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Spoor JKH, Eelkman Rooda OHJ, Kik C, van Meeteren J, Westendorp T, DeKoninck PLJ, Eggink AJ, van Veelen MLC, Dirven C, de Jong THR. Newborns with myelomeningocele: their health-related quality of life and daily functioning 10 years later. J Neurosurg Pediatr 2023; 31:3-7. [PMID: 36334287 DOI: 10.3171/2022.8.peds22162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ten years ago, the authors reported on the outcome of their study investigating the degree of discomfort and pain in newborns with myelomeningocele (MMC), using the parameters of unbearable and hopeless suffering. In the current study, they investigated the quality of life, daily functioning, pain and fatigue, ability to communicate, and number of surgeries in the same cohort of patients. They subdivided their study population into severe (Lorber) and less severe (non-Lorber) cases and compared these cases with a healthy population (non-MMC group) and with each other. METHODS The parents of 22 of 28 patients gave informed consent for this study. The KIDSCREEN-27 and PEDI-CAT (Pediatric Evaluation of Disability Inventory) were used to assess quality of life and daily functioning. Pain and fatigue were self-reported on a 10-point numeric rating scale. Communication and ambulation levels were determined using the Communication Function Classification System (CFCS) and the Hoffer ambulation scale. Using reference data from the KIDSCREEN-27 and PEDI-CAT, the authors created a healthy population comparison group. RESULTS There was no significant difference in health-related quality-of-life (HRQOL) scores between Lorber and non-Lorber patients, except that school environment domain scores were lower in the Lorber group. When comparing the HRQOL of MMC patients with that of the non-MMC group, the physical well-being and parent relations and autonomy domains scored significantly lower. The daily functioning of MMC patients was lower on all domains of the PEDI-CAT compared with the non-MMC group. Lorber MMC patients scored lower on all domains of the PEDI-CAT when compared with non-Lorber patients. All patients were capable of communicating effectively; most patients (n = 18) were considered CFCS level I, and 4 patients were considered CFCS level II. CONCLUSIONS This study shows that MMC is a severe, lifelong condition that affects patients' lives in many domains. All the patients in this study are capable of effective communication, irrespective of severity of MMC. Overall, the data show that in newborn MMC patients, future unbearable suffering with respect to pain, mobility, cognition, and communication is hard to predict and may not always occur.
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Affiliation(s)
| | | | | | - Jetty van Meeteren
- 2Rijndam Rehabilitation, Rotterdam, The Netherlands
- 3Rehabilitation Medicine, and
| | | | - Philip L J DeKoninck
- 4Obstetrics and Gynaecology, Erasmus Medical Center, University Medical Center, Rotterdam; and
| | - Alex J Eggink
- 4Obstetrics and Gynaecology, Erasmus Medical Center, University Medical Center, Rotterdam; and
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Levin-Decanini T, Houtrow A, Katz A. The Evolution of Spina Bifida Treatment Through a Biomedical Ethics Lens. HEC Forum 2018; 29:197-211. [PMID: 28555303 DOI: 10.1007/s10730-017-9327-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Spina bifida is a neurodevelopmental disorder that results in a broad range of disability. Over the last few decades, there have been significant advances in diagnosis and treatment of this condition, which have raised concerns regarding how clinicians prognosticate the extent of disability, determine quality of life, and use that information to make treatment recommendations. From the selective treatment of neonates in the 1970s, to the advent of maternal-fetal surgery today, the issues that have been raised surrounding spina bifida intervention invoke principles of medical bioethics such as beneficence and nonmaleficence, while also highlighting how quality of life judgments may drive care decisions. Such changes in treatment norms are also illustrative of how disability is viewed both within the medical community and by society at large. An examination of the changes in spina bifida treatment provides a model through which to understand how ethically complex decisions regarding care for children with disabilities has evolved, and the challenges faced when medical information is combined with value-based judgments to guide medical decision making.
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Affiliation(s)
- Tal Levin-Decanini
- Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA. .,University of Pittsburgh School of Nursing, 3500 Victoria Street, Pittsburgh, PA, 15213, USA.
| | - Amy Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Aviva Katz
- Division of General and Thoracic Surgery, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
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First 60 fetal in-utero myelomeningocele repairs at Saint Louis Fetal Care Institute in the post-MOMS trial era: hydrocephalus treatment outcomes (endoscopic third ventriculostomy versus ventriculo-peritoneal shunt). Childs Nerv Syst 2017; 33:1157-1168. [PMID: 28470384 DOI: 10.1007/s00381-017-3428-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The published results of the Management of Myelomeningocele Study (MOMS) trial in 2011 showed improved outcomes (reduced need for shunting, decreased incidence of Chiari II malformation, and improved scores of mental development and motor function) in the fetal prenatal repair group compared to the postnatal group. Historically, endoscopic third ventriculostomy (ETV) remains as a controversial hydrocephalus treatment option with high failure rates in pediatric patients with a history of myelomeningocele (MMC). We report hydrocephalus treatment outcomes in the fetal in-utero myelomeningocele repair patients who underwent repair at our Saint Louis Fetal Care Institute following the MOMS trial. We looked carefully at ETV outcomes in this patient population and we identified risk factors for failure. METHODS At our Saint Louis Fetal Care Institute, we followed the maternal and fetal inclusion and exclusion criteria used by the MOMS trial. The records of our first 60 fetal MMC repairs performed at our institute between 2011 and 2017 were examined. We retrospectively reviewed the charts, prenatal fetal magnetic resonance imaging (MRI) and ultrasound (US) imaging findings, postnatal brain MRI, and Bayley neurodevelopment testing results for infants and children who underwent surgical treatment of symptomatic hydrocephalus (VP shunt versus ETV). Multiple variables possibly related to ETV failure were considered for identifying risk factors for ETV failure. RESULTS Between May 2011 and March 2017, 60 pregnant female patients underwent the prenatal MMC repair for their fetuses between 20 and 26 weeks' gestational age (GA) utilizing the standard hysterotomy for exposure of the fetus, and microsurgical repair of the MMC defect. All MMC defects underwent successful in-utero repair, with subsequent progression of the pregnancy. At the time of this study, 58 babies have been born, 56 are alive since there were 2 mortalities in the neonatal period due to prematurity. One patient was excluded given lack of consent for research purposes. From the remaining 55 patient included in this study, a total of 30 infants and toddlers underwent treatment of hydrocephalus (ETV and VPS groups). Twenty-five patients underwent ETV (24 primary ETV and 1 after shunt failure). Nineteen patients underwent shunt placements (6 primary/13 after ETV failure). Mean GA at time of MMC repair for the ETV group was 24 + 6/7 weeks (range 22 + 4/7 to 25 + 6/7). Mean follow up for patients who had a successful ETV was 17.25 months (range 4-57 months). Bayley neurodevelopmental testing results were examined pre- and post-ETV. Overall ETV success rate was 11/24 (45.8%) at the time of this study. The total number of patients who underwent shunt placement was 19/55 (34.5%), while shunting rate was 40% in the MOMS trial. Using a simple logistic regression analysis to identify predictors of ETV failure, ETV age ≤6 months and gestational age ≥23 weeks at repair of myelomeningocele were significant predictors for ETV failure while in-utero ventricular stability ≤4 mm and in-utero ventricular size post-repair ≤15.5 mm were significant predictors for ETV success. None of the listed variables independently predicted classification into ETV success versus ETV failure groups when entered into multiple logistic regression analysis. CONCLUSIONS ETV, as an alternative to initial shunting, may continue to show promising results for treating fetal MMC repair patient population who present with symptomatic hydrocephalus during infancy and early childhood. Although our overall CSF diversion rate (ETV and VPS groups) in our fetal MMC group is higher than the MOMS trial, our shunting rate is lower given our higher incidence of patients with successful ETV. To our knowledge, this is the largest reported ETV series in patients who underwent fetal MMC repair. ETV deserves a closer look in the setting of improved hindbrain herniation in fetal in-utero MMC repair patients. In our series, young age (less than 6 months) and late GA at time of fetal MMC repair (after 23 weeks GA) were predictors for ETV failure, while in-utero stability of ventricular size (less than 4 mm) and in-utero ventricular size post-repair ≤15.5 mm were predictors for ETV success. Larger series and potential prospective randomized studies are required for further evaluation of risk factors for ETV failure in the fetal MMC patient population.
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Lim SW, Yi M. Mothers’ Perceived Difficulties in the Management of Chronic Conditions of Children with Spina Bifida: A Qualitative Descriptive Approach. CHILD HEALTH NURSING RESEARCH 2016. [DOI: 10.4094/chnr.2016.22.4.247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Voultsos P, Chatzinikolaou F. Involuntary euthanasia of severely ill newborns: is the Groningen Protocol really dangerous? Hippokratia 2014; 18:193-203. [PMID: 25694750 PMCID: PMC4309136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Advances in medicine can reduce active euthanasia of newborns with severe anomalies or unusual prematurity, but they cannot eliminate it. In the Netherlands, voluntary active euthanasia among adults and adolescents has been allowed since 2002, when the so-called Groningen Protocol (GP) was formulated as an extension of the law on extremely premature and severely ill newborns. It is maintained that, at bioethical level, it serves the principle of beneficence. Other European countries do not accept the GP, including Belgium. Admissibility of active euthanasia is a necessary, though inadequate, condition for acceptance of the GP. Greece generally prohibits euthanasia, although the legal doctrine considers some of the forms of euthanasia permissible, but not active or involuntary euthanasia. The wide acceptance of passive newborns euthanasia, especially when the gestational age of the newborns is 22-25 weeks ("grey zone"), admissibility of practices within the limits between active and passive euthanasia (e.g., withholding/withdrawing), of "indirect active euthanasia" and abortion of the late fetus, the tendency to accept after-birth-abortion (infanticide) in the bioethical theory, the lower threshold for application of withdrawing in neonatal intensive care units compared with pediatric intensive care units, all the above advocate wider acceptance of the GP. However, the GP paves the way for a wide application of involuntary (or pseudo-voluntary) euthanasia (slippery slope) and contains some ambiguous concepts and requirements (e.g., "unbearable suffering"). It is suggested that the approach to the sensitive and controversial ethical dilemmas concerning the severely ill newborns is done not through the GP, but rather, through a combination of virtue bioethics (especially in the countries of the so-called "Mediterranean bioethical zone") and of the principles of principlism which is enriched, however, with the "principle of mutuality" (enhancement of all values and principles, especially with the principles of "beneficence" and "justice"), in order to achieve the "maximal" bioethical approach, along with the establishment of circumstances and alternatives that minimize or eliminate the relevant bioethical dilemmas and conflicts between the fundamental principles. Thus, the most appropriate/fairest choices are made (by trained parents and physicians), considering all interests involved as much as possible. Hippokratia 2014; 18 (3): 196-203.
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Affiliation(s)
- P Voultsos
- Department of Forensic Medicine & Toxicology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - F Chatzinikolaou
- Department of Forensic Medicine & Toxicology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Ross LF, Frader JE. Newborns and other children: in defense of differential attitudes and treatment. J Pediatr 2013; 162:1096-9. [PMID: 23419591 DOI: 10.1016/j.jpeds.2013.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 01/08/2013] [Indexed: 10/27/2022]
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Laing JA. Infanticide: a reply to Giubilini and Minerva. JOURNAL OF MEDICAL ETHICS 2013; 39:336-340. [PMID: 23637448 PMCID: PMC3632995 DOI: 10.1136/medethics-2012-100664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 06/01/2012] [Accepted: 01/29/2013] [Indexed: 06/02/2023]
Abstract
Alberto Giubilini and Francesco Minerva's recent infanticide proposal is predicated on their personism and actualism. According to these related ideas, human beings achieve their moral status in virtue of the degree to which they are capable of laying value upon their lives or exhibiting certain qualities or being desirable to third-party family members. This article challenges these criteria, suggesting that these and related ideas are rely on arbitrary and discriminatory notions of human moral status. Our propensity to sleep, fall unconscious, pass out and so on, demonstrates that we often exhibit our status as 'potential persons' who are not in the condition of attributing any value to their own existence. Our abilities, age and desirability can and do fluctuate. The equal dignity principle, distinguished in turn from both the excesses of vitalism and consequentialism, is analysed and defended in the context of human rights logic and law. The normalisation of non- and involuntary euthanasia, via such emerging practices as the self-styled Groningen Protocol, is considered. Substituted consent to the euthanasia of babies and others is scrutinised and the implications of institutionalising non-voluntary euthanasia in the context of financial, research and political interests are considered. The impact on the medical and legal professions, carers, families and societies, as well as public attitudes more generally, is discussed. It is suggested that eroding the value of human life carries with it significant destructive long-term implications. To elevate some, often short-term, implications while ignoring others demonstrates the irrational nature of the effort to institutionalise euthanasia.
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Affiliation(s)
- Jacqueline A Laing
- Department of Law, Human Rights and Social Justice Research Institute, London Metropolitan University, 16 Goulston Street, London E1 7TP, UK.
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Affiliation(s)
- Lisa J. Pruitt
- Middle Tennessee State University, Murfreesboro, Tennessee
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Ottenhoff MJ, Dammers R, Kompanje EJO, Tibboel D, de Jong THR. Discomfort and pain in newborns with myelomeningocele: a prospective evaluation. Pediatrics 2012; 129:e741-7. [PMID: 22371456 DOI: 10.1542/peds.2011-1645] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In a worldwide debate on deliberately terminating the lives of newborns, proponents point at newborns with very severe forms of myelomeningocele (MMC) and their assumed suffering, claiming there are no effective means of alleviating their distress. Nevertheless, the degree of discomfort and pain in these newborns has never been assessed in a structured manner. METHODS In a prospective cohort study, 28 consecutive newborns with MMC were included over a 5-year period and were followed up throughout their hospital stay for initial treatment. We created 2 disease severity groups on the basis of the Lorber criteria. The primary outcomes were discomfort and pain, assessed by simultaneously scoring 2 validated scales: the visual analog scale for pain and the Comfort Behavioral Scale for discomfort. These scores were coupled to a validated and evidence-based analgesia algorithm. RESULTS Overall, discomfort related to pain was measured in 3.3% of the scores. This percentage differed little between the preoperative and postoperative periods and did not significantly differ between newborns with less severe MMC and severe MMC (3.9% vs 2.8%; P = .3). The mean dosage of paracetamol was 35 mg/kg per day (95% confidence interval: 32-39); the mean dosage of morphine was 0.9 μg/kg per hour (95% confidence interval: 0.6 -1.2). CONCLUSION Over the length of their hospital stays for initial treatment, all newborns with MMC presented with low levels of discomfort and pain independent of disease severity and time frame.
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Affiliation(s)
- Myrthe J Ottenhoff
- Department of Neurosurgery, Erasmus MC, Sophia Children’s Hospital, Rotterdam, Netherlands
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Jernigan SC, Berry JG, Graham DA, Bauer SB, Karlin LI, Hobbs NM, Scott RM, Warf BC. Risk factors of sudden death in young adult patients with myelomeningocele. J Neurosurg Pediatr 2012; 9:149-55. [PMID: 22295919 DOI: 10.3171/2011.11.peds11269] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although survival for patients with myelomeningocele has dramatically improved in recent decades, the occasional occurrence of sudden, unexplained death in young adult patients with myelomeningocele has been noted by the authors. This study was undertaken to determine risk factors for sudden death in this population. METHODS The authors performed a retrospective chart review of patients born between 1978 and 1990 who received care at Children's Hospital Boston. The relationship between sudden death and patient demographics, presence of CSF shunt and history of shunt revisions, midbrain length as a marker for severity of hindbrain malformation, seizures, pulmonary and ventilatory dysfunction, body mass index, scoliosis, renal dysfunction, and cardiac disease was evaluated using the t-test, Fisher exact test, and logistic regression analysis. RESULTS The age range for 106 patients in the study cohort was 19-30 years, with 58 (54.7%) women and 48 (45.3%) men. Six patients, all of whom were young women, experienced sudden death. In multivariate analysis, female sex, sleep apnea, and midbrain elongation ≥ 15 mm on MR imaging remained significantly associated with a higher risk of sudden death. These risk factors were cumulative, and female patients with sleep apnea and midbrain length ≥ 15 mm had the greatest risk (adjusted risk ratio 24.0, 95% CI 7.3-79.0; p < 0.05). No other comorbidities were found to significantly increase the risk of sudden death. CONCLUSIONS Young adult women with myelomeningocele are at significantly increased risk of sudden death in the setting of midbrain elongation and sleep apnea. Further investigation is needed to determine the benefit of routine screening to identify at-risk patients for closer cardiopulmonary monitoring and treatment.
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Affiliation(s)
- Sarah C Jernigan
- Department of Neurosurgery, Children’s Hospital, Boston, Massachusetts 02115, USA
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de Rooy L, Aladangady N, Aidoo E. Palliative care for the newborn in the United Kingdom. Early Hum Dev 2012; 88:73-7. [PMID: 22325846 DOI: 10.1016/j.earlhumdev.2011.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 12/08/2011] [Indexed: 11/28/2022]
Abstract
Palliative care for the newborn is a developing area. There are more than 2000 estimated neonatal deaths each year in the UK from causes likely to benefit from palliative care. There is an increasing recognition that while the goals of care may be different for dying newborns, they deserve the same high standard of care as those babies who go on to survive. Recent neonatal palliative care guidance is available from the British Association for Perinatal Medicine (BAPM), the General Medical Council (GMC), and ACT (the U.K. association for children's palliative care). We attempt to answer the question: 'What does the provision of good neonatal palliative care look like?' by examining the factors important in the provision of such care.
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Teisseyre N, Vanraet C, Sorum PC, Mullet E. The acceptability among lay persons and health professionals of actively ending the lives of damaged newborns. Monash Bioeth Rev 2010; 20:1-24. [PMID: 22032021 DOI: 10.1007/bf03351524] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Euthanasia is performed on occasion, even on newborns, but is highly controversial, and it is prohibited by law and condemned by medical ethics in most countries. AIM To characterise and compare the judgments of lay persons, nurses, and physicians of the acceptability of actively ending the life of a damaged newborn. METHODS Convenience samples of 237 lay persons, 214 nurses, and 76 physicians in the south of France rated the acceptability on a scale of 0-10 of giving a lethal injection in 54 scenarios composed of all combinations of 4 within-subject factors: gestational age of 6, 7, or 9 months; 3 levels of severity of either perinatal asphyxia or of genetic disease; attitude of the parents about prolonging care unknown, favourable, or unfavourable; and decision made individually by the physician or collectively by the medical team. Overall ratings were subjected to cluster analysis and each cluster to analysis of variance and graphic representation. RESULTS Lay persons (mean acceptability rating 4.29) were significantly more favourable to euthanasia than nurses (2.84), p < .005, or physicians (2.12), p < .005. Five clusters were found with different judgment rules, i.e., how the information was integrated. More physicians (30 per cent) than nurses (14 per cent), p < .01, or lay persons (11 per cent), p < .01, rated euthanasia as never, under any condition, acceptable. Most, however, asserted that it was increasingly acceptable as the factors combined to favour it, especially when the parents desired to stop treatment. More physicians (45 per cent) and nurses (46 per cent) than lay persons (21 per cent), p < .01, used a complex conjunctive rule (level of parent's attitude x level of severity of damage x consultation with team or not) rather than a simple additive rule. CONCLUSIONS Unlike law and medical ethics, most of the lay persons, nurses, and physicians judged the acceptability of euthanasia as a function of the circumstances. Most health professionals combined the factors in a conjunctive (multiplicative), rather than additive, fashion in accordance with legislation for adults in The Netherlands and elsewhere that requires a set of criteria to be fulfilled before it is legitimate to end a patient's life.
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Chervenak FA, McCullough LB, Arabin B. The Groningen Protocol: is it necessary? Is it scientific? Is it ethical? J Perinat Med 2010; 37:199-205. [PMID: 19127990 DOI: 10.1515/jpm.2009.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To explore whether the Groningen Protocol is clinically necessary, scientific, and ethically justified. RESULTS The Groningen Protocol is clinically unnecessary because the withdrawal of life-sustaining treatment from seriously ill infants is already ethically accepted globally without the need for the Protocol and because spina bifida, to which the Protocol has been most often applied, can be detected by ultrasound before viability, affording pregnant women the opportunity of termination of pregnancy. The Groningen Protocol is unscientific because it does not meet the accepted standards of evidence-based reasoning concerning the four clinical criteria for its application. The Groningen Protocol is unethical because it does not meet the standards of argument-based ethics in defining its four clinical criteria. CONCLUSIONS The Groningen Protocol is clinically unnecessary, unscientific, and unethical. Physicians should condemn its use. The Dutch Association of Paediatrics should revoke its approval and adoption of the Groningen Protocol.
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Affiliation(s)
- Frank A Chervenak
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital-Weill Cornell Medical College, New York, USA.
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Aronin PA, George TM. Commentary on 'quality of life and myelomeningocele: an ethical and evidence-based analysis of the Groningen Protocol' by Sean Barry, Pediatr Neurosurg 2010;46:409-414. Pediatr Neurosurg 2010; 46:415-6. [PMID: 21540617 DOI: 10.1159/000325152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 02/02/2011] [Indexed: 11/19/2022]
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Barry S. Quality of life and myelomeningocele: an ethical and evidence-based analysis of the Groningen Protocol. Pediatr Neurosurg 2010; 46:409-14. [PMID: 21540616 DOI: 10.1159/000322895] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 11/06/2010] [Indexed: 11/19/2022]
Abstract
In 2005, a group of pediatricians at the University Medical Center in Groningen, The Netherlands, published the Groningen Protocol (GP) for Euthanasia in Newborns. This protocol is a set of guidelines devised in 2001 to clarify and facilitate the assessment of clinically stable neonates deemed to be in unbearable suffering for whom the prognosis is felt to be hopeless. At the time of publication, the GP had been in use for 7 years, and 22 patients, all with diagnosed myelomeningocele (MMC), had met the selection criteria for euthanasia by lethal injection. MMC is the most common neurological congenital anomaly, affecting approximately 300,000 newborns yearly worldwide. Neurosurgeons have a unique perspective on this disease and therefore an important voice, given the significant role they have in caring for these patients at all stages of their lives. This paper reviews the principal ethical arguments presented to date in the literature regarding the GP. It also provides an evidence-based critique of the GP in light of quality-of-life studies addressing adults with MMC, and ascertains whether or not the GP meets the criteria for an evidence-based guideline.
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Affiliation(s)
- Sean Barry
- Center for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium.
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Bowman RM, Boshnjaku V, McLone DG. The changing incidence of myelomeningocele and its impact on pediatric neurosurgery: a review from the Children's Memorial Hospital. Childs Nerv Syst 2009; 25:801-6. [PMID: 19326126 DOI: 10.1007/s00381-009-0865-z] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Indexed: 01/26/2023]
Abstract
INCIDENCE Worldwide, the incidence of neural tube defects (NTDs) varies from 0.17 to 6.39 per 1,000 live births. The declining prevalence of myelomeningocele, the most common NTD, is secondary to several factors including folic acid fortification, prenatal diagnosis with termination of affected fetuses, and unknown factors. IMPACT OF CHANGES Of those born with myelomeningocele, survival during infancy and preschool years has improved over the last 25 years (Bowman et al., Pediatr Neurosurg 34:114-120). Fewer newborns today require shunt placement, which will hopefully improve the long-term mortality associated with this disease (Chakraborty et al., J Neurosurg Pediatr 1(5):361-365, unpublished data). Of a cohort born in 1975-1979 and treated at a single US institution, 74% have survived into young adulthood. CLINICAL IMPLICATIONS One of the greatest challenges facing these young adults is the transitioning of their medical care into an adult medical community.
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Affiliation(s)
- Robin M Bowman
- Division of Neurosurgery, Children's Memorial Hospital, 2300 Children's Plaza, P. O. Box 28, Chicago, IL 60614, USA.
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Castelló A, Francès F, Verdú F. A role for judges in assisted dying. J Med Ethics Hist Med 2009; 2:3. [PMID: 23908717 PMCID: PMC3713891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2009] [Accepted: 05/27/2009] [Indexed: 11/04/2022] Open
Abstract
Medically provoked death, whether euthanasia or assisted suicide, is a common issue for discussion in various forums, participants coming from widely differing fields of knowledge, among who are, of course, doctors. Substantial legal differences exist in Europe on this issue and in an ever-wider Europe, it is essential, for practical reasons, that legislation be standardised. We would like to propose possible regulations that would provide effective safeguards in the application of euthanasia or assisted suicide.
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Affiliation(s)
- Ana Castelló
- Professor of Legal Medicine, Department of Forensic and Legal Medicine, Faculty of Medicine, University of Valencia EG, Spain
| | | | - Fernando Verdú
- Professor of Legal Medicine, Department of Forensic and Legal Medicine, Faculty of Medicine, University of Valencia EG, Spain.,Corresponding author: Fernando Verdú, Facultad de Medicina, U. D. Medicina Legal, Av/ Blasco Ibañez, nº15, 46010 Valencia, Spain., Tel: +34 963864165, +34 96864820, Fax: +34963864165, E-mail:
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Abstract
UNLABELLED We examined the literature on ethical decisions regarding neonates, to assess whether personal beliefs and prejudices influence end-of-life decisions taken by caregivers. Studies show that religion and familiarity with disability influence caregivers' decisions, whereas the influx of already being a parent, age, sex and professional experience is controverse. Caregivers' attitudes towards end-of-life decisions are also affected by personal concerns about litigation, prejudices and their view of disability. The concept of 'poor quality of life' is widely used as a reference in end-of-life decisions, but this can be interpreted differently, leaving room for a wide range of personal viewpoints. In most cases, parents' opinions are considered important and are sometimes the main determinant in decision making. However, it is unclear whether parents' decisions are based on their own wishes or on the best interests of the newborn. CONCLUSION In neonatal end-of-life decisions, patients may not receive cures based only on their best interests.
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Affiliation(s)
- Carlo V Bellieni
- Department of Pediatrics, Obstetrics and Reproduction Medicine, University of Siena, Italy.
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