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Song IG, Lee J, Kim MS, Lee JW, Jeon SY, Yoo SH, Park HY. Beyond Legal Boundaries: Public and Clinician Perspectives on Treatment Withdrawal in Infants With Poor Neurological Prognosis. J Korean Med Sci 2024; 39:e196. [PMID: 38952347 PMCID: PMC11216905 DOI: 10.3346/jkms.2024.39.e196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 05/26/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Despite medical advancements in neonatal survival rates, many children have poor neurological outcomes. Because the law in Korea restricts the withdrawal of life-sustaining treatment to only cases of imminent death, treatment discontinuation may not be an option, even in patients with poor neurological prognosis. This study investigated the opinions of the general population and clinicians regarding life-sustaining treatment withdrawal in such cases using hypothetical scenarios. METHODS We conducted a cross-sectional study on the general population and clinicians using a web-based questionnaire. The sample of the general population from an online panel comprised 500 individuals aged 20-69 years selected by quota sampling. The clinician sample comprised 200 clinicians from a tertiary university hospital. We created hypothetical vignettes and questionnaire items to assess attitudes regarding mechanical ventilation withdrawal for an infant at risk of poor neurological prognosis due to birth asphyxia at 2 months and 3 years after the incidence. RESULTS Overall, 73% of the general population and 74% of clinicians had positive attitudes toward mechanical ventilator withdrawal at 2 months after birth asphyxia. The proportion of positive attitudes toward mechanical ventilator withdrawal was increased in the general population (84%, P < 0.001) and clinicians (80.5%, P = 0.02) at 3 years after birth asphyxia. Religion, spirituality, the presence of a person with a disability in the household, and household income were associated with the attitudes of the general population. In the multivariable logistic regression analysis of the general population, respondents living with a person with a disability or having a disability were more likely to find the withdrawal of the ventilator at 2 months and 3 years after birth asphyxia not permissible. Regarding religion, respondents who identified as Christians were more likely to find the ventilator withdrawal at 2 months after birth asphyxia unacceptable. CONCLUSION The general population and clinicians shared the perspective that the decision to withdraw life-sustaining treatment in infants with a poor neurological prognosis should be considered before the end of life. A societal discussion about making decisions centered around the best interest of pediatric patients is warranted.
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Affiliation(s)
- In Gyu Song
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Lee
- Integrative Care Hub, Seoul National University Hospital, Seoul, Korea
| | - Min Sun Kim
- Integrative Care Hub, Seoul National University Hospital, Seoul, Korea
- Department of Pediatrics, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea.
| | - Ji Weon Lee
- Integrative Care Hub, Seoul National University Hospital, Seoul, Korea
| | - So Yeon Jeon
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Korea
- Department of Psychiatry, Chungnam National University College of Medicine, Daejeon, Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
| | - Hye Yoon Park
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Korea
- Department of Psychiatry, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Mariani GL, Contrera PJ, Virasoro MDLA, Portela MC, Urquizu Handal MI, Ávila AS, Fernández AL, Fernandez Riera P, Cardigni G, Vain NE. End-of-Life Care for Newborn Infants: A Multicenter Real-Life Prospective Study. Neonatology 2024:1-9. [PMID: 38801819 DOI: 10.1159/000538814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/07/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Most neonatal deaths in industrialized countries follow a process of redirection of care. The objectives of this study were to describe how neonates die in a middle-income country, whether there was redirection of care, and the reason for this decision. METHODS This was a prospective, multicenter, cross-sectional study. Neonates who died in the delivery room or in the neonatal intensive care unit in 97 hospitals over a 6-month period were included. After each neonatal death, one investigator interviewed a member of the healthcare team who had been involved in the end-of-life care process. Perinatal data, conditions that led to death, whether there was redirection of care, and details of the end-of-life process were recorded. RESULTS Data from 697 neonatal deaths were analyzed, which represent 80% of the total deaths occurring in Argentina in that period. The main causes of death were complications of prematurity (47%) and congenital anomalies (27%). Overall, 32% of neonates died after a process of redirection of care, and this was less frequent in the neonatal intensive care unit (28%) than in the delivery room (70%, p < 0.001). The reasons for withholding/withdrawing care were inevitable death (75%) and severe compromise of expected quality of life (25%). Redirection of care consisted in withholding therapies in 66% and withdrawal in 34%. A diagnosis of a major congenital anomaly increased the odds of redirection of care (OR 5.45; 95% CI: 3.59-8.27). CONCLUSION Most neonates who die in Argentina do so while receiving full support. Redirection of care mainly follows a condition of inevitable death.
