Do neonatologists limit parental decision-making authority? A Canadian perspective

Parent and interdisciplinary professional perceptions of family-centered care in Thai NICU: A qualitative study

BACKGROUND

Family-centered care (FCC) has been successfully incorporated into daily practice in many neonatal intensive care units (NICUs) worldwide. However, the implementation of FCC in lower-resourced settings, such as Thailand, can be challenging and needs to be further explored.

AIMS

To identify parents' and interdisciplinary professionals' perceptions of FCC and to describe the opportunities to improve FCC in a Thai NICU.

DESIGN

An exploratory qualitative approach was used.

METHODS

The data were collected through face-to-face, semi-structured, individual interviews based on an interview guide. This study was conducted before the outbreak of coronavirus disease 2019 (February 2020) in a hospital in southern Thailand. Inductive thematic analysis was used to analyse interview data.

RESULTS

Participants were parents (n = 9) and interdisciplinary professionals (n = 8). The results revealed four key themes: (a) Recognizing and responding to individual families' different readiness and their rights and values, (b) working in a parent-interdisciplinary partnership to provide care, (c) lacking resources and motivation and (d) understanding of care requirements and providing help/sympathy.

CONCLUSIONS

The interdisciplinary professionals accepted that FCC is necessary for clinical practice, but there are some challenges in the Thai NICUs context because of the system of health care delivery. The findings highlighted that interdisciplinary professionals often viewed parents' involvement as an obstacle to providing neonatal care.

RELEVANCE TO CLINICAL PRACTICE

Further research is recommended to investigate how FCC is operationalized by interdisciplinary professionals and how hospital administrators can be supported to implement the FCC approach into clinical practice in Thai NICUs.

Decision-Making for Extremely Preterm Infants: A Qualitative Systematic Review

OBJECTIVE

To synthesize and describe important elements of decision-making during antenatal consultation for threatened preterm delivery at the margin of gestational viability.

STUDY DESIGN

Data sources including PubMed, EMBASE, Web of Science, and CINAHL Plus were searched. We included all qualitative literature published on decision-making from 1990 to July 2021. Two authors independently screened and evaluated each study using the Critical Appraisal Skills Programme checklist; studies reaching moderate and high quality were included. We developed an extraction tool to collect and categorize data from each qualitative article, then used thematic analysis to analyze and describe the findings.

RESULTS

Twenty-five articles incorporating the views of 504 providers and 352 parents were included for final review. Thematic analysis revealed 4 main themes describing the experience of health care providers and parents participating in decision-making: factors that influence decision-making, information sharing, building a partnership, and making the decision. Parents and providers were not always in agreement upon which elements were most essential to the process of decision-making. Articles published in languages other than English were excluded.

CONCLUSIONS

Qualitative literature highlighting key factors which are important during antenatal counseling can inform and guide providers through the process of shared decision-making. Communicating clear, honest, and balanced information; avoiding artificially dichotomized options; and focusing on partnership building with families will help providers use the antenatal consultation to reach personalized decisions for each infant.

Family-centred care change during COVID-19

BACKGROUND

Family-centred care (FCC) is an approach to promote family and health care provider partnership. This has been incorporated into neonatal intensive care units (NICUs) worldwide. However, FCC in low resource health settings, such as Thailand, is challenging and further impacted by coronavirus disease 2019 (COVID-19).

AIMS

To evaluate FCC innovations to improve respect, collaboration and support in a Thai NICU.

STUDY DESIGN

A quasi-experimental study was conducted in an NICU in southern Thailand. Pre-implementation was prior to COVID-19, and parental and staff perceptions of FCC were measured via Perceptions of Family Centred Care-Parent (PFCC-P) and -Staff (PFCC-S) survey. The FCC innovations were developed by stakeholders based on the COVID-19 restrictions, pre-survey results, parents' and clinicians' interviews and integrative review, then implemented via a flowchart. Post-implementation evaluation was via repeated surveys. Comparisons were made pre-and post-implementation, with Mann-Whitney U-test statistics for parents and Wilcoxon's Rank Sum for staff.

RESULTS

A total of 185 (85 pre; 100 post) parents and 20 (pre and post; paired group) health care professionals participated. Because of COVID-19, many planned interventions were unfeasible, however, other innovations achieved (e.g., structured telephone updates, information booklet revision). There was an increase in parents' perception of respect ([median] 2.50-3.50), collaboration (2.33-3.33) and support (2.60-3.60) domains and overall (2.50-3.43; p < .001; 95% CI: 2.93-3.11). Interdisciplinary professionals' perception of FCC did not significantly change pre-and post-implementation/COVID-19 pandemic for respect (3.00-2.92), collaboration (3.22-3.33), support (3.20-3.20) and overall (3.15-3.20; 95% CI: 3.10-3.25).

