Allison Silverstein – University of Colorado School of Medicine, CO, USA Allison Silverstein is a Pediatric Palliative Medicine physician at the University of Colorado and Children’s Hospital Colorado, where she serves as the inpatient medical director and physician informaticist. She also currently serves as the chair of the American Academy of Hospice and Palliative Medicine’s Pediatrics Council.
Featured Articles
Major-Kincade, T., Kim, E., Price, C. A., Banerjee, A., Franklin, N., Castaneda Almendarez, I., Jump, J., Rubenstein, J., & Jarrell, J. A. (2025). The Use of Biased Language in the Care of Seriously Ill Children: A Pilot Study. The American Journal of Hospice & Palliative Care, 10499091251345723.
Commentary
The study led by Dr. Major Kincade et al. represents a crucial early step in unveiling how linguistic biases manifest in documentation of pediatric patients who are critically ill. The authors retrospectively analyzed the medical charts of 63 patients in a U.S. quaternary care PICU who received palliative consults in 2019. They sought to detect biased language—phrasing that could perpetuate testimonial injustice or stigma—in electronic health records (EHRs), specifically exploring differences based on patient demographics and clinical characteristics. Their analysis focused on themes such as questioning patient credibility, expressing disapproval, stereotyping, portraying patients as difficult, and asserting physician authority—often reflected in terms like “non-compliant,” “challenging,” or “claims.” In contrast, positively biased language, such as “pleasant,” “lovely,” or “engaging,” tended to express approval, minimize blame, and personalize the patient.
Implicit bias in clinical documentation is increasingly recognized as a mechanism by which harm may be transmitted systemically: once language enters the record, it may shape subsequent clinicians’ perceptions and decisions. While much attention has focused on adult populations, the featured study is notable for targeting children who are critically ill, a vulnerable group whose ability to communicate or advocate for themselves is limited.
The authors used a structured data abstraction tool to identify descriptors in provider documentation that reflected judgment, tone, or assumptions about patients or families. Ultimately, they found biased language—both positive and negative—was more frequently used by physicians and social workers compared to other health care providers. Examples included subjectively characterizing family emotional responses or casting doubt on parental decisions, which may introduce subtle yet significant shifts in how subsequent teams interpret the family’s behavior and credibility. Notably, documentation of biased language did not significantly correlate with demographic factors (e.g., race, ethnicity) or clinical features—a finding that suggests bias may be widespread rather than targeted, though this could also reflect the study’s limited statistical power.
As a pilot study, this work successfully establishes feasibility of identifying biased language in a setting deeply relevant to palliative medicine teams. Its inclusion of diverse clinical roles expands our understanding of possible factors associated with biased language. Moreover, by explicitly linking biased documentation to testimonial injustice—a form of epistemic injustice where individuals are discredited based on prejudice—the study elevates the ethical and theoretical stakes of narrative choices.
The small, single-center nature of the study constrains generalizability and statistical power. The absence of demographic associations should thus be viewed cautiously—it’s unclear whether bias is truly uniform, or whether detection methods lacked sensitivity. Furthermore, the analysis does not address the downstream effects of biased language: Does encountering such language in the record alter care decisions or outcomes? Future research should examine how language patterns influence care trajectories and shape trust between patients, families, and medical teams.
The findings reinforce recommendations that encourage providers to use neutral or humanizing language, avoid doubt-casting qualifiers (“claims,” “insists”), and prioritize patient- and family-centered documentation.1 Institutional interventions might include modifying note templates, integrating bias-awareness into training, or deploying natural language processing (NLP)-based tools to flag potentially biased phrases in real time.
As a physician working in pediatric palliative medicine, considering the weight of the words I choose in my narration deeply resonates. Documentation is not a passive record—it is an active influence on how patients and families are perceived, and ultimately, how they are treated. In high-acuity environments like the PICU, where multiple rotating teams rely on handoffs and EHR entries, a single line casting doubt or assigning blame can ripple through days or weeks of care. This work compels me to reflect critically on my own language habits.
