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1. Utilizing a case-based approach plus content expert didactic presentation, participants will self-report ability to identify 3 defensive mechanisms utilized by caregivers and providers during shared decision making (SDM) that can compromise its outcome. 2. Utilizing content expert didactic presentation and a case-based approach, participants will self-report ability to articulate strategies to survey for and engage in defense mechanisms when engaged in value-based decision making with caregivers. Pediatrics is posited upon family centered care. Pediatric Palliative Care seeks to elucidate values and ensure goal concordant care within this dynamic. Yet, does radical acceptance equal agreement with a medical decision and should Pediatric Palliative Care always champion a caregiver request? This session explores this question and if the field needs a course correction. 1. Participants will identify at least 3 defensive mechanisms utilized by caregivers and providers during shared decision making that can compromise its outcome. 2. Participants will be able to discern a caregiver's desired outcome from their values and how their conflation can lead to discordant caregiver decision making. 3. Participants will identify at least 2 healthcare provider strategies to use during shared decision making to optimize value-based decision making. This presentation will utilize slide presentation, expert opinion, and clinical vignettes to review perceived changes over the past decade in how pediatric palliative care (PPC) specialists engage with caregiver decision making regarding medical interventions. It will challenge participants to consider that the field is increasingly teaching and practicing alignment with families via validation is a primary objective rather than our historic focus on actively guiding a decision-making process through value alignment. Pediatrics' emphasis on family-centered decision-making challenges PPC providers by inadvertently increasing caregiver decisional-stress and fatigue, which induces reliance on pre-existing coping skills and psychological defense mechanisms to navigate their distress. This reliance risks PPC provider alignment with decisions rather than values, and as many of these defense mechanisms are in the higher functioning range of defense mechanisms, they are more challenging to detect and address. These concepts will be explored by a palliative psychiatrist and palliative psychologist as well as strategies PPC providers can deploy to identify some of these barriers and to better engage with patients and families to optimize value-based decision making. Shared Decision Making / Advance Care Planning; Interdisciplinary Teamwork / Professionalism [ABSTRACT FROM AUTHOR]

Background: Patients with neurologic impairment (NI) experience gastrointestinal symptoms as one of three common problems associated with NI, including occasional persistent total parenteral nutrition (TPN) use. Objective: To describe the incidence of persistent TPN use in patients with NI. Design: Retrospective chart review on patients 0–38 years old enrolled in the Complex Health Care Program from January 2011 to October 2015. Setting/Subjects: This study occurred in a United States pediatric tertiary care hospital. Two hundred and eight participants were included based on NI, utilizing a surgical feeding tube, and having encounters with a dietitian. Measurements: The primary outcome was incidence of persistent TPN use in patients with NI. Secondary outcomes included mortality rate, hospitalization frequency, time-to-TPN initiation, and describing symptoms preceding persistent TPN use. Results: Median number of admissions was 4 for 168 hospitalized patients (59% male, 58% White). One hundred twenty-five patients required admission for unplanned bowel rest with average length-of-stay of 7.3 days. Twenty-six patients required TPN initiation. Average time-to-TPN was two years since enrollment. Mortality rate was 14% (n = 28). TPN initiation (odds ratio [OR]: 3.99; 95% confidence interval [CI]: 1.16–13.8) was significantly associated with increased OR of mortality. Conclusions: Our study demonstrates a substantial population of patients with NI and surgical feeding tube are affected by persistent feeding intolerance. We propose that persistent TPN use may be a risk factor for mortality. Additional research is needed to delineate relationships between persistent TPN use, hospitalizations, and mortality. [ABSTRACT FROM AUTHOR]