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Affiliation(s)
- Gonzalo Luis Mariani
- Servicio de Neonatología Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pamela Judith Contrera
- Servicio de Neonatología, Sanatorio de la Trinidad San Isidro, Provincia de Buenos Aires, Buenos Aires, Argentina
| | | | - María Constanza Portela
- Servicio de Neonatología Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" (CEMIC), sede Saavedra, Buenos Aires, Argentina
| | - María Ines Urquizu Handal
- Servicio de Neonatología, Sanatorio de la Trinidad San Isidro, Provincia de Buenos Aires, Buenos Aires, Argentina
- Servicio de Neonatología, Sanatorio de la Trinidad Ramos Mejía, Provincia de Buenos Aires, Buenos Aires, Argentina
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Aldana Soledad Ávila
- Servicio de Neonatología, Sanatorio de la Trinidad Ramos Mejía, Provincia de Buenos Aires, Buenos Aires, Argentina
- Dirección de Salud Perinatal y Niñez, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | | | - Patricia Fernandez Riera
- Dirección de Salud Perinatal y Niñez, Ministerio de Salud de la Nación, Buenos Aires, Argentina
- Servicio de Neonatología, Hospital Británico, Buenos Aires, Argentina
| | - Gustavo Cardigni
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Néstor Eduardo Vain
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
- Facultad de Medicina Universidad de Buenos Aires, Buenos Aires, Argentina
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Lakhani J, Mack C, Kunyk D, Kung J, van Manen M. Considerations for Practice in Supporting Parental Bereavement in the Neonatal Intensive Care Unit-a Systematic Review. J Palliat Care 2024; 39:138-160. [PMID: 36846871 PMCID: PMC10960324 DOI: 10.1177/08258597231158328] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Parental bereavement after the death of an infant in a neonatal intensive care unit (NICU) is a complex and nuanced experience. Support from healthcare practitioners can have a significant impact on bereavement experiences in the short- and long-term. Although several studies exist exploring parental perceptions of their experience of loss and bereavement, there has not been a recent review of beneficial practices and common themes in the current literature. OBJECTIVE This review synthesizes empirical research to identify considerations that ought to guide the caregiving practices of healthcare professionals to support parental bereavement. SETTINGS/SUBJECTS Data was collected from studies identified in MEDLINE, Embase, and CINAHL. The search was limited to English-language studies describing parental bereavement in the NICU population from January 1990 to November 2021. RESULTS Of 583 studies initially identified, 47 studies of varying geographic locations were included in this review. Various themes surrounding healthcare support in parental bereavement were identified including ensuring the opportunity for parents to spend time caring for their child, understanding their perception of infant suffering, recognizing the impact of communication experiences with healthcare providers, and offering access to alternative means of support, all of which have been described as suboptimal. Parents generally want the opportunity to say goodbye to their infant in a private and safe space, be supported through their decision-making and be offered bereavement follow-up after loss. CONCLUSION This review identifies methods of support in parental bereavement based on first-hand parental experiences and routine implementation of these strategies may be beneficial in supporting parents through their bereavement after the loss of a baby in the NICU.
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Affiliation(s)
- Jenna Lakhani
- University of Alberta, Stollery Children's Hospital, Edmonton, Canada
| | - Cheryl Mack
- University of Alberta, Stollery Children's Hospital, Edmonton, Canada
| | | | | | - Michael van Manen
- University of Alberta, Stollery Children's Hospital, John Dossetor Health Ethics Centre, Edmonton, Canada
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Cain MR, de Waal K. Mortality in the neonatal intensive care setting: Do benchmarks tell the whole story? J Paediatr Child Health 2024; 60:107-112. [PMID: 38605553 DOI: 10.1111/jpc.16542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 02/26/2024] [Accepted: 03/29/2024] [Indexed: 04/13/2024]
Abstract
AIM Australian neonatal mortality data are collected and shared within collaborative networks. Individual unit outcomes are benchmarked between units and presented in quarterly or yearly reports. Low mortality is commonly interpreted as optimal performance. However, current collected data do not differentiate between death due to severe illness and death following treatment limitation. This study aims to explore the physiological condition immediately before death, and the proportion of deaths attributed to treatment limitation. METHODS This retrospective single centre study of 100 consecutive deaths classified the physiological condition 12 h prior to death as stable or unstable using a clinical illness score based upon pH, oxygen saturation index, medications and blood product use. Documented discussions regarding expected outcomes and goals of management were reviewed for agreed upon treatment limitations and analysed against physiological stability. RESULTS Causes of death were sepsis (n = 24), congenital anomalies (n = 20), extreme prematurity (n = 19), hypoxic ischaemic encephalopathy (n = 18), intraventricular haemorrhage (n = 11) and other (n = 8). Forty-eight infants were physiologically stable at 12 h before death. In infants classified as physiologically stable, 90% of deaths were in a scenario where palliative care was discussed and intensive care treatment was ceased. These deaths accounted for 43% of total mortality in our unit. CONCLUSION A large portion of mortality in our unit could be attributed to treatment limitations in physiologically stable infants with high risk of neurodevelopmental impairment. Our study emphasises the need to consider the physiological status around time of death for optimal benchmarking of mortality between neonatal units.
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Affiliation(s)
- Madeleine-Rose Cain
- Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | - Koert de Waal
- Neonatal Intensive Care Unit, John Hunter Children's Hospital, Newcastle, New South Wales, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
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Verhagen AAE. Death, dying and palliative care in the NICU. J Pediatr (Rio J) 2024; 100:119-120. [PMID: 38008124 PMCID: PMC10943320 DOI: 10.1016/j.jped.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Affiliation(s)
- A A Eduard Verhagen
- University Medical Center Groningen, Department of Pediatrics, University of Groningen, Groningen, the Netherlands.
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Lakhani J, Mack C, Kunyk D, van Manen M. Exploring and Supporting Parents' Stories of Loss in the NICU: A Narrative Study. QUALITATIVE HEALTH RESEARCH 2023; 33:1279-1290. [PMID: 37933825 PMCID: PMC10666488 DOI: 10.1177/10497323231201023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Death is no stranger to the neonatal intensive care unit (NICU). Extreme prematurity, congenital abnormalities, and other complexities can turn what was hoped to be a very exciting moment in a family's life into one of despair and grief. There are many infants that not only do not survive but also have a medicalized death necessitating complex decision-making, weighing quality versus duration of life. We can learn from the stories of parents who chose palliative care for their children. In this narrative inquiry study, we elicited bereaved parents' stories and reflections on the lives of their children and the care they received in the NICU. From a narrative ethics perspective, their stories speak to normative aspects of parenting, decision-making, and receiving medical care that affect their moral sense-making of their NICU experiences as well as their longer-term living with the loss of their children. Their stories express the importance of having had meaningful time with their children, maintaining direct and frequent communication, acknowledging uncertainty, and emphasizing compassion as methods of providing support to parents as they navigate their bereavement.