Beyond individual practice, the study also invites institutional accountability. We must ask: how are we training clinicians to narrate complexity without judgment? How can our EHRs scaffold reflective, respectful documentation rather than propagate unconscious bias? An important next step involves implementing broader chart review exercises to support interdisciplinary teams in identifying biased language and promoting more equitable and respectful documentation practices.
This study serves as both a call to awareness and a compelling prompt for action. If we are committed to advancing equity in care, we must begin by ensuring equity in how patients and families are represented in the clinical narrative.
Additional References
- Casau and Beach. Words Matter: Strategies to Reduce Bias in Electronic Health Records. Center for Health Care Strategies. October 2022. https://www.chcs.org/media/Words-Matter-Strategies-to-Reduce-Bias-in-Electronic-Health-Records_102022.pdf
View the 2025 Issue #8 Citation List in Library
View a PDF of the 2025 Issue #8 Citation List
View Commentary 2025 Issue #8 on Zenodo
Trends in Pediatric Palliative Care Citation List; 2025; Issue 8
Click the links above to view this months full list in desired format.
Alcon-Najera, S., Ortiz-Pizarro, R. B., Pena-Melendez, E., Sanchez-Gallego, A., & Gonzalez-Gil, M. T. (2025). “The good death”: Experience of parents who have suffered the loss of a child in a pediatric intensive care unit. A phenomenological study.Journal of Pediatric Nursing, 84, 107EP – 113.
Barrett, L., Peat, G., McLorie, E. V., Weatherly, H., Hinde, S., Walker, G. L., Noyes, J., Oddie, S., Vasudevan, C., Feltbower, R. G., Phillips, B., Hewitt, C., Hain, R., Subramanian, G., Haynes, A., Murtagh, F. E. M., Hackett, J., & Fraser, L. K. (2025). Parents’ experiences of the financial and employment impacts of their child receiving end-of-life care: A national qualitative study.BMC Palliative Care, 24(1), 157.
Beck, M., & van Manen, M. (2025). Sharing in the community of having lost a child.Medical Humanities.
Beghe, A., Mancin, S., Cacciapaglia, E., Piccolomini, G., Trombetta, M., Bonotti, G., Tognetti, E., Cattani, D., Dacomi, A., Lopane, D., Crippa, C., Coldani, C., Tomaiuolo, G., Iadeluca, A., & Mazzoleni, B. (2025). Electronic nursing documentation in paediatric palliative care: A scoping review.International Journal of Palliative Nursing, 31(6), 278–286.
Beresford, B., Richardson, N., Mukherjee, S., Nye, R., Aldridge, J., Atkin, K., Clayton, M., Gibson, F., Hackett, J., Hain, R., Arshad, M., Nash, P., & Phillips, B. (2025). The spiritual needs and care of children and young people with life-threatening or life-shortening conditions, and parents (SPARK): A mixed-method investigation.Health & Social Care Delivery Research, 13, 16.
Cohen, R. S., & Wright, R. (2025). The case for investigating the palliative needs of children in foster care: A call to action.Journal of Clinical and Translational Science, 9(Supplement 1), 90.
Corvest, V., & Frache, S. (2025). Understanding complexity in pediatric palliative care: A qualitative study of specialist physicians’ perception.Med. Palliative.
Crane, E., Scales, A., McLaughlin, L., Hollinger, R., Mildner, R. J., & Noyes, J. (2025). Understanding Why Parents Say Yes or No to Organ Donation When Their Child Dies: Mixed-Methods Study.Journal of Advanced Nursing.
DeRose, L., Godfrey, S., Peyvandi, S., Cresalia, N. M., Steiner, J. M., & Morell, E. (2025). Palliative Care Education in Pediatric Cardiology Fellowships: A Survey of Program Directors.Pediatric Cardiology.
El Ali, M., O’Neill, J., & Gillam, L. (4067). Paediatric Nurses’ Personal Accounts of Being Told Not to Disclose Information to Children With Serious Illness—An Interpretative Phenomenological Study.Journal of Advanced Nursing.
