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Boize P, Garner Y, Neaud E, Borrhomee S. Parents' participation in collegial meetings to discuss withholding or withdrawing treatment for their newborn: Working to improve information-sharing. Arch Pediatr 2024; 31:95-99. [PMID: 38262860 DOI: 10.1016/j.arcped.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/23/2023] [Accepted: 10/21/2023] [Indexed: 01/25/2024]
Abstract
AIM The role of parents in decision-making concerning their child's end-of-life care is not clearly defined. Their participation is encouraged by ethical reflection, in particular by the CCNE (French National Ethics Advisory Committee), but laws are limited to imposing a duty to provide information to doctors. Decisions are taken at the end of a collegial meeting (CM) intended to better inform the child's referring physician (RP) who is in charge of the final decision following the French law. The aim of this study was to describe the support provided to bereaved families after they had been invited to attend a CM concerning their child, if they so wished. Additional aims were to determine the differences resulting from their acceptance or their refusal to participate as regards their perception of their child's history and as regards their grieving process. MATERIAL AND METHOD We conducted a retrospective study of all CMs held between November 2016 and May 2021, drawing a distinction between proposals made or not made to parents and their decision to accept or refuse. RESULTS In total, 49 CMs concerning 46 children were held during the study period. The proposal was not made to the parents in three cases; the parents chose to be present in 28 cases. The psychological follow-up (15/28 parents attending, 10/16 parents absent) illustrated that their presence enabled them to reflect on their child's death after having listened to and understood the reasons why it happened. They did not dispute the team's approach or decisions taken. CONCLUSION It is possible to include parents in CMs if they so wish. It would appear more beneficial than merely providing them with the information required. Studies must be carried out to ensure potential long-term benefit.
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Affiliation(s)
- Philippe Boize
- Neonatal Intensive Care Unit, Hôpital NOVO, 6 avenue Île de France 95300 Pontoise, France.
| | - Yaëlle Garner
- Clinical psychologist, reception and care unit for deaf patients, mother-child unit, CH ANNECY-GENEVOIS, 1 avenue de l'hôpital 74370 Eragny Metz-Tessy, France
| | - Enora Neaud
- Neonatal Intensive Care Unit, Hôpital NOVO, 6 avenue Île de France 95300 Pontoise, France
| | - Suzanne Borrhomee
- Neonatal Intensive Care Unit, Hôpital NOVO, 6 avenue Île de France 95300 Pontoise, France
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Duval C, Porcheret F, Toulouse J, Alexandre M, Roulland C, Viallard ML, Brossier D. Withholding life support for children with severe neurological impairment: Prevalence and predictive factors prior to admission in the PICU. Arch Pediatr 2024; 31:66-71. [PMID: 37989656 DOI: 10.1016/j.arcped.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/17/2023] [Accepted: 09/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Our study aimed to evaluate the prevalence and predictive factors of withholding life support for children suffering from severe neurological impairment before admission to the pediatric intensive care unit (PICU). METHOD Children under 18 years of age with severe neurological impairment, who were hospitalized between January 2006 and December 2016, were included in this retrospective study. They were allocated to a withholding group or a control group, depending on whether life support was withheld or not, before admission to the PICU. RESULTS Overall, 119 patients were included. At admission to the PICU, the rate of withholding life support was 10 % (n = 12). Predictive factors were: (1) a previous stay in the PICU (n = 11; 92 %, p<0.01, odds ratio [OR]: 14 [2-635], p = 0.001); (2) the need for respiratory support (n = 5; 42 %, p = 0.01, OR: 6 [1-27], p = 0.01); (3) the need for feeding support (n = 10; 83 %, p = 0.01, OR: 10 [2-100], p = 0.001); and (4) a higher functional status score (FSS: 16 [12.5-19] vs. 10 [8-13], p<0.01). CONCLUSION The withholding of life support for children suffering from severe neurological impairment appeared limited in our pediatric department. The main predictor was at least one admission to the PICU, which raised the question of the pediatrician's role in the decision to withhold life support.
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Affiliation(s)
- Christophe Duval
- CH Monod, Neonatal Intensive Care Unit, Le Havre, F-76620, France
| | | | - Joseph Toulouse
- CHU de Lyon, Pediatric Neurology Unit, Bron, F-69677, France
| | | | | | - Marcel-Louis Viallard
- Necker Children's University, Neonate & Pediatric Palliative Medicine Team, Paris, F-75015, France
| | - David Brossier
- CHU de Caen, Pediatric Intensive Care Unit, Caen, F-14000, France; CHU de Caen, Pediatric department, Caen, F-14000, France; Université Caen Normandie, medical school, Caen, F-14000, France; Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France.
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Cremer R, de Saint Blanquat L, Birsan S, Bordet F, Botte A, Brissaud O, Guilbert J, Le Roux B, Le Reun C, Michel F, Millasseau F, Sinet M, Hubert P. Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations. Arch Pediatr 2021; 28:325-337. [PMID: 33875345 DOI: 10.1016/j.arcped.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Abstract
In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.