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Affiliation(s)
- Jenna Lakhani
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Cheryl Mack
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, AB, Canada
- John Dossetor Health Ethics Centre, University of Alberta, Edmonton, AB, Canada
| | - Diane Kunyk
- John Dossetor Health Ethics Centre, University of Alberta, Edmonton, AB, Canada
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Michael van Manen
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
- John Dossetor Health Ethics Centre, University of Alberta, Edmonton, AB, Canada
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Wilkinson DJ, Bertaud S. End of life care in the setting of extreme prematurity - practical challenges and ethical controversies. Semin Fetal Neonatal Med 2023; 28:101442. [PMID: 37121832 PMCID: PMC10914670 DOI: 10.1016/j.siny.2023.101442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
While the underlying principles are the same, there are differences in practice in end of life decisions and care for extremely preterm infants compared with other newborns and older children. In this paper, we review end of life care for extremely preterm infants in the delivery room and in the neonatal intensive care unit. We identify potential justifications for differences in the end of life care in this population as well as practical and ethical challenges.
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Affiliation(s)
- Dominic Jc Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK; John Radcliffe Hospital, Oxford, UK; Murdoch Children's Research Institute, Melbourne, Australia; Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore.
| | - Sophie Bertaud
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK
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Ng PC, Fung GPG. Spiritual and cultural influences on end-of-life care and decision-making in NICU. Semin Fetal Neonatal Med 2023; 28:101437. [PMID: 37105859 DOI: 10.1016/j.siny.2023.101437] [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] [Indexed: 04/29/2023]
Abstract
Understanding and respecting the spiritual beliefs, ethnic roots, cultural norms and customs of individual families is essential for neonatologists to provide clinically appropriate and humane end-of-life care. This review describes the religious/philosophical principles, cultural-related practices/rituals, and traditions in end-of-life care in major spiritual groups of today's multi-cultural, multi-faith societies. The spiritual groups include Christians, Muslims, Jewish Judaism believers and Asian religious/philosophy followers such as Buddhists, Hindus, Taoists, Confucianism devotees and ancestral worshippers. It is vital to understand that substantial variation in views and practices may exist even within the same religion and culture in different geographic locations. Ethical views and cultural practices are not static elements in life but behave in a fluidic and dynamic manner that could change with time. Interestingly, an evolving pattern has been observed in some Asian and Middle East countries that more parents and/or religious groups are beginning to accept a form of redirection of care most compatible with their spiritual belief and culture. Thus, every family must be assessed and counseled individually for end-of-life decision-making. Also, every effort should be made to comply with parents' requests and to treat infants/parents of different religions and cultures with utmost dignity so that they have no regret for their irreversible decisions.
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Affiliation(s)
- Pak C Ng
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| | - Genevieve P G Fung
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Boutillier B, Biran V, Janvier A, Barrington KJ. Survival and Long-Term Outcomes of Children Who Survived after End-of-Life Decisions in a Neonatal Intensive Care Unit. J Pediatr 2023; 259:113422. [PMID: 37076039 DOI: 10.1016/j.jpeds.2023.113422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/10/2023] [Accepted: 03/21/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To investigate long-term outcomes of infants who survive despite life-and-death discussions with families and a decision to withdraw or withhold life-sustaining interventions (WWLST) in one neonatal intensive care unit. STUDY DESIGN Medical records for neonatal intensive care unit admissions from 2012 to 2017 were reviewed for presence of WWLST discussions or decisions, as well as the 2-year outcome of all children who survived. WWLST discussions were prospectively recorded in a specific book; follow-up to age 2 years was determined by retrospective chart review. RESULTS WWLST discussions occurred for 266 of 5251 infants (5%): 151 (57%) were born at term and 115 (43%) were born preterm. Among these discussions, 164 led to a WWLST decision (62%) and 130 were followed by the infant's death (79%). Of the 34 children (21%) surviving to discharge after WWLST decisions, 10 (29%) died before 2 years of age and 11 (32%) required frequent medical follow-up. Major functional limitations were common among survivors, but 8 were classified as functionally normal or with mild-to-moderate functional limitations. CONCLUSIONS When a WWLST decision was made in our cohort, 21% of the infants survived to discharge. By 2 years of age, the majority of these infants had died or had major functional limitations. This highlights the uncertainty of WWLST decisions during neonatal intensive care and the importance of ensuring that parents are informed of all possibilities. Additional studies including longer-term follow-up and ascertaining the family's views will be important.
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Affiliation(s)
- Béatrice Boutillier
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Hôpital universitaire Robert-Debré, Université de Paris Cité, Paris, France; Division of Neonatology, Centre de recherche, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada.
| | - Valérie Biran
- Neonatal Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Hôpital universitaire Robert-Debré, Université de Paris Cité, Paris, France; Inserm UMR 1141 Neurodiderot, Université de Paris Cité, Hôpital Robert-Debré, Paris, France
| | - Annie Janvier
- Division of Neonatology, Centre de recherche, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Department of Pediatrics, Université de Montréal, Montréal, Canada; Bureau de l'éthique Clinique (BEC), Université de Montréal, Montréal, Canada; Unité d'éthique clinique, Unité de soins palliatifs, CHU Sainte-Justine, Montréal, Canada
| | - Keith J Barrington
- Division of Neonatology, Centre de recherche, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Department of Pediatrics, Université de Montréal, Montréal, Canada
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10
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Bouma S, Cobben N, Bouman K, Gaytant M, van de Biggelaar R, van Doorn J, Reumers SFI, Voet NB, Doorduin J, Erasmus CE, Kamsteeg EJ, Jungbluth H, Wijkstra P, Voermans NC. Respiratory features of centronuclear myopathy in the Netherlands. Neuromuscul Disord 2023; 33:580-588. [PMID: 37364426 DOI: 10.1016/j.nmd.2023.06.003] [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: 12/28/2022] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023]
Abstract
Centronuclear myopathy (CNM) is a heterogeneous group of muscle disorders primarily characterized by muscle weakness and variable degrees of respiratory dysfunction caused by mutations in MTM1, DNM2, RYR1, TTN and BIN1. X-linked myotubular myopathy has been the focus of recent natural history studies and clinical trials. Data on respiratory function for other genotypes is limited. To better understand the respiratory properties of the CNM spectrum, we performed a retrospective study in a non-selective Dutch CNM cohort. Respiratory dysfunction was defined as an FVC below 70% of predicted and/or a daytime pCO2 higher than 6 kPa. We collected results of other pulmonary function values (FEV1/FVC ratio) and treatment data from the home mechanical ventilation centres. Sixty-one CNM patients were included. Symptoms of respiratory weakness were reported by 15/47 (32%) patients. Thirty-three individuals (54%) with different genotypes except autosomal dominant (AD)-BIN1-related CNM showed respiratory dysfunction. Spirometry showed decreased FVC, FEV1 & PEF values in all but two patients. Sixteen patients were using HMV (26%), thirteen of them only during night-time. In conclusion, this study provides insight into the prevalence of respiratory symptoms in four genetic forms of CNM in the Netherlands and offers the basis for future natural history studies.
