Ethical Guidance of Pediatric Device Use: A Rapid Systematic Review

Abstract

Objective: To provide a comprehensive review of existing ethical guidance on use of extra/paracorporeal devices in children by summarizing the quantity, quality, and themes of existing published literature. Data Sources: PubMed, Web of Science, and EMBASE databases were systematically searched for citations from 1.1.2000.1.1.2022. Study Selection: Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses rapid review. Two reviewers independently evaluated abstracts and full text of identified citations that discussed ethical guidance for, utilization of, or decision-making related to initiation, continuation, discontinuation, or allocation of devices in children. Extra/paracorporeal devices included mechanical ventilation (MV), tracheostomy, renal replacement therapy (RRT), mechanical circulatory support (MCS), and extracorporeal life support (ECLS). We included policy statements from authoritarian bodies/institutions, guidelines, expert opinion statements, and surveys evaluating attitudes/preferences. Adult specific guidelines were excluded. Data Extraction: Content analysis used a standardized data extraction tool with inductive thematic analysis. Quality of ethical analysis was categorized using a multimodal tool based on methodology for opinion pieces and ethics literature. Data Synthesis: Of 3187 citations screened, 74 met inclusion criteria, including 37 (50%) pediatric specific. Ethical analysis was the primary objective in 21 (28%). 80% were multi-author, 25% represented a society, 40% explicitly stated Bioethics affiliations. One-third had international authorship, predominantly from US and Europe with Low- Middle-Income Countries represented in 14%. Half related to MV, 24% RRT, 21% MCS; 65% focused on a specific device and referred broadly to life-sustaining therapies. Only 18% were high-quality and low risk-of-bias. Of 14 (19%) guidelines, 1 (1.4%) was pediatric specific with a primary goal ethical analysis of device use. Of 7 (9%) literature reviews, 3 used systematic search strategies, all concluded limited ethical guidance existed. Of 24 (32%) quantitative/qualitative analyses, 4 (17%) presented patient-level data (2 pediatric), 19 (79%) were surveys or qualitative analyses of interview data exploring clinician/public perspectives on resource allocation or device utilization decisions (70% pediatric specific). Of 29 (39%) conceptual, theoretical, or normative ethical analyses, or commentaries, 5 (17%) were pediatric specific with ethical analysis of device use the primary aim. Conclusions: This descriptive summary of published literature on ethical use of devices in children identified numerous gaps, including lack of consistent guidelines and recommendations. Future research regarding ethical guidance on device use in pediatrics globally is warranted to promote use in those who will benefit, avoid prolonged nonbeneficial therapy and minimize harm, ensure equitable access to life-sustaining extra/paracorporeal therapies, and provide just allocation of resources.