Evaluating Clinician Perspectives on Tracheostomy Placement in Children With Severe Neurologic Injury

Outcomes

1. Participants will appreciate the diversity of clinician sentiment surrounding destination tracheostomy placement in children with SNI, and the role that professional/subspecialty lens plays in shaping that perspective.

2. Participants will be able to consider and weigh the ethical principles at place in children with SNI being considered for destination tracheostomy placement: among these are autonomy, beneficence, non-maleficence, futility, shared decision making, and the zone of parental discretion.

Key Message

Destination tracheostomy placement in children with severe neurologic injury is a weighty decision fraught with moral distress and competing ethical principles. There is evidence that professional lens impacts both extent of moral distress and which ethical principles are given primacy by providers.

Abstract

“Destination” tracheostomies are increasingly considered in children with permanent severe neurologic injury (SNI) [1]. Though life-prolonging, the decision is weighty given the likelihood of high morbidity, increased healthcare utilization, and the lifestyle change required of caregivers [2-3]. There is evidence of added provider distress and concomitant conflict where provider and caregiver values disagree [4-6]. National surveys on provider perspectives are few, narrow in scope, and do not consider how the subspecialty lens influences provider perspectives.

Objectives

To evaluate the diversity of clinician sentiment surrounding destination tracheostomy placement in children with SNI, to evaluate how varied subspecialty lenses impact that perspective, and to review the complex ethical principles surrounding these cases.

Methods

A national survey of clinicians who care for children with tracheostomies. The survey introduced an example case of destination tracheostomy placement in a child with SNI and then evaluated professional experience and perspectives.

Results

Four hundred and thrity-eight initial respondents represented a diversity of subspecialty and professional experience. Respondents were divided on whether tracheostomy should be offered in the example case (55.4%) revealing significant discordance both with how many felt their institution would offer tracheostomy (90.2%) and how few would select tracheostomy if the child were their own (1.4%). There was significant discordance between respondents’ rating of quality-of-life in the example case (mean 27.7 ± 19.2) and respondent assumption for how caregivers would rate quality-of-life (mean 58.6 ± 16.0). Respondents reported regular moral distress in these situations (41.5% “sometimes,” 43.2% “frequently/always”). Respondents varied in judging whether caregivers or clinicians should bear primary responsibility for the decision. Only 18.5% of respondents reported institutional protocols for managing such cases, though 73% felt protocolization would be helpful. Analysis of subspecialty variability is ongoing.

Conclusion

There is significant variability in provider perspectives on destination tracheostomy placement in SNI. Early evidence suggests subspecialty lens influences those perspectives.

References

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