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Affiliation(s)
- Sietse Bouma
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicolle Cobben
- Department of Pulmonary Diseases & Home Mechanical Ventilation, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Karlijn Bouman
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michael Gaytant
- Center for Home Mechanical Ventilation, Department of Pulmonology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ries van de Biggelaar
- Department of Pulmonary Diseases & Home Mechanical Ventilation, Erasmus MC, Rotterdam, the Netherlands
| | - Jeroen van Doorn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stacha F I Reumers
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicoline Bm Voet
- Department of Rehabilitation, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands; Rehabilitation Center Klimmendaal, Arnhem, the Netherlands
| | - Jonne Doorduin
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Corrie E Erasmus
- Department of Paediatric Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center - Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Erik-Jan Kamsteeg
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Heinz Jungbluth
- Department of Paediatric Neurology, Neuromuscular Service, Evelina's Children Hospital, Guy's & St. Thomas' Hospital NHS Foundation Trust, London, UK; Randall Centre for Cell and Molecular Biophysics, Muscle Signalling Section, FoLSM, King's College, London, UK
| | - Peter Wijkstra
- Department of Pulmonary Diseases & Home Mechanical Ventilation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Centre Groningen, the Netherlands
| | - Nicol C Voermans
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.
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11
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Chevallier M, Barrington KJ, Terrien Church P, Luu TM, Janvier A. Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills. Semin Fetal Neonatal Med 2023; 28:101444. [PMID: 37150640 DOI: 10.1016/j.siny.2023.101444] [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] [Indexed: 05/09/2023]
Abstract
Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.
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Affiliation(s)
- M Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France; TIMC-IMAG Research Department; Grenoble Alps University; Grenoble, France
| | - K J Barrington
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - P Terrien Church
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - T M Luu
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - A Janvier
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada; Bureau de L'éthique Clinique, Université de Montréal, Canada; Unité D'éthique Clinique, Unité de Soins Palliatifs, Bureau Du Partenariat Patients-Familles-Soignants; CHU Sainte-Justine, Montréal, Canada.
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12
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Verhagen AAE. Neonatal euthanasia in the context of palliative and EoL care. Semin Fetal Neonatal Med 2023; 28:101439. [PMID: 37105858 DOI: 10.1016/j.siny.2023.101439] [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] [Indexed: 04/29/2023]
Abstract
Neonatal deaths can be categorized in 5 modes along the dimension of intervention and physiology. This classification can be helpful to analyze the choices that can be made in end-of-life care in the NICU. In the Netherlands, neonatal euthanasia became an optional 6th mode of death since publication and legalization of the Groningen Protocol. This paper summarizes the history, legal status and ethical justification of the Groningen Protocol, and describes end-of-life practice in the subsequent years. Since the implementation of the Groningen Protocol, the practice of neonatal euthanasia has almost disappeared. Simultaneously, there has been spectacular growth in neonatal palliative care programs in the Netherlands. Is there still a need for this last-resort option?
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Affiliation(s)
- A A Eduard Verhagen
- University Medical Center Groningen, Dept of Pediatrics, University of Groningen, PO Box 30.001, 9700RB, Groningen, the Netherlands.
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Dong XY, Zhang WW, Han JM, Bi D, Yang ZY, Wang XL, Wang H, Yang DJ, Zhang CL, Gao R, Zhang BJ, Hu LL, Reddy S, Yuan SK, Yu YH. Determining resuscitation threshold for extremely preterm infants based on the survival rates without severe neurological injury. J Glob Health 2023; 13:04059. [PMID: 37227033 PMCID: PMC10210526 DOI: 10.7189/jogh.13.04059] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
Background Published guidelines on decision-making and resuscitation of extremely preterm infants primarily focus on high-income countries. For rapidly industrializing ones like China, there is a lack of population-based data for informing prenatal management and practice guidelines. Methods The Sino-northern Neonatal Network conducted a prospective multi-centre cohort study between 1 January 2018 and 31 December 2021. Infants with a gestational age (GA) between 22 (postnatal age in days = 0) and 28 (postnatal age in days = 6) admitted to 40 tertiary NICUs in northern China were included and evaluated for death or severe neurological injury before discharge. Results For all extremely preterm infants (n = 5838), the proportion of admission to the neonatal was 4.1% at 22-24 weeks, 27.2% at 25-26 weeks, and 75.2% at 27 and 28 weeks. Among 2228 infants admitted to the NICU, 216 (11.1%) were still elected for withdrawal of care (WIC) due to non-medical factors. Survival rates without severe neurological injury were 6.7% for infants at 22-23 weeks, 28.0% at 24 weeks, 56.7% at 24 weeks, 61.7% at 25 weeks, 79.9% at 26 weeks, and 84.5% at 27 and 28 weeks. Compared with traditional criterion at 28 weeks, the relative risk for death or severe neurological injury were 1.53 (95% confidence interval (CI) = 1.26-1.86) at 27 weeks, 2.32 (95% CI = 1.73-3.11) at 26 weeks, 3.62 (95% CI = 2.43-5.40) at 25 weeks, and 8.91 (95% CI = 4.69-16.96) at 24 weeks. The NICUs with higher proportion of WIC also had a higher rate of death or severe neurological injury after maximal intensive care (MIC). Conclusions Compared to the traditional threshold of 28 weeks, more infants received MIC after 25 weeks, leading to significant increases in survival rates without severe neurological injury. Therefore, the resuscitation threshold should be gradually adjusted from 28 to 25 weeks based on reliable capacity. Registration China Clinical Trials Registry. ID: ChiCTR1900025234.
