title: End-of-life decision-making for children with severe developmental disabilities: The parental perspective.
abstract: OBJECTIVE
  The objectives of this integrative review were to understand how parents of children with severe developmental disorders experience their involvement in end-of-life decision-making, how they prefer to be involved and what factors influence their decisions.
  
  
  METHODS
  We searched MEDLINE, EMBASE, CINAHL and PsycINFO. The search was limited to articles in English or Dutch published between January 2004 and August 2014. We included qualitative and quantitative original studies that directly investigated the experiences of parents of children aged 0-18 years with severe developmental disorders for whom an end-of-life decision had been considered or made.
  
  
  RESULTS
  We identified nine studies that met all inclusion criteria. Reportedly, parental involvement in end-of-life decision-making varied widely, ranging from having no involvement to being the sole decision-maker. Most parents preferred to actively share in the decision-making process regardless of their child's specific diagnosis or comorbidity. The main factors that influenced parents in their decision-making were: their strong urge to advocate for their child's best interests and to make the best (possible) decision. In addition, parents felt influenced by their child's visible suffering, remaining quality of life and the will they perceived in their child to survive.
  
  
  CONCLUSIONS
  Most parents of children with severe developmental disorders wish to actively share in the end-of-life decision-making process. An important emerging factor in this process is the parents' feeling that they have to stand up for their child's interests in conversations with the medical team.
authors.affiliation: Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: i.h.schuller@amc.nl.
authors.forename: I H
authors.initials: IH
authors.lastname: Zaal-Schuller
authors.affiliation: Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: m.a.devos@amc.nl.
authors.forename: M A
authors.initials: MA
authors.lastname: de Vos
authors.affiliation: Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands. Electronic address: f.ewals@erasmusmc.nl.
authors.forename: F V P M
authors.initials: FV
authors.lastname: Ewals
authors.affiliation: Department of Paediatrics, Emma Children's Hospital-Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands. Electronic address: h.vangoudoever@amc.nl.
authors.forename: J B
authors.initials: JB
authors.lastname: van Goudoever
authors.affiliation: Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: d.l.willems@amc.nl.
authors.forename: D L
authors.initials: DL
authors.lastname: Willems
mesh_terms: D003657:Decision Making; D002658:Developmental Disabilities; D006801:Humans; D010290:Parents; D011788:Quality of Life; D012720:Severity of Illness Index; D013727:Terminal Care
keywords: Critical treatment decision; Decision-making; End-of-life; Integrative review; Parents; Quality of life; Severe developmental disorder; To advocate