Fisher, V., Atkin, K., & Fraser, L. K. (2025). A mixed methods exploration of the health and caregiving experiences of fathers of children with a life-limiting condition.Palliative Medicine, 39(6), 678–688.
Freitas, J., Heneghan, C., & Xenakis, L. (2025). Pediatric Palliative Care Nurse Practitioners: Catalysts of Care in a Liminal Space.Journal of Hospice and Palliative Nursing : JHPN : The Official Journal of the Hospice and Palliative Nurses Association.
Heifner, A. L., Ortiz, M. M., Major-Kincade, T. L., & O’Connor, C. (2025). Parental Authority and the Weight of Assent: Navigating Moral Dilemmas in Adolescent End of Life Care.Journal of Bioethical Inquiry.
Jarvi, S., Richardson, G., Flemming, K., & Fraser, L. K. (2022). Numbers, characteristics, and medical complexity of children with life-limiting conditions reaching age of transition to adult care in England: A repeated cross-sectional study [version 1; peer review: 2 approved].NIHR Open Research, 2, 27.
Jones, A. M., O’Connor, E., & Price, J. (n.d.). “Enabling Families to Find Their Own Path” – A Narrative Exploration of the Role of Social Workers When a Child is Receiving End-of-Life Care in Hospital.Journal of Social Work in End of Life & Palliative Care.
Kaempf, J. W., Brunelli, L., Vidaeff, A., & Albersheim, S. (2025). When Is Intensive Care Warranted for the Most Immature Infants?American Journal of Perinatology.
Kim, E. S., Park, M., Kim, S. B., Choi, S., Yoon, N., & Kim, S. (2025). Current Practices and Perspectives of Pediatric Palliative Care Workers in South Korea.J Hosp Palliat Care, 28(2), 56–70.
Korzeniewska-Eksterowicz, A., Przysło, Ł., & Moczulska, H. (2025). Development and results of perinatal palliative care program: A retrospective cohort study.European Journal of Pediatrics, 184, 7.
Legorburu Brezmes, L. (2025). Descriptive study on nurses’ coping with the death of a pediatric patient.Enfermeria Intensiva, 36(3), 500547.
Lin, M., Bertaud, S., & Wilkinson, D. (2025). Injustice and inequality in the provision of perinatal palliative care.Seminars in Perinatology, 152097.
Linane, H., Allen, J., Devins, M., Twomey, M., O’Reilly, M., McElligott, F., & Molcho, M. (2025). Clinical heterogeneity of adolescents referred to paediatric palliative care; a quantitative observational study.International Journal of Adolescent Medicine and Health.
Lyons, K. A., Ashworth, R., Rissman, L., Henderson, N., Certo, M., Palumbo, K., Dickerman, M., Cohn, M., Alladin, A., & DeCourcey, D. (2025). Pediatric Palliative Care Subcompetencies for Pediatric Critical Care Medicine Fellowship Trainees.Pediatric Critical Care Medicine.
Major-Kincade, T., Kim, E., Price, C. A., Banerjee, A., Franklin, N., Castaneda Almendarez, I., Jump, J., Rubenstein, J., & Jarrell, J. A. (2025). The Use of Biased Language in the Care of Seriously Ill Children: A Pilot Study.The American Journal of Hospice & Palliative Care, 10499091251345723.
McDonnell, M., Connolly, M., Bell, M., & Lawler, F. (2025). Adult specialist palliative care services caring for children in the community: A scoping review.BMC Palliative Care, 24(1), 167.
Mohamed Hussin, N. A., & Aho, A. L. (2025). Meaning-making Coping in Finnish Parents Following the Traumatic Death of a Child.Illness, Crisis & Loss, 33, 3.
Ontrakrai, N., Bailey, C., Valler, T., & Neilson, S. (2025). Palliative care training programmes for community volunteers working with children and their families: A scoping review.Frontiers in Public Health, 13, 1469854.
