Ethics in the PED: An Untimely Death.

ABSTRACT: Death is an uncommon event in the pediatric emergency department. The sudden end of a young life is always an undesirable event. Staff and family members are never prepared. Although staff in the emergency department can become routinized to caring for acutely ill and dying patients, family members may become shocked by this novel and terrible experience. Whether the patient is old or young, previously sick or healthy, it is important to stop and consider how hard it must be for the assembled family. As frontline clinicians, we all deeply care about the outcome of our patients and their families, yet for them to feel they have been understood and well cared for, it is recognized that clinicians must attend to health care conversations on a deeper and more relational level. Consideration that these events happen and reinforcing that it is difficult for all involved ensure staff that their challenges are recognized.

Confronting Subconscious Bias: Ethics in the Pediatric Emergency Department.

Physicians are only human. Upon graduating from medical school, physicians take an oath declaring veracity and fidelity toward our patients. We are told to lay aside negative feelings toward patients in exchange for integrity, truth, honor, and compassion. The idea is simple, but following through on it is quite a challenge. Pediatric emergency medicine physicians generally have rapid focused patient interactions, yet even in these brief encounters, instantaneous and subconscious reactions to difficult patients occur. Difficult patients are those who raise negative feelings within the clinician such as anxiety, frustration, guilt, and dislike. Recognition of these reactions and emotions will help physicians understand more about themselves, and assist in interacting more favorably with challenging patients. It is common for doctors to attempt to suppress their human reactions to maintain clinical objectivity, yet these reactions facilitate a better doctor-patient relationship. Allowing ourselves to yield to our emotions help the patient realize that the physician is a human being.

Health Equity Demands Health Literacy: Ethics in the Pediatric Emergency Department.

The ability of the patient or the parent, in pediatrics, to read, understand, and act upon health information is termed health literacy. Health literacy has been shown to be of primary importance when determining a patient's ability to achieve optimal health. As physicians, we often fail to recognize the enormous obstacles facing our patients. In the pediatric emergency department (PED), communication is complicated. Physicians must be able to effectively relay information to the patient's caregiver while still not forgetting to provide developmentally appropriate instructions to the child. Individuals who do not have a good understanding of what is needed to properly care for themselves or their children are at a disadvantage, and it is therefore the responsibility of the pediatric provider to do all they can to identify gaps in health literacy. As providers, we need to always be questioning as to whether we properly conveyed the information to our patients. Teaching which results in good understanding is the ultimate goal when treating and releasing our patients in the pediatric emergency department. Matching the method of delivery of information and education to the family's health literacy will help the care team deliver effective information so that it is applied at home hopefully preventing a rapid revisit.

Resurgence of Vaccine-Preventable Disease: Ethics in the Pediatric Emergency Department.

After a decades-long reduction in vaccine-preventable illnesses worldwide, there has been a reappearance of childhood illnesses once thought to be eradicated. This resurgence in illnesses such as polio and measles is a consequence of multifactorial events leading to decreased vaccination rates. A lack of resources in poor and war-torn countries, coupled with increasing global travel, and decisions to delay or defer vaccinations because of inaccurate studies further emphasized by media have combined to result in current state of frequent local and widespread epidemics, specifically the current outbreak of measles. As providers in the pediatric emergency department, we are often the first to encounter children manifesting these diseases. It is imperative that we understand the circumstances leading to these encounters, so that we can have engaged conversations with families, gain an understanding of their motivations, dispel any misinformed beliefs, and encourage positive health behaviors for their children.

Complexities of Consent: Ethics in the Pediatric Emergency Department.

Informed consent is a communicative process of sharing information with patients, which helps assure their understanding of the information provided and asks for their permission to proceed. Informed consent allows a patient or a patient's family to use his or her own value system to determine the need for a particular procedure or test. Asking a patient for permission to treat requires the provider to respect the patient's autonomy through allowing him or her to be an active part of the decision-making process. Consent in the pediatric emergency department can be a complex process. Parental consent is generally required for medical evaluation and treatment of pediatric patients, but in the pediatric emergency department, there are exceptions to this rule. If the provider determines that a parent's refusal of consent places the child at risk of harm, then consent is not necessary. By using the concepts of Emergency Medical Treatment and Active Labor Act, in emergent situations, consent may not be necessary. Finally, adolescents are often deeply concerned about privacy-their acceptance of appropriate care is often based on this promise of confidentiality. In the emergency department, adolescents can therefore be treated for issues relating to reproductive care without parental consent. It is important for the emergency department physician to understand the rules surrounding the care of pediatric patients to avoid compromising their privacy and ultimately their well-being and medical care.

Ethics in the Pediatric Emergency Department: When Mistakes Happen: An Approach to the Process, Evaluation, and Response to Medical Errors.

The emergency department (ED) is an environment that is conducive to medical errors. The ED is a time-pressured environment where physicians aim to rapidly evaluate and treat patients. Quick thinking and problem-based solutions are often used to assist in evaluation and diagnosis. Error analysis leads to an understanding of the cause of a medical error and is important to prevent future errors. Research suggests mechanisms to prevent medical errors in the pediatric ED, but prevention is not always possible. Transparency about errors is necessary to assure a trusting doctor-patient relationship. Patients want to be informed about all errors, and apologies are hard. Apologizing for a significant medical error that may have caused a complication is even harder. Having a systematic way to go about apologizing makes the process easier, and helps assure that the right information is relayed to the patient and his or her family. This creates an environment of autonomy and shared decision making that is ultimately beneficial to all aspects of patient care.

Comparison of temporal artery thermometry and rectal thermometry in febrile pediatric emergency department patients.

OBJECTIVES: Fever is among the most common reasons for emergency department (ED) visits by children. This study compares temporal artery thermometry to rectal thermometry in febrile children in an ED. METHODS: This was a retrospective evaluation of children younger than 36 months treated consecutively in an urban medical center. Patients underwent triage with temporal artery thermometry, and after transfer to the pediatric ED, they underwent rectal thermometry. Fever was defined as rectal temperature of 100.4 °F (38 °C) or greater, and 147 patients met this definition. Data extraction from electronic charts obtained paired temporal artery and rectal temperatures, and these were compared by Bland-Altman analysis. Temperature points of 100.4 °F (38 °C) and 102.2 °F (39 °C) were evaluated to compare temporal artery thermometry with rectal thermometry sensitivity and specificity. RESULTS: A statistically and clinically significant difference between temporal artery and rectal temperature was found. Temporal artery thermometry was 53% sensitive detecting rectal temperature 100.4 °F (38 °C) or greater, and 27% sensitive detecting rectal temperature of 102.2 °F (39 °C) or greater. Mean rectal temperature was 102.36 °F (39.09 °C) (95% confidence interval [CI], 102.14 °F-102.58 °F); mean temporal artery temperature was 100.36°F (37.98 °C) (95% CI, 100.08 °F-100.65 °F), and mean difference between the two was 1.99 °F (1.11 °C) (95% CI, 1.75 °F-2.23 °F). CONCLUSIONS: Temporal artery thermometry is poorly sensitive detecting fever and does not accurately reflect rectal temperature. Temporal artery thermometry should not be used for clinical management of children younger than 36 months if detection of fever is of importance.