Ethical Decisions: Weight Management for the Pediatric Patient
Donna A. Caniano, MD, Surgeon-in-Chief, Chief of the Department of Pediatric Surgery Nationwide Children's Hospital
The medical community is beginning to acknowledge obesity as a global epidemic. However, medical care is disproportionate among groups with health care access limitations. In order to accept that obesity is now a major health care issue, the medical community will require a new way of addressing pediatric health care, such as defining the roles and responsibilities of major pediatric organizations and implementing changes in pediatric medical education. Furthermore, focusing on prevention as a key priority should also be part of the medical training strategy, identifying the morbidly obese and referring them to appropriate pediatric obesity centers. Also, there must be an establishment of transparent mechanisms, for review of outcomes, complications and development of better surgical techniques and operations is a necessary step forward to help provide better standards of care for pediatric patients.
The Healthy Weight and Nutrition program at Nationwide Children’s Hospital provides complete care to the adolescent patient by providing nutritional and lifestyle counseling, before and after surgical intervention. In addition, Nationwide Children's is in the process of reviewing outcomes to help improve care, and is one of only five institutions nationally to join the multi-institution clinical research study to understand the benefits and risks of bariatric surgery in adolescents.
The Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) research study is funded by the National Institutes of Health (NIH). Marc P. Michalsky, MD, surgical director of the Center for Healthy Weight and Nutrition, will lead this study at Nationwide Children's Hospital. The Teen-LABS consortium members include Nationwide Children's Hospital, Cincinnati Children's Hospital Medical Center, Texas Children's Hospital, Children's Hospital of Alabama and the University of Pittsburgh.
Teen-LABS is being conducted in parallel with LABS, an NIH study designed to examine similar outcomes in adult patients undergoing bariatric surgical treatment. By comparing features of adolescent and adult bariatric surgery patients, research could help clarify medical and psychological health outcomes of bariatric surgery. This comparison could lead to better decision-making regarding appropriate timing of surgery for young Americans whose health is increasingly threatened by extreme obesity.
The decision to proceed with bariatric surgery in pediatric patients carries profound ethical burdens for stakeholders, such as morbidly obese children and adolescents, their friends and families, pediatricians and pediatric surgeons, pediatric healthcare organizations and society. That is why the decision for bariatric intervention should be made only after all other treatments have been considered. It should be established that the patient’s co-morbidities could not be treated with less invasive means, the patient has a favorable risk/benefit profile, the patient and the family have received extensive pre-operative counseling and given informed consent, and the pediatric bariatric team has a comprehensive system setup for long-term care, such as the program offered at Nationwide Children's.
Society assumes that parents are in the best position to make medical /surgical decisions for their child, and expects parents to be active participants in their child’s health care, along with supporting necessary dietary and lifestyle changes for successful post-operative outcomes. There is an ethical burden when helping a child deal with co-morbid conditions, as well as helping them through the extensive pre-surgical evaluation process. There is also an ethical burden of helping and understanding the risk/benefit profile of bariatric surgery and an ethical burden of decision making for a particular bariatric operation.
For the physicians and healthcare personnel at Nationwide Children’s, the goal of identifying and treating childhood obesity is to reverse co-morbidities of morbidly obese children and adolescents. The bariatric surgeons work integrally with the physicians, therapists and nurses within the Healthy Weight and Nutrition program so that all options for weight loss are considered. When or if bariatric surgery is considered to be the best option, then the team works together to select the most appropriate type of bariatric surgery for the patient that is referred.
