title: Novel legislation for pediatric advance directives: surveys and focus groups capture parent and clinician perspectives.
abstract: BACKGROUND
  Legislative measures increasingly require consideration of pediatric inpatients for Medical Orders for Life-Sustaining Treatment.
  
  
  OBJECTIVE
  To explore pediatric clinicians' experiences with life-sustaining treatments prior to the Medical Orders for Life-Sustaining Treatment mandate and to describe clinician and family concerns and preferences regarding pediatric Medical Orders for Life-Sustaining Treatment.
  
  
  METHODS
  Clinician surveys and clinician and parent focus groups.
  
  
  METHODS
  Pediatric clinicians and parents from one of Maryland's largest health systems.
  
  
  RESULTS
  Of 96 survey respondents, 72% were physicians and 28% were nurse practitioners. A total of 73% of physicians and 34% of nurse practitioners felt able to lead discussions about limiting therapies "most" or "all" of the time. A total of 75% of physicians and 37% of nurse practitioners led such a discussion in the prior year. A total of 55% of physicians and 96% of nurse practitioners had written no order to limit therapies in the past year. Only for children predicted to die within 30 days did >80% of clinicians agree that limitation discussions were warranted. A total of 100% of parent focus group participants, but 17% of physicians and 33% of nurse practitioners, thought that all pediatric inpatients warranted Medical Orders for Life-Sustaining Treatment discussions. Parents felt that universal Medical Orders for Life-Sustaining Treatment would decrease the stigma of limitation discussions. Participants believed that Medical Orders for Life-Sustaining Treatment would clarify decision making and increase utilization of palliative care. Medical Orders for Life-Sustaining Treatment communication skills training was recommended by all.
  
  
  CONCLUSIONS
  A minority of clinicians, but all parents, support universal pediatric Medical Orders for Life-Sustaining Treatment. Immediately prior to the Medical Orders for Life-Sustaining Treatment mandate, many clinicians felt unprepared to lead limitation discussions, and few had written relevant orders in the prior year. Communication training is perceived essential to successful Medical Orders for Life-Sustaining Treatment conversations.
authors: Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA rboss1@jhmi.edu.
authors: Renee D
authors: RD
authors: Boss
authors: Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors: Nancy
authors: N
authors: Hutton
authors: Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors: Pamela L
authors: PL
authors: Griffin
authors: Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors: Beth H
authors: BH
authors: Wieczorek
authors: Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors: Pamela K
authors: PK
authors: Donohue
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000331:legislation & jurisprudence*; D001291:Attitude of Health Personnel; D002648:Child; D005260:Female; D017144:Focus Groups; D006801:Humans; D008020:Life Support Care / Q000331:legislation & jurisprudence*; D008297:Male; D008875:Middle Aged; D010290:Parents / Q000523:psychology*; D010372:Pediatrics / Q000331:legislation & jurisprudence*; D010817:Physician-Patient Relations; D016414:Resuscitation Orders; D013727:Terminal Care / Q000331:legislation & jurisprudence / Q000379:methods*; D028761:Withholding Treatment
keywords: Advance directives; pediatric palliative care; physician–patient communication