be respected, with the support of clinical ethics committees.

Reduction in Central Line-Associated Bloodstream Infection Rates After Implementations of Infection Control Measures at a Level 3 Neonatal Intensive Care Unit.

Advances in neonatology led to survival of micro-preemies, who need central lines. Central line-associated bloodstream infection (CLABSI) causes prolonged hospitalization, morbidities, and mortality. Health care team education decreases CLABSIs. The objective was to decrease CLABSIs using evidence-based measures. The retrospective review compared CLABSI incidence during and after changes in catheter care. In April 2011, intravenous (IV) tubing changed from Interlink to Clearlink; IV tubing changing interval increased from 24 to 72 hours. CLABSIs increased. The following measures were implemented: July 2011, reeducation of neonatal intensive care staff on Clearlink; August 2011, IV tubing changing interval returned to 24 hours; September 2011, changed from Clearlink back to Interlink; November 2011, review of entire IV process and in-service on hand hygiene; December 2011, competencies on IV access for all nurses. CLABSIs were compared during and after interventions. Means were compared using the t test and ratios using the χ2 test; P <.05. CLABSIs decreased from 4.4/1000 to 0/1000 catheter-days; P < .05. Evidence-based interventions reduced CLABSIs.

Longitudinal relationship between social media activity and article citations in the journal Gastrointestinal Endoscopy.

BACKGROUND AND AIMS: Social media activity in the area of scientific journal publications has increased significantly over the last decade. Several studies have suggested that journal article citations can be positively impacted by an increase in social media activity. Preliminary data have also suggested that published articles in the field of gastroenterology and hepatology that were discussed on Twitter were independently associated with higher citation rates compared with those that were not. Gastrointestinal Endoscopy (GIE) is the most widely cited endoscopy-focused journal in the world. We aimed to assess the association of social media exposure of published articles in GIE and its impact on article citations. METHODS: Data regarding journal article publication status, number of citations per article, and social media exposure per article using Altmetric data were collected from the publisher. All original articles published in GIE from 2000 to 2016 were reviewed. Editorials, case reports, and other nonresearch correspondence were excluded. Multivariable linear regression was used to assess for independent Altmetric predictors of higher citation rates over time. Logistic regression was used to assess the impact of an article mention on various social media platforms and whether it was cited during the study period. RESULTS: A total of 2361 original research articles were evaluated; 2050 articles (86.8%) were cited at least once during the follow-up period. Mean number of citations per article was 16.8 ± 23. The average Altmetric Attention score was 2.0 ± 13. The most profound independent predictor of article citation was whether an article was tweeted (odds ratio [OR], 14.2; 95% confidence interval [CI], 8.93-22.45). Other predictors were Facebook posts (OR, 1.08; 95% CI, 1.03-1.51) and number of Mendeley readers (OR, 1.359; 95% CI, 1.28-1.45). On multivariable linear regression, number of tweeters (ß = 2.3, P = .022), F1000 reviews (ß = 5.87, P < .001), policy documents (ß = 7.6, P < .001), and number of Mendeley readers (ß = 14.21, P < .001) were significantly associated with higher citation rates of published articles. CONCLUSIONS: For original articles published in GIE, there was a strong association between social media exposure on Twitter and rates of journal article citations. To a lesser degree, Facebook posts and Mendeley readers also were associated with a higher rate of article citations. This could represent both cause and effect and may be representative of higher quality articles being more commonly mentioned on social media by third-party users. A randomized controlled study evaluating different degrees of social media exposure on individual articles could be considered to further assess for causality.

Vulnerability, survival and shame in Nina Raine's Tiger Country.

Shame in healthcare remains relatively underexplored, yet it is commonplace and its impact is significant. This paper explores shame in healthcare using Nina Raine's 2011 play Tiger Country Three manifestations of shame are explored, namely (1) shame in relation to professional identity and survival in the clinical workplace; (2) shame and illness as experienced by both patients and doctors; and (3) the systemic and organisational influences on shame within healthcare systems. I suggest that the theatre is particularly well-placed to elucidate shame, and that Tiger Country demonstrates the prevalence and impact of shame on clinical work. Shame has a fundamental and overlooked relationship with damaging and well-documented phenomena in healthcare, including moral distress, ethical erosion, compassion fatigue, burnout, stress and ill health. Attention to shame is essential for those interested in medicine and healthcare and must, I propose, include the experiences and perceptions of those who provide care, as well as attending to those who receive care.

The Moral of the Tale: Stories, Trust, and Public Engagement with Clinical Ethics via Radio and Theatre.

Trust is frequently discussed with reference to the professional-patient relationship. However, trust is less explored in relation to the ways in which understanding of, and responses to, questions of ethics are discussed by both the "public" and "experts." Public engagement activity in healthcare ethics may invoke "trust" in analysing a moral question or problem but less frequently conceives of trust as integral to "public engagement" itself. This paper explores the relationship between trust and the ways in which questions of healthcare ethics are identified and negotiated by both "experts" and the public. Drawing on two examples from the author's "public engagement" work-a radio programme for the British Broadcasting Corporation and work with a playwright and theatre-the paper interrogates the ways in which "public engagement" is often characterized. The author argues that the common approach to public engagement in questions of ethics is unhelpfully constrained by a systemic disposition which continues to privilege the professional or expert voice at the expense of meaningful exchange and dialogue. By creating space for novel interactions between the "expert" and the "public," authentic engagement is achieved that enables not only the participants to flourish but also contributes to trust itself.