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How pediatricians counsel parents when no "best-choice" management exists: lessons to be learned from hypoplastic left heart syndrome.

BACKGROUND
Hypoplastic left heart syndrome (HLHS) is a life-threatening congenital cardiac defect. Three mutually exclusive management options exist: the Norwood palliative procedure, cardiac transplantation, and comfort care without surgical intervention.


OBJECTIVES
To assess which management options are presented to parents of infants with HLHS, and to determine what factors influence physicians' recommendations.


DESIGN
Cross-sectional survey.


SETTING
Fourteen of the largest pediatric cardiac surgery centers in the United States.


PARTICIPANTS
Attending physicians in neonatology, cardiology, critical care practice, and cardiac surgery.


INTERVENTION
A survey was distributed asking physicians what options they present to parents of infants with HLHS and what their recommendations are in general, as well as physician perceptions of HLHS outcomes and demographic information.


MAIN OUTCOME MEASURES
Which options physicians discuss and which they recommend.


RESULTS
Of 454 eligible physicians 257 (57%) responded to the survey, of which 110 make treatment recommendations to parents. Neonatologists were least likely to recommend surgery. Physicians who recommend surgery recommend procedures performed at their own institution over those performed elsewhere (odds ratio, 2.80; 95% confidence interval, 2.24-3.51). Twenty-six percent of physicians do not discuss nonsurgical management, and 25% of those at centers that do not perform cardiac transplantation do not discuss this option. The recommendations physicians make to parents are poorly associated with their predictions of postoperative outcomes.


CONCLUSIONS
Physician recommendations to parents are poorly associated with their estimates of outcomes, and some physicians recommend the treatment preferred at their own institution over other options even when they predict better outcomes from another approach. Further, many physicians do not disclose all reasonable management options to parents of infants with HLHS. These findings raise doubts as to whether parents are given adequate information to make truly informed decisions.