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Affiliation(s)
- Xiao-Yu Dong
- Shandong Provincial Maternal and Child Health Care Hospital Affiliated to Qingdao University, Jinan, China
| | - Wen-Wen Zhang
- Department of Paediatrics, Jinan Maternal and Child Health Hospital, Jinan, China
| | - Jun-Ming Han
- Department of Paediatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Dan Bi
- Department of Paediatrics, Qilu Hospital Affiliated to Shandong University, Jinan, China
| | - Zhen-Ying Yang
- Department of Paediatrics, Taian Maternal and Child health Care Hospital, Taian, China
| | - Xiao-Liang Wang
- Department of Paediatrics, Yantai Yuhuangding Hospital, Yantai, China
| | - Hui Wang
- Department of Paediatrics, Hebei PetroChina Central Hospital, Langfang, China
| | - De-Juan Yang
- Department of Paediatrics, The First Affiliated Hospital of Shandong First Medical University, Jinan China
| | - Chun-Lei Zhang
- Department of Paediatrics, Wei Fang Maternal and Child Health Hospital, Weifang, China
| | - Rui Gao
- Department of Paediatrics, Liaocheng People's Hospital, Liaocheng, China
| | - Bing-Jin Zhang
- Department of Paediatrics, Shengli Oilfield Central Hospital, Dongying, China
| | - Li-Li Hu
- Department of Paediatrics, Baogang Third Hospital of Hongci Group, Baotou, China
| | - Simmy Reddy
- Department of Paediatrics, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Sen-Kang Yuan
- Inspur Electronic Information Industry Co. Ltd, China
| | - Yong-Hui Yu
- Department of Paediatrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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14
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Cambonie G, Desage C, Thaller P, Lemaitre A, de Balanda KB, Combes C, Gavotto A. Context of a neonatal death affects parental perception of end-of-life care, anxiety and depression in the first year of bereavement. BMC Palliat Care 2023; 22:58. [PMID: 37173678 PMCID: PMC10182590 DOI: 10.1186/s12904-023-01183-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Neonatal death is often preceded by end-of-life medical decisions. This study aimed to determine whether the context of death - after a decision of withholding or withdrawing life-sustaining treatment (WWLST) or despite maximum care - was associated with subsequent risk of parental anxiety or depression. The secondary objective was to assess parents' perceptions of end-of-life care according to death context. METHODS Prospective single center observational study of all neonatal deaths in a neonatal intensive care unit over a 5-year period. Data were collected during hospitalization and from face-to-face interviews with parents 3 months after the infant's death. Anxiety and depression were assessed using Hospital Anxiety and Depression Scale (HADS) questionnaires, completed by parents 5 and 15 months after death. RESULTS Of 179 deaths, 115 (64%) occurred after the WWLST decision and 64 (36%) despite maximum care. Parental satisfaction with newborn care and received support by professionals and relatives was higher in the first condition. Sixty-one percent of parents (109/179) attended the 3-month interview, with the distribution between groups very close to that of hospitalization. The completion rates of the HADS questionnaires by the parents who attended the 3-month interview were 75% (82/109) at 5 months and 65% (71/109) at 15 months. HADS scores at 5 months were consistent with anxiety in at least one parent in 73% (60/82) of cases and with depression in 50% (41/82). At 15 months, these rates were, respectively, 63% (45/71) and 28% (20/71). Risk of depression at 5 months was lower after a WWLST decision (OR 0.35 [0.14, 0.88], p = 0.02). Explicit parental agreement with the WWLST decision had an equivocal impact on the risk of anxiety at 5 months, being higher when expressed during hospitalization, but not at the 3-month interview. CONCLUSIONS Context of death has a significant impact on the emotional experience of parents after neonatal loss, which underlines the importance of systematic follow-up conversations with bereaved parents.
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Affiliation(s)
- Gilles Cambonie
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France.
- Pathogenesis and Control of Chronic Infection, UMR 1058, INSERM, University of Montpellier, Montpellier, France.
| | - Chloé Desage
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Pénélope Thaller
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Anne Lemaitre
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Karine Bertran de Balanda
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Clémentine Combes
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Arthur Gavotto
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France
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15
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Fortney CA, Baughcum AE, Garcia D, Winning AM, Humphrey L, Cistone N, Moscato EL, Keim MC, Nelin LD, Gerhardt CA. Characteristics of Critically Ill Infants at the End of Life in the Neonatal Intensive Care Unit. J Palliat Med 2023; 26:674-683. [PMID: 36480799 PMCID: PMC11079611 DOI: 10.1089/jpm.2022.0408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives: About 16,000 infants die in the neonatal intensive care unit (NICU) each year with many experiencing invasive medical treatments and high number of symptoms.1 To inform better management, we characterized diagnoses, symptoms, and patterns of care among infants who died in the NICU. Method: Retrospective electronic medical record (EMR) review of 476 infants who died following admission to a large regional level IV NICU in the United States over a 10-year period. Demographic, symptom, diagnosis, treatment, and end-of-life characteristics were extracted. Results: About half of infants were male (55.9%, n = 266), average gestational age was 31.3 weeks (standard deviation [SD] = 6.5), and average age at death was 40.1 days (SD = 84.5; median = 12; range: 0-835). Race was documented for 65% of infants, and most were White (67.0%). One-third of infants (n = 138) were seen by fetal medicine. Most infants experienced pain through both the month and week before death (79.6%), however, infants with necrotizing enterocolitis had more symptoms in the week before death. Based on EMR, infants had more symptoms, and received more medical interventions and comfort measures during the week before death compared with the month prior. Only 35% (n = 166) received a palliative care referral. Conclusions: Although the medical profiles of infants who die in the NICU are complex, the overall number of symptoms was less than in older pediatric populations. For infants at high risk of mortality rate, providers should assess for common symptoms over time. To manage symptoms as effectively as possible, both timely and continuous communication with parents and early referral to palliative care are recommended.