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Affiliation(s)
- R Cremer
- Réanimation et soins continus pédiatriques, hôpital Jeanne-de-Flandre, ERER des Hauts-de-France, CHU de Lille, 59037 Lille, France.
| | - L de Saint Blanquat
- Réanimation pédiatrique, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France
| | - S Birsan
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - F Bordet
- Réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Lyon-Bron, France
| | - A Botte
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - O Brissaud
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - J Guilbert
- Réanimation néonatale pédiatrique, hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - B Le Roux
- Réanimation pédiatrique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - C Le Reun
- Réanimation pédiatrique, hôpital Clocheville, CHU de Tours, 2, boulevard Tonnelle, 37000 Tours, France
| | - F Michel
- Anesthésie et réanimation pédiatrique, hôpital de la Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - F Millasseau
- Réanimation pédiatrique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - M Sinet
- Réanimation néonatale pédiatrique, hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Réanimation et surveillance continue pédiatriques, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| | - P Hubert
- Réanimation pédiatrique, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France
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Penven G, de Saint Blanquat L, Bordet F, Dray S, Série M. Quand le réanimateur devient prophète, la décision part en biais. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Une prophétie autoréalisatrice (PAR) [self-fulfilling prophecy] désigne le fait que la croyance en une situation entraîne sa réalisation, renforçant alors la croyance initiale. D’abord décrite en sociologie, la notion de PAR a également une pertinence en médecine, car la pratique clinique se fonde en grande partie sur le pronostic des patients et de leurs maladies. Ainsi, la croyance en un pronostic péjoratif peut être à l’origine d’une prise en charge médicale qui aboutira à une évolution défavorable ou ne l’empêchera pas. Ce risque est particulièrement aigu en médecine intensive-réanimation où les pratiques de limitation ou d’arrêt des thérapeutiques (LAT) conduisent fréquemment au décès du patient. Il est d’autant plus prégnant que les grandes séries de données à partir desquelles le pronostic d’un patient est évalué incluent des malades ayant fait l’objet de décisions de LAT. Cela peut aboutir à un raisonnement circulaire, difficile à interrompre. Les patients de neuroréanimation, victimes d’accidents vasculaires cérébraux, d’encéphalopathies anoxo-ischémiques postarrêt cardiaque, ou de traumatismes crâniens, sont particulièrement sujets au risque de PAR, car la perspective de séquelles neurologiques sévères motive souvent une décision de LAT. Prendre le contre-pied des PAR nécessite de trouver un compromis entre le temps d’observation indispensable pour établir un pronostic le plus précis possible et la prolongation de traitements invasifs qui s’avérerait a posteriori inutile chez des patients sans espoir d’amélioration neurologique.
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Boize P, Borrhomee S, Michel P, Betremieux P, Hubert P, Moriette G. Neonatal end-of-life decision-making almost 20 years after the EURONIC study: A French survey. Arch Pediatr 2019; 26:330-336. [PMID: 31353145 DOI: 10.1016/j.arcped.2019.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/02/2019] [Accepted: 06/18/2019] [Indexed: 11/28/2022]
Abstract
Nearly 20 years ago the EURONIC study reported that French neonatologists sometimes deemed it legitimate to terminate the lives of newborn infants when the prognosis appeared extremely poor. Parents were not always informed of these decisions. Major change has occurred since then and is described herein. MATERIAL AND METHODS A survey was conducted in the Île-de-France region, from 1 January to 31 January 2016. Professionals from 15 neonatal intensive care units (NICUs) were invited to complete a questionnaire. RESULTS A total of 702 questionnaires were collected and 670 responses were analyzed. Knowledge of the law differed according to professional status, with 71% of MDs (medical staff, MS), compared with 28% of nonmedical staff (NMS) declaring that they had good knowledge of the law. Most MDs and NMS believed that withholding or withdrawing life-sustaining treatments (WWLST) could be decided and implemented after a delay. Half of them thought that WWLST would always result in death. Although required by law, a consulting MD attended the collegial meeting required before deciding on WWLST in only half of the cases. Parents were almost always informed of the decision thereafter by the physician in charge of their infant. The most frequent disagreement with parents was observed when WWLST was the option selected. In this case, most professionals suggested postponing WWLST, continuing intensive care and dialogue with parents, aiming at a final shared decision. Major differences were observed between NICUs with regard to the withdrawal of artificial nutrition and hydration. Finally, 14% of MDs declared that infant active terminations of life still occurred in their NICU. Major differences concern WWLST and active termination of life, whose meaning has been partly modified since 2001. CONCLUSION Several major changes were observed in this survey: (1) treatment withdrawal decisions are made today in agreement with the law; (2) parents' information and involvement in the decision process have profoundly changed; (3) active termination of life (euthanasia) very rarely occurs; only at the end of a process in accordance with ethical principles and within the law is this decision made.
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Affiliation(s)
- P Boize
- Réanimation néonatale, centre hospitalier René Dubos, 6, avenue Île-de-France, 95300 Pontoise, France.
| | - S Borrhomee
- Réanimation néonatale, centre hospitalier René Dubos, 6, avenue Île-de-France, 95300 Pontoise, France
| | - P Michel
- Réanimation néonatale, centre hospitalier René Dubos, 6, avenue Île-de-France, 95300 Pontoise, France
| | - P Betremieux
- Réanimation polyvalente, centre hospitalier René Dubos, 6, avenue Île-de-France, 95300 Pontoise, France
| | - P Hubert
- Université Paris Descartes, Hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - G Moriette
- Université Paris Descartes, 12, rue de l'École de Médecine, 75006 Paris, France
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de Saint Blanquat L, Viallard ML. Réflexions éthiques et démarche palliative intégrée dans les réanimations pédiatriques françaises en 2017. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
En réanimation pédiatrique, 40 % des décès surviennent à la suite d’une décision de limitation ou d’arrêt de traitement (LAT). Ces situations sont sources de questionnements éthiques complexes au sein de l’équipe soignante. La législation française et les recommandations des sociétés savantes donnent un cadre aux réanimateurs pédiatres pour les prises de décisions de LAT. Les enquêtes de pratiques nous montrent qu’ils se sont approprié certains éléments de la procédure collégiale comme la nécessité de la concertation pluriprofessionnelle, l’information et la communication avec les parents. Néanmoins, certains points tels que la présence du consultant, la réalité de la collégialité avec l’expression de toutes les personnes soignantes présentes sont encore insuffisamment appliqués. La place des parents dans les décisions doit être également réfléchie. La collaboration entre les équipes de réanimation pédiatrique et de médecine palliative est une possibilité pour améliorer sensiblement la qualité des soins et de l’accompagnement proposés. Cette collaboration élargit également les possibilités de la réflexion éthique nécessaire dans les situations de fin de vie complexes. L’intégration dans l’enseignement de la réanimation des principes de la médecine palliative est en cours de réflexion.
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Carnevale FA, Farrell C, Cremer R, Séguret S, Canouï P, Leclerc F, Lacroix J, Hubert P. Communication in pediatric critical care: A proposal for an evidence-informed framework. J Child Health Care 2016; 20:27-36. [PMID: 25038056 DOI: 10.1177/1367493514540817] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this investigation was to conduct a comprehensive examination of communication between parents and health care professionals (HCPs) in the pediatric intensive care unit (PICU). A secondary analysis was performed on data from 3 previous qualitative studies, which included 30 physicians, 37 nurses, and 38 parents in France and Quebec (Canada). All three studies examined a mix of cases where children either survived or died. All data referring to communication between parents (and patients when applicable) and HCPs were examined to identity themes that related to communication. Thematic categories for parents and HCPs were developed. Three interrelated dimensions of communication were identified: (1) informational communication, (2) relational communication, and (3) communication and parental coping. Specific themes were identified for each of these 3 dimensions in relation to parental concerns as well as HCP concerns. This investigation builds on prior research by advancing a comprehensive analysis of PICU communication that includes (a) cases where life-sustaining treatments were withdrawn or withheld as well as cases where they were maintained, (b) data from HCPs as well as parents, and (c) investigations conducted in 4 different sites. An evidence-informed conceptual framework is proposed for PICU communication between parents and HCPs. We also outline priorities for the development of practice, education, and research.
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A Nursing Survey on Nutritional Care Practices in French-Speaking Pediatric Intensive Care Units: NutriRéa-Ped 2014. J Pediatr Gastroenterol Nutr 2016; 62:174-9. [PMID: 26237373 DOI: 10.1097/mpg.0000000000000930] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Malnutrition in critically ill children contributes to morbidity and mortality. The French-speaking pediatric intensive care nutrition group (NutriSIP) aims to promote optimal nutrition through education and research. METHODS The NutriSIP-designed NutriRéa-Ped study included a cross-sectional survey. This 62-item survey was sent to the nursing teams of all of the French-speaking pediatric intensive care units (PICUs) to evaluate nurses' nutrition knowledge and practices. One nurse per PICU was asked to answer and describe the practices of their team. RESULTS Of 44 PICUs, 40 responded in Algeria, Belgium, Canada, France, Lebanon, Luxemburg, and Switzerland. The majority considered nutrition as a priority care but only 12 of the 40 (30%) had a nutrition support team, 26 of the 40 (65%) had written nutrition protocols, and 19 of 39 (49%) nursing teams felt confident with the nutrition goals. Nursing staff generally did not know how to determine nutritional requirements or to interpret malnutrition indices. They were also unaware of reduced preoperative fasting times and fast-track concepts. In 17 of 35 (49%) PICUs, the target start time for enteral feeding was within the first 24 hours; however, frequent interruptions occurred because of neuromuscular blockade, fasting for extubation or surgery, and high gastric residual volumes. Combined pediatric neonatal intensive care units were less likely to perform systematic nutritional assessment and to start enteral nutrition rapidly. CONCLUSIONS We found a large variation in nursing practices around nutrition, exacerbated by the lack of nutritional guidelines but also because of the inadequate nursing knowledge around nutritional factors. These findings encourage the NutriSIP to improve nutrition through focused education programs and research.
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