CONCLUSION

Despite the challenges of COVID-19 restricting NICU access, the provision of FCC was maintained and even improved.

RELEVANCE TO CLINICAL PRACTICE

Further research is necessary to develop FCC practice innovations associated with communication, across diverse health care systems and resources.

Parents' Perspectives: An Expanded View of Occupational and Co-Occupational Performance in the Neonatal Intensive Care Unit

IMPORTANCE

One limitation of occupation-based neonatal practice is the lack of clarity surrounding what parent and infant occupations exist in the neonatal intensive care unit (NICU). Without clear definitions and examples of these constructs, occupational therapists may not recognize or value them as part of practice.

OBJECTIVE

To explore concepts of occupational and co-occupational performance in the NICU and provide richly expanded descriptions of parent and infant occupations in this setting.

DESIGN

Phenomenological study with convenience sampling. Participants engaged in semistructured interviews. Inductive content analysis, in vivo and process coding methods, and cross-case analysis were used. Member checking and expert review of emergent themes were used to ensure authenticity.

SETTING

A metropolitan 48-bed Level 3 NICU with single-family rooms in the midwestern United States.

PARTICIPANTS

Fourteen parents (mean age = 29.7 yr; range = 19-37 yr) volunteered for the study.

RESULTS

Five themes of active occupational engagement emerged: (1) perceiving "they" versus "I"; (2) maintaining proximity; (3) expressing emotions, values, and beliefs; (4) addressing health issues; and (5) analyzing. A matrix framework displayed emergent themes with definitions of parent occupations, infant occupations, and parent-infant co-occupations. Examples of both directly observable and hidden occupations were found at matrix intersections.

CONCLUSIONS AND RELEVANCE

Occupational performance prevalently reflected attempts to balance power differentials and pursue meaningful engagement through observable and hidden participation in caregiving. Findings suggest that beyond typical occupations (e.g., feeding, socializing), neonatal therapists can address the doing, being, and becoming occupations expressed by parents in this study.

WHAT THIS ARTICLE ADDS

Parents described five broad thematic categories of NICU-based occupation and co-occupation, which may be valuable to therapists seeking to strengthen the occupational focus of neonatal intervention. Neonatal therapists may need to advocate for service provision policy change to fully address the observable and nonobservable doing, being, and becoming occupational and co-occupational needs of parents and infants.

Prenatal parental involvement in decision for delivery room management at 22-26 weeks of gestation in France - The EPIPAGE-2 Cohort Study

OBJECTIVE

Our main objective was to examine if parental prenatal preferences predict delivery-room management of extremely preterm periviable infants. The secondary objectives were to describe parental involvement and the content of prenatal counseling given to parents for this prenatal decision.

DESIGN

Prospective study of neonates liveborn between 22 and 26 weeks of gestation in France in 2011 among the neonates included in the EPIPAGE-2 study.

SETTING

18 centers participating in the "Extreme Prematurity Group" substudy of the EPIPAGE-2 study.

PATIENTS

302 neonates liveborn between 22-26 weeks among which 113 with known parental preferences while parental preferences were unknown or unavailable for 186 and delivery room management was missing for 3.

RESULTS

Data on prenatal counseling and parental preferences were collected by a questionnaire completed by professionals who cared for the baby at birth; delivery room (DR) management, classified as stabilization or initiation of resuscitation (SIR) vs comfort care (CC). The 113 neonates studied had a mean (SD) gestational age of 24 (0.1) weeks. Parents of neonates in the CC group preferred SIR less frequently than those with neonates in the SIR group (16% vs 88%, p < .001). After multivariate analysis, preference for SIR was an independent factor associated with this management. Professionals qualified decisions as shared (81%), exclusively medical (16%) or parental (3%). Information was described as medical with no personal opinion (71%), complete (75%) and generally pessimistic (54%).

CONCLUSION

Parental involvement in prenatal decision-making did not reach satisfying rates in the studied setting. When available, prenatal parental preference was a determining factor for DR management of extremely preterm neonates. Potential biases in the content of prenatal counselling given to parents need to be evaluated.

Thresholds for Resuscitation of Extremely Preterm Infants in the UK, Sweden, and Netherlands

BACKGROUND

It is widely acceptable to involve parents in decision-making about the resuscitation of extremely preterm infants (EPIs) in the gray zone. However, there are different views about where the boundaries of the gray zone should lie. Our aim in this study was to compare the resuscitation thresholds for EPIs between neonatologists in the United Kingdom, Sweden, and the Netherlands.

METHODS

We distributed an online survey to consultant neonatologists and neonatal registrars and fellows that included clinical scenarios in which parents requested resuscitation or nonresuscitation. Respondents were asked about the lowest gestational age and/or the worst prognosis at which they would provide resuscitation and the highest gestational age and/or the best prognosis at which they would withhold resuscitation. In additional scenarios, influence of the condition at birth or consideration of available health care resources was assessed.

RESULTS

The survey was completed by 162 neonatologists (30% response rate). There was a significant difference between countries; the gray zone for most UK respondents was 23 + 0/7 to 23 + 6/7 or 24 weeks' gestation, compared with 22 + 0/7 to 22 + 6/7 or 23 weeks' gestation in Sweden and 24 + 0/7 to 25 + 6/7 or 26 weeks' gestation in the Netherlands. Resuscitation thresholds were higher if an infant was born in poor condition. There was wide variation in the prognosis that warranted resuscitation or nonresuscitation. Consideration of resource scarcity did not alter responses.

CONCLUSIONS

In this survey, we found significant differences in approach to the resuscitation of EPIs, with a spectrum from most proactive (Sweden) to least proactive (Netherlands). Most survey respondents indicated shifts in decision-making that were associated with particular weeks' gestation. Despite the different approaches to decision-making in the 3 countries, there was relatively little difference between countries in neonatologists' prognostic thresholds for resuscitation.

The ethical issues regarding consent to clinical trials with pre-term or sick neonates: a systematic review (framework synthesis) of the empirical research

BACKGROUND

Conducting clinical trials with pre-term or sick infants is important if care for this population is to be underpinned by sound evidence. Yet approaching parents at this difficult time raises challenges for the obtaining of valid informed consent to such research. This study asked: what light does the empirical literature cast on an ethically defensible approach to the obtaining of informed consent in perinatal clinical trials?

METHODS

A systematic search identified 49 studies. Analysis began by applying philosophical frameworks which were then refined in light of the concepts emerging from empirical studies to present a coherent picture of a broad literature.

RESULTS

Between them, studies addressed the attitudes of both parents and clinicians concerning consent in neonatal trials; the validity of the consent process in the neonatal research context; and different possible methods of obtaining consent.

CONCLUSIONS

Despite a variety of opinions among parents and clinicians there is a strongly and widely held view that it is important that parents do give or decline consent for neonatal participation in trials. However, none of the range of existing consent processes reviewed by the research is satisfactory. A significant gap is evaluation of the widespread practice of emergency 'assent', in which parents assent or refuse their baby's participation as best they can during the emergency and later give full consent to ongoing participation and follow-up. Emergency assent has not been evaluated for its acceptability, how such a process would deal with bad outcomes such as neonatal death between assent and consent, or the extent to which late parental refusal might bias results. This review of a large number of empirical papers, while not making fundamental changes, has refined and developed the conceptual framework from philosophy for examining informed consent in this context.

The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments

INTRODUCTION

Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees.

METHODS

Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared.

RESULTS

Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent.

CONCLUSIONS

Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.

Parental influence on clinical management during neonatal intensive care: a survey of US neonatologists

OBJECTIVE

Family-centered care (FCC), which includes involving parents in conversations about medical management, is increasingly employed in the neonatal intensive care unit (NICU). Our aim was to determine which care decisions are discussed by neonatologists with families most frequently and the percentage of clinicians influenced by such conversations.

METHODS

Anonymous web-based survey provided to 2137 neonatologists assessing information sharing and parental involvement.

RESULTS

Thousand and two neonatologists responded in which 893 fully completed the surveys. 88% practice FCC. Topics most frequently discussed with parents were blood transfusion, steroids for lung disease and patent ductus arteriosus (PDA) surgery, each being reported and discussed by more than 90% of respondents. Many therapies, including aminoglycoisdes, total parenteral nutrition, and phototherapy, were discussed with parents by far fewer clinicians. Additionally, parents had most influence on clinicians in two categories, blood transfusion and steroids, with more than 70% reporting that their practice was influenced by parental opinion if communicated. For some topics, such as PDA surgery and central line placement, conversations impacted few clinicians.

CONCLUSIONS

FCC appears to have an impact on NICU clinical decision-making processes, some more than others. Further investigation in this area may provide information on how to best communicate with families and run effective, efficient FCC rounds.