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Affiliation(s)
- Christine A. Fortney
- College of Nursing, Martha S. Pitzer Center for Women, Children, and Youth, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amy E. Baughcum
- College of Medicine, Department of Pediatrics, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio USA
| | - Dana Garcia
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Lisa Humphrey
- College of Medicine, Department of Pediatrics, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Hospice and Palliative Medicine, Nationwide Children's Hospital, Columbus, Ohio USA
| | - Nicole Cistone
- College of Nursing, Martha S. Pitzer Center for Women, Children, and Youth, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
| | - Emily L. Moscato
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Madelaine C. Keim
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - Leif D. Nelin
- College of Medicine, Department of Pediatrics, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio USA
| | - Cynthia A. Gerhardt
- College of Medicine, Department of Pediatrics, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- College of Medicine, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio USA
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16
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Barry A, Prentice T, Wilkinson D. End-of-life care over four decades in a quaternary neonatal intensive care unit. J Paediatr Child Health 2023; 59:341-345. [PMID: 36495233 PMCID: PMC10107744 DOI: 10.1111/jpc.16296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022]
Abstract
AIM Death in the neonatal intensive care unit (NICU) commonly follows a decision to withdraw or limit life-sustaining treatment. Advances in medicine have changed the nature of life-sustaining interventions available and the potential prognosis for many newborn conditions. We aimed to assess changes in causes of death and end-of-life care over nearly four decades. METHODS A retrospective review of infants dying in the NICU was performed (2017-2020) and compared with previous audits performed in the same centre (1985-1987 and 1999-2001). Diagnoses at death were recorded for each infant as well as their apparent prognosis and any withdrawal or limitations of medical treatment. RESULTS In the recent epoch, there were 88 deaths out of 2084 admissions (4.2%), a reduction from the previous epochs (132/1362 (9.7%) and 111/1776 (6.2%), respectively, for epochs 1 and 2). More than 90% of infants died after withdrawal of life-sustaining treatment, an increase from the previous two epochs (75%). There was a reduction in deaths from chromosomal abnormalities, complications related to prematurity and severe birth asphyxia. CONCLUSIONS There continue to be changes in both the diagnoses leading to death and approaches to withdrawal of treatment in the NICU. These may reflect ongoing changes in both prenatal and post-natal diagnostics as well as changing attitudes towards palliative care within the medical and wider community.
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Affiliation(s)
- Alexandra Barry
- Neonatal Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Trisha Prentice
- Neonatal Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Dominic Wilkinson
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, United Kingdom.,Newborn Care, John Radcliffe Hospital, Oxford, United Kingdom
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17
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Palliative Care in the Delivery Room: Challenges and Recommendations. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010015. [PMID: 36670565 PMCID: PMC9856529 DOI: 10.3390/children10010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
Palliative care in the delivery room is an interprofessional and interdisciplinary challenge addressing the dying newborn and parents as well as the caregivers. It differs in some significant aspects from palliative care in the neonatal intensive care unit. Clinical experience suggests that many details regarding this unique specialized palliative care environment are not well known, which may result in some degree of insecurity and emotional distress for health care providers. This article presents basic background information regarding the provision of palliative care to newborns within the delivery room. It offers orientation along with a preliminary set of practical recommendations regarding the following central issues: (i) the basic elements of perinatal palliative care, (ii) the range of non-pharmacological and pharmacological interventions available for infant symptom control near the end of life, (iii) meeting the personal psychological, emotional, and spiritual needs of the parents, and (iv) care and self-care for medical personnel.
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18
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Alexander D, Quirke MB, Berry J, Eustace-Cook J, Leroy P, Masterson K, Healy M, Brenner M. Initiating technology dependence to sustain a child's life: a systematic review of reasons. JOURNAL OF MEDICAL ETHICS 2022; 48:1068-1075. [PMID: 34282042 PMCID: PMC9726963 DOI: 10.1136/medethics-2020-107099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/13/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Decision-making in initiating life-sustaining health technology is complex and often conducted at time-critical junctures in clinical care. Many of these decisions have profound, often irreversible, consequences for the child and family, as well as potential benefits for functioning, health and quality of life. Yet little is known about what influences these decisions. A systematic review of reasoning identified the range of reasons clinicians give in the literature when initiating technology dependence in a child, and as a result helps determine the range of influences on these decisions. METHODS Medline, EMBASE, CINAHL, PsychINFO, Web of Science, ASSIA and Global Health Library databases were searched to identify all reasons given for the initiation of technology dependence in a child. Each reason was coded as a broad and narrow reason type, and whether it supported or rejected technology dependence. RESULTS 53 relevant papers were retained from 1604 publications, containing 116 broad reason types and 383 narrow reason types. These were grouped into broad thematic categories: clinical factors, quality of life factors, moral imperatives and duty and personal values; and whether they supported, rejected or described the initiation of technology dependence. The majority were conceptual or discussion papers, less than a third were empirical studies. Most discussed neonates and focused on end-of-life care. CONCLUSIONS There is a lack of empirical studies on this topic, scant knowledge about the experience of older children and their families in particular; and little written on choices made outside 'end-of-life' care. This review provides a sound basis for empirical research into the important influences on a child's potential technology dependence.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Mary Brigid Quirke
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Jay Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | | | - Piet Leroy
- Pediatric Intensive Care Unit & Pediatric Procedural Sedation Unit, Maastricht UMC+, Maastricht, The Netherlands
| | - Kate Masterson
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Martina Healy
- Paediatric Intensive Care, Our Lady's Hospital Crumlin, Crumlin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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19
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Janvier A, Barrington KJ. Delayed Withholding: Disguising Withdrawal of Life Sustaining Interventions in Extremely Preterm Infants. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:43-46. [PMID: 36332036 DOI: 10.1080/15265161.2022.2123986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Annie Janvier
- Université de Montréal
- CHU Sainte-Justine Research Center
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20
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Lin M, Deming R, Wolfe J, Cummings C. Infant mode of death in the neonatal intensive care unit: A systematic scoping review. J Perinatol 2022; 42:551-568. [PMID: 35058594 DOI: 10.1038/s41372-022-01319-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To characterize literature that describes infant mode of death and to clarify how limitation of life-sustaining treatment (LST) is defined and rationalized. STUDY DESIGN Eligible studies were peer-reviewed, English-language, and included number of infant deaths by mode out of all infant deaths in the NICU and/or delivery room. RESULT 58 included studies were primarily published in the last two decades from North American and European centers. There was variation in rates of infant mode of death by study, with some showing an increase in deaths following limitation of LST over time. Limitation of LST was defined by the intervention withheld/withdrawn, the relationship between the two practices, and prior frameworks. Themes for limiting LST included diagnoses, low predicted survival and/or quality of life, futility, and suffering. CONCLUSION Limitation of LST is a common infant mode of death, although rates, study definitions, and clinical rationale for this practice are variable.
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Affiliation(s)
- Matthew Lin
- Boston Children's Hospital, Division of Newborn Medicine, Boston, MA, USA.
| | - Rachel Deming
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Boston Children's Hospital, Boston, USA
| | - Joanne Wolfe
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Boston Children's Hospital, Boston, USA
| | - Christy Cummings
- Boston Children's Hospital, Division of Newborn Medicine, Boston, MA, USA
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21
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Dombrecht L, Beernaert K, Chambaere K, Cools F, Goossens L, Naulaers G, Cornette L, Laroche S, Theyskens C, Vandeputte C, Van de Broek H, Cohen J, Deliens L. End-of-life decisions in neonates and infants: a nationwide mortality follow-back survey. BMJ Support Palliat Care 2022:bmjspcare-2021-003357. [PMID: 35459686 DOI: 10.1136/bmjspcare-2021-003357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/12/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Neonatology has undergone important clinical and legal changes; however, the implications for end-of-life decision-making in seriously ill neonates to date are unknown. Our aim was to examine changes in prevalence and characteristics of end-of-life decisions (ELDs) in neonatology. METHODS We performed a nationwide mortality follow-back survey in August 1999 to July 2000 and September 2016 to December 2017 in Flanders, Belgium. Data were linked to information from death certificates. For each death under the age of 1, physicians were asked to complete an anonymous questionnaire about which ELDs were made preceding death. RESULTS The response rate was 87% in 1999-2000 (253/292) and 83% in 2016-2017 (229/276). The proportion of deaths of infants born before 26 weeks' gestation was increased (14% vs 34%, p=0.001). Prevalence of ELDs remained stable at 60%, with non-treatment decisions occurring in about 35% of all deaths. Use of medication with an explicit life-shortening intention was prevalent in 7%-10% of all deaths. In early neonatal death (<7 days old) medication with an explicit life-shortening intention decreased from 12% to 6%, in late neonatal death (7-27 days old), it increased from 0% to 26%, and in postneonatal death (>27 days old), it increased from 2% to 10%. CONCLUSIONS Over a timespan of 17 year, the prevalence of neonatal ELDs has remained stable. A substantial number of deaths was preceded by the intentionally hastening of death by administrating medication. While surveying solely the physician perspective in this paper, there is a need for an open multidisciplinary debate, including, for example, nursing staff and family members, based on clinical as well as ethical and jurisdictional reflections to discuss the need for international guidelines.
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Affiliation(s)
- Laure Dombrecht
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Brussel, Belgium
| | - Linde Goossens
- Department of Neonatology, University Hospital Ghent, Gent, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Luc Cornette
- Department of Neonatology, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | - Sabrina Laroche
- Department of Neonatology, University Hospital Antwerp, Edegem, Belgium
| | - Claire Theyskens
- Department of Neonatology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Christine Vandeputte
- Department of Neonatology, GZA Ziekenhuizen Campus Sint-Augustinus, Wilrijk, Belgium
| | - Hilde Van de Broek
- Department of Neonatology, ZNA Middelheim, Antwerpen, Antwerpen, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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22
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Abstract
This article explores the ethical concept of "the equivalence thesis" (ET), or the idea that withdrawing and withholding life sustaining treatments are morally equivalent practices, within neonatology. We review the historical origins, theory, and clinical rationale behind ET, and provide an analysis of how ET relates to literature that describes neonatal mode of death and healthcare professional and parent attitudes towards end-of-life care. While ET may serve as an ethical tool to optimize resource allocation in theory, its clinical utility is limited given the complexity of end-of-life care decisions.
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Affiliation(s)
- Matthew Lin
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
| | | | - Christy L Cummings
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Center for Bioethics, Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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23
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Personalized communication with parents of children born at less than 25 weeks: Moving from doctor-driven to parent-personalized discussions. Semin Perinatol 2022; 46:151551. [PMID: 34893335 DOI: 10.1016/j.semperi.2021.151551] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Communication with parents is an essential component of neonatal care. For extremely preterm infants born at less than 25 weeks, this process is complicated by the substantial risk of mortality or major morbidity. For some babies with specific prognostic factors, the majority die. Although many of these deaths occur after admission to the intensive care unit, position statements have focused on communication during the prenatal consultation. This review takes a more comprehensive approach and covers personalized and parent-centered communication in the clinical setting during three distinct yet inter-related phases: the antenatal consultation, the neonatal intensive care hospitalization, and the dying process (when this happens). We advocate that a 'one-size-fits-all' communication model focused on standardizing information does not lead to partnerships. It is possible to standardize personalized approaches that recognize and adapt to parental heterogeneity. This can help clinicians and parents build effective partnerships of trust and affective support to engage in personalized decision-making. These practices begin with self-reflection on the part of the clinician and continue with practical frameworks and stepwise approaches supporting personalization and parent-centered communication.
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Juul SE, Wood TR, Comstock BA, Perez K, Gogcu S, Puia-Dumitrescu M, Berkelhamer S, Heagerty PJ. Deaths in a Modern Cohort of Extremely Preterm Infants From the Preterm Erythropoietin Neuroprotection Trial. JAMA Netw Open 2022; 5:e2146404. [PMID: 35129596 PMCID: PMC8822378 DOI: 10.1001/jamanetworkopen.2021.46404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Understanding why and how extremely preterm infants die is important for practitioners caring for these infants. OBJECTIVE To examine risk factors, causes, timing, and circumstances of death in a modern cohort of extremely preterm infants. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort review of infants enrolled in the Preterm Erythropoietin Neuroprotection Trial between December 13, 2013, and September 26, 2016, was conducted. A total of 941 infants born between 24 0/7 and 27 6/7 weeks of gestation enrolled at 19 US sites comprising 30 neonatal intensive care units were included. Data analysis was performed from October 16, 2020, to December 1, 2021. MAIN OUTCOMES AND MEASURES Risk factors, proximal causes, timing, and circumstances of in-hospital death. RESULTS Of the 941 enrolled infants, 108 died (11%) before hospital discharge: 38% (n = 41) at 24 weeks' gestation, 30% (n = 32) at 25 weeks' gestation, 19% (n = 20) at 26 weeks' gestation, and 14% (n = 15) at 27 weeks' gestation. An additional 9 infants (1%) died following hospital discharge. In descending order, the primary causes of death included respiratory distress or failure, pulmonary hemorrhage, necrotizing enterocolitis, catastrophic intracranial hemorrhage, sepsis, and sudden unexplained death. Fifty percent of deaths occurred within the first 10 days after birth. The risk of death decreased with day of life and postmenstrual age such that an infant born at 24 weeks' gestation who survived 14 days had the same risk of death as an infant born at 27 weeks' gestation: conditional proportional risk of death, 0.08 (95% CI, 0.03-0.13) vs 0.06 (95% CI, 0.01-0.11). Preterm labor was associated with a decreased hazard of death (hazard ratio [HR], 0.45; 95% CI, 0.31-0.66). Infant clinical factors associated with death included birth weight below the tenth percentile for gestational age (HR, 2.11; 95% CI, 1.38-3.22), Apgar score less than 5 at 5 minutes (HR, 2.19; 95% CI, 1.48-3.24), sick appearance at birth (HR, 2.49; 95% CI, 1.69-3.67), grade 2b-3 necrotizing enterocolitis (HR, 7.41; 95% CI, 5.14-10.7), pulmonary hemorrhage (HR, 10.0; 95% CI, 6.76-18.8), severe intracranial hemorrhage (HR, 4.60; 95% CI, 3.24-5.63), and severe sepsis (HR, 4.93; 95% CI, 3.67-7.21). Fifty-one percent of the infants received comfort care before death. CONCLUSIONS AND RELEVANCE In this cohort study, an association between mortality and gestational age at birth was noted; however, for each week that an infant survived, their risk of subsequent death approximated the risk observed in infants born 1 to 2 weeks later, suggesting the importance of an infant's postmenstrual age. This information may be useful to include in counseling of families regarding prognosis of survival.
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Affiliation(s)
- Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | | | - Krystle Perez
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Semsa Gogcu
- Division of Neonatology, Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Sara Berkelhamer
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
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Caserío S, Arnaez J. Eligible neonatal donors after circulatory determination of death (Maastricht type III): A national survey of level III NICUs. Pediatr Transplant 2022; 26:e14129. [PMID: 34472170 DOI: 10.1111/petr.14129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Organ donation continues to increase worldwide, but in general paediatric patients remain less likely to receive a transplant. The inclusion of neonates as donors after cDCD should be considered in an effort to increase donation rates. METHODS The survey for a cross-sectional national study of potential cDCD neonatal donors (Maastricht type III) was sent to all 90 level III Spanish neonatal units to explore: 1) protocols, education, and specific opinions on donation and 2) potential cDCD that could have been eligible over a 2-year period (2014-2015). RESULTS Forty-five centers (50%) completed the survey, and 38/45 gave information about potential eligible donors. In 16% of the centers specific protocols on neonatal donation exist. All hospitals demanded more specific training, and 65% noted that the donation process could be a problem in the family's dismissal of the child. During the study period 46 805 neonates were admitted in the 38 centers, and 625 neonates died. Ninety-five born at a gestational age ≥34 weeks and above 2000 gr died after an EoL decision, 38 (40%) and 13 (14%) of them due to neonatal encephalopathy and multiple congenital anomalies, respectively. There were 31 (33%) elegible infants who died in less than 120 min due to pathologies that did not contraindicate donation. CONCLUSIONS Neonatal cDCD could help to reduce the gap between the supply of and demand for organs according to the potentially eligible patients emerging from this study. Training in EoL and donation processes should be provided to healthcare professionals.
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Affiliation(s)
- Sonia Caserío
- Neonatology, Hospital Universitario Rio Hortega de Valladolid, Valladolid, Spain.,NeNe Foundation, Madrid, Spain
| | - Juan Arnaez
- NeNe Foundation, Madrid, Spain.,Neonatology, Complejo Universitario de Burgos, