{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T11:48:43Z","timestamp":1791805723299,"version":"4.3.4"},"reference-count":52,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T00:00:00Z","timestamp":1791763200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T00:00:00Z","timestamp":1791763200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Pediatric Anesthesia"],"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>Induction of anesthesia is one of the most distressing moments for pediatric patients during their perioperative experience. They may consequently refuse induction at the last minute. Anesthesia providers are then placed in a challenging ethical dilemma: they must seek to gain the child's cooperation, force the child to undergo induction using restraint, or delay the case. In the moment, it can be difficult to parse the relevant clinical and ethical factors to determine the most appropriate course of action. The purpose of this perspective paper is to provide a clinical ethics framework to support anesthesia provider decision making during instances of last\u2010minute pediatric refusal of anesthesia induction. Three prominent pediatric ethics concepts support this framework, including the harm principle, best interests, and emerging autonomy. This framework uses the criteria of (1) urgency of intervention, (2) decision\u2010making ability of the patient, and (3) harms to the patient from a forced induction. Each of these criteria is discussed in depth as it relates to last\u2010minute pediatric refusal. Case illustrations are provided to demonstrate the clinical utility of this framework in everyday practice.<\/jats:p>","DOI":"10.1002\/pan.70328","type":"journal-article","created":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T11:21:26Z","timestamp":1791804086000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Clinical Ethics Framework for Last\u2010Minute Pediatric Refusal of Anesthesia Induction"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8414-4989","authenticated-orcid":false,"given":"J. Patrick","family":"Haltom","sequence":"first","affiliation":[{"name":"Charles Warren Fairbanks Center for Medical Ethics Indiana University Health  Indianapolis Indiana USA"},{"name":"Department of Clinical and Organizational Ethics Indiana University Health  Indianapolis Indiana USA"},{"name":"Department of Anesthesia, Riley Children's Health Indiana University Health  Indianapolis Indiana USA"},{"name":"Department of Anesthesia, Indiana University School of Medicine Indiana University  Indianapolis Indiana USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-3114-3759","authenticated-orcid":false,"given":"Amy S.","family":"Martin","sequence":"additional","affiliation":[{"name":"Charles Warren Fairbanks Center for Medical Ethics Indiana University Health  Indianapolis Indiana USA"},{"name":"Department of Clinical and Organizational Ethics Indiana University Health  Indianapolis Indiana USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0141-5094","authenticated-orcid":false,"given":"Hugo","family":"Wellesley","sequence":"additional","affiliation":[{"name":"Anaesthetic Department Great Ormond Street Hospital for Children  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,10,12]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1460\u20109592.2010.03263.x"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.1213\/ane.0b013e3181b412cf"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1097\/ACO.0b013e3283466b27"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1186\/s13019\u2010022\u201001889\u20105"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.bjao.2025.100411"},{"key":"e_1_2_7_7_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1460\u20109592.2010.03324.x"},{"key":"e_1_2_7_8_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1460\u20109592.2007.02331.x"},{"key":"e_1_2_7_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/pan.14921"},{"key":"e_1_2_7_10_1","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2016\u20101485"},{"key":"e_1_2_7_11_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11017\u2010004\u20103146\u20106"},{"key":"e_1_2_7_12_1","doi-asserted-by":"publisher","DOI":"10.1111\/anae.13762"},{"key":"e_1_2_7_13_1","doi-asserted-by":"publisher","DOI":"10.1136\/archdischild\u20102025\u2010329204"},{"key":"e_1_2_7_14_1","unstructured":"\u201cOpinion of Lady Tait in the Petition of a Scottish Health Board for the Court to Exercise Its Parens Patriae Jurisdiction to Authorise Medical Treatment of Child A. (Outer House Court of Session 2025) \u201d(2025) https:\/\/www.scotcourts.gov.uk\/media\/gj4ku0fd\/2025csoh121\u2010petition\u2010of\u2010a\u2010scottish\u2010health\u2010board\u2010for\u2010the\u2010court\u2010to\u2010exercise\u2010its\u2010parens\u2010patriae\u2010jurisdiction\u2010to\u2010authorise\u2010medical\u2010treatment\u2010of\u2010child\u2010a.pdf."