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Management dilemmas in pediatric nephrology: moving from friction to flourishing in “challenging” cases

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Abstract

Background

The circumstances surrounding chronic kidney disease and its impact on families can be complex and difficult to navigate, leading to these cases being labeled “challenging.”

Case presentation

We present the case of an adolescent with kidney failure due to unremitting systemic illness and multiple complications ultimately resulting in the family’s request to forgo dialysis. Medical team members wrestled with meeting the family’s needs among internal and external constraints.

Conclusion

Past experiences, systemic inequities, differing perspectives, and consequential decision-making within individual belief systems can lead to friction between and among medical team members and families. As pediatric nephrologists, we must shift our focus from the “challenging” patient or family to addressing what is challenging their ability to flourishing.

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Acknowledgements

This manuscript was developed in follow-up to “When we don’t see eye to eye: when two worlds collide, and patient care is compromised,” our workshop presented at the Pediatric Academic Society meeting in Washington, DC 2023.

Author information

Author notes

  1. Celina Brunson and Taylor R. House report equal contributions to the manuscript and joint first authorship.

Authors and Affiliations

  1. Department of Pediatrics, George Washington University, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC, USA

    Celina Brunson

  2. Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin Madison, 600 Highland Ave, Madison, WI, 53792, USA

    Taylor R. House

  3. Department of Pediatrics, Hospital for Sick Children, University of Toronto, 555 University Ave., Toronto, ON, M5G 1X8, Canada

    Damien Noone

  4. Department of Pediatrics, Seattle Children’s Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA, 98105, USA

    Aaron Wightman

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  1. Celina Brunson
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  4. Aaron Wightman
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Correspondence to Taylor R. House.

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Key points

• Pediatric nephrologists should be attuned to their individual perspectives that inform clinical interactions, the breadth of challenges encountered by patients with marginalized identities, and the need to approach these power dynamics with cultural humility.

• Medical mistrust can be based in historical legacies of medical misconduct and reinforced by current issues of structural racism affecting the way that patients interact with the medical system leading to poorer health outcomes.

• Ethical frameworks and concepts can provide a structured approach to understanding the competing tensions that contribute to “challenging” cases.

• Pediatric nephrologists should apply principles of palliative care including attending to physical symptoms and psychosocial suffering and delivering high quality serious illness communication to enable patient and family flourishing in “challenging” cases.

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Brunson, C., House, T.R., Noone, D. et al. Management dilemmas in pediatric nephrology: moving from friction to flourishing in “challenging” cases. Pediatr Nephrol (2024). https://doi.org/10.1007/s00467-024-06384-8

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  • DOI: https://doi.org/10.1007/s00467-024-06384-8

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