Papworth, A., Hackett, J., Beresford, B., Murtagh, F., Weatherly, H., Hinde, S., Bedendo, A., Walker, G., Noyes, J., Oddie, S., Vasudevan, C., Feltbower, R., Phillips, B., Hain, R., Subramanian, G., Haynes, A., & Fraser, L. K. (2022). End of life care for infants, children and young people (ENHANCE): Protocol for a mixed methods evaluation of current practice in the United Kingdom [version 1; peer review: 2 approved]. NIHR Open Research, 2, 37.
Peterson, J., Smith, D. M., Johnstone, E. D., Harvey, K., & Mahaveer, A. (2025). A network analysis of timing and conditions present at time of death for periviable infants (22+0-23+6 weeks) admitted to neonatal intensive care after receiving survival-focused care at birth.Frontiers in Pediatrics, 13, 1552352.
Peterson, J., Southwood, G., Smith, D. M., Johnstone, E. D., & Mahaveer, A. (2025). A structured comparison and reflection on international position statements and professional guidance for the management of periviable infants.Frontiers in Pediatrics, 13, 1553033.
Pyle, A. K., & Mercurio, M. R. (2025). Ethical challenges and justice concerns for infants and children with life-limiting conditions and significant disability, including trisomy 13 and 18.Seminars in Perinatology, 152101.
Rubio-Garrido, P., Bazo-Hernandez, L., Enrich-Font, A., & Jimenez-Herrera, M. F. (2025). Experience of Families During Admission of Their Minors to a Paediatric Intensive Care Unit: A Phenomenological Study.Scandinavian Journal of Caring Sciences, 39(2), e70055.
Salas Arrambide, M., Gabaldon Poc, O., Mayoral Miravete, J. L., Gonzalez Perez-Yarza, E., & Amayra Caro, I. (2004). Pediatric palliative care: A comprehensive model of care for children with life-threatening conditions and their families.Anales de Pediatria, 61(4), 330EP – 335.
Salerno, A., Baratiri, F., La Piana, C., Bincoletto, A., Benini, F., & Zanin, A. (2025). Alpha-2 agonists for refractory neurological symptoms in pediatric palliative care: A scoping review.Frontiers in Pediatrics, 13, 1542482.
Salgado-Reguero, M. E., Furtado-Eraso, S., Bujanda-Sainz de Murieta, A., Garcia-Vivar, C., Soto-Ruiz, N., & Escalada-Hernandez, P. (2025). Humanization strategies in pediatric intensive care: A scoping review.Enfermeria Intensiva, 36(2), 500531.
Serrano-Pejenaute, I., Astigarraga, I., & Sanchez Perez, A. (2025). Impact of complex chronic diseases and life-limiting condition status on paediatric hospitalization: Observational study. European Journal of Pediatrics, 184(6), 378.
Solito, C., Plaza Luna, L., Navarro Marchena, L., & Navarro Villarubi, S. (2023). Clinical implications of artificial nutrition and hydration withdrawal in children at the end of life.Medicina Paliativa, 30(1), 11EP – 17.
St Louis, J. R., Weiss, M. J., Al-Ayass, S., Tierney, S., Wright, A. L., Dhanani, S., & Widger, K. (2025). Infant Organ Donation after Death by Circulatory Criteria: A Literature Scoping Review.Pediatric Critical Care Medicine.
Stoslein, S., Gramm, J., Hein, K. K., Borasio, G. D., & Fuhrer, M. (2025). “I’m not a physician, but i’m the expert for my child” experiences of parents caring for their child with a life-limiting condition in an inpatient setting—A qualitative study.Palliative & Supportive Care, 23, e127.
Thivierge, E., Luu, T. M., Rosenbaum, P., Church, P. T., Pearce, R., & Janvier, A. (2025). Looking beyond diagnoses to functioning: Using the F words and personalizing care in neonatology.Seminars in Perinatology, 152102.
Van Breemen, C., Lusney, N., Hermansen, A. M., & Vang, L. (2025). Bereaved Parents as Communication Workshop Facilitators for Clinicians Caring for Seriously Ill Children.Palliative Medicine Reports, 6(1), 351EP – 355.