},{"key":"e_1_2_7_15_1","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2020\u20100818F"},{"key":"e_1_2_7_16_1","volume-title":"Pediatric Decision Making","author":"American Medical Association"},{"key":"e_1_2_7_17_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12871\u2010026\u201003717\u2010y"},{"key":"e_1_2_7_18_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.pedn.2018.03.004"},{"key":"e_1_2_7_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpeds.2006.04.047"},{"key":"e_1_2_7_20_1","doi-asserted-by":"publisher","DOI":"10.1136\/tsaco\u20102025\u2010001775"},{"key":"e_1_2_7_21_1","doi-asserted-by":"publisher","DOI":"10.1111\/jocn.17056"},{"key":"e_1_2_7_22_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamasurg.2017.0918"},{"key":"e_1_2_7_23_1","volume-title":"The NCEPOD Classification of Intervention","author":"National Confidential Enquiry Into Patient Outcome and Death","year":"2024"},{"key":"e_1_2_7_24_1","doi-asserted-by":"publisher","DOI":"10.1111\/pan.14644"},{"key":"e_1_2_7_25_1","volume-title":"Informed Consent","author":"American Medical Association"},{"key":"e_1_2_7_26_1","volume-title":"Clinical Ethics in Pediatrics: A Case\u2010Based Textbook","author":"Goodlander E.","year":"2011"},{"key":"e_1_2_7_27_1","unstructured":"National Health Service \u201cChildren and Young People \u201d(2022) https:\/\/www.nhs.uk\/tests\u2010and\u2010treatments\/consent\u2010to\u2010treatment\/children\/."},{"key":"e_1_2_7_28_1","unstructured":"\u201cEthics Toolkit: Treating 16 and 17\u2010Year\u2010Olds in England Wales and Northern Ireland \u201d(2025)."},{"key":"e_1_2_7_29_1","doi-asserted-by":"crossref","unstructured":"\u201cEthics Toolkit: Children and Young People Under 16 \u201d(2025) https:\/\/www.bma.org.uk\/advice\u2010and\u2010support\/ethics\/children\u2010and\u2010young\u2010people\/children\u2010and\u2010young\u2010people\u2010under\u201016.","DOI":"10.12968\/cypn.2025.2.16"},{"key":"e_1_2_7_30_1","unstructured":"\u201cGillick v West Norfolk and Wisbech Area Health Authority \u201d(1986)."},{"key":"e_1_2_7_31_1","doi-asserted-by":"publisher","DOI":"10.1080\/21645515.2015.1091548"},{"key":"e_1_2_7_32_1","doi-asserted-by":"publisher","DOI":"10.1111\/anae.13883"},{"key":"e_1_2_7_33_1","volume-title":"Mental Capacity Act 2005: Code of Practice","author":"Britain G.","year":"2007"},{"key":"e_1_2_7_34_1","unstructured":"\u201cEthics Toolkit: Treating 16 and 17\u2010Year\u2010Olds in Scotland \u201d(2025) https:\/\/www.bma.org.uk\/advice\u2010and\u2010support\/ethics\/children\u2010and\u2010young\u2010people\/treating\u201016\u2010and\u201017\u2010year\u2010olds\u2010in\u2010scotland."},{"key":"e_1_2_7_35_1","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0000000000007153"},{"issue":"1","key":"e_1_2_7_36_1","first-page":"40","article-title":"Evaluating Medical Decision\u2010Making Capacity in Practice","volume":"98","author":"Barstow C.","year":"2018","journal-title":"American Family Physician"},{"key":"e_1_2_7_37_1","doi-asserted-by":"publisher","DOI":"10.1111\/pan.14119"},{"key":"e_1_2_7_38_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMcp074045"},{"key":"e_1_2_7_39_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamapsychiatry.2025.0102"},{"key":"e_1_2_7_40_1","doi-asserted-by":"publisher","DOI":"10.1177\/1367493520976300"},{"key":"e_1_2_7_41_1","first-page":"114","volume-title":"Miller's Anesthesia","author":"Lucero J.","year":"2025"},{"key":"e_1_2_7_42_1","doi-asserted-by":"publisher","DOI":"10.1186\/s12887\u2010017\u20100869\u2010x"},{"key":"e_1_2_7_43_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1460\u20109592.2005.01501.x"},{"key":"e_1_2_7_44_1","doi-asserted-by":"publisher","DOI":"10.1111\/pan.13931"},{"key":"e_1_2_7_45_1","doi-asserted-by":"publisher","DOI":"10.1097\/ALN.0000000000005105"},{"key":"e_1_2_7_46_1","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2005\u20102920"},{"key":"e_1_2_7_47_1","doi-asserted-by":"publisher","DOI":"10.1093\/bmb\/ldac038"},{"key":"e_1_2_7_48_1","doi-asserted-by":"publisher","DOI":"10.1002\/hast.980"},{"key":"e_1_2_7_49_1","doi-asserted-by":"publisher","DOI":"10.1007\/s12630\u2010018\u201001274\u20108"},{"key":"e_1_2_7_50_1","doi-asserted-by":"publisher","DOI":"10.1213\/ANE.0000000000000632"},{"key":"e_1_2_7_51_1","doi-asserted-by":"publisher","DOI":"10.3390\/children7120253"},{"key":"e_1_2_7_52_1","doi-asserted-by":"publisher","DOI":"10.1111\/pan.14201"},{"key":"e_1_2_7_53_1","doi-asserted-by":"publisher","DOI":"10.1111\/pan.14242"}],"container-title":["Pediatric Anesthesia"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/pan.70328","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1002\/pan.70328","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1002\/pan.70328","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T11:21:30Z","timestamp":1791804090000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1002\/pan.70328"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,12]]},"references-count":52,"alternative-id":["10.1002\/pan.70328"],"URL":"https:\/\/doi.org\/10.1002\/pan.70328","archive":["Portico"],"relation":{},"ISSN":["1155-5645","1460-9592"],"issn-type":[{"value":"1155-5645","type":"print"},{"value":"1460-9592","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,12]]},"assertion":[{"value":"2026-06-26","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-10-03","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-10-12","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"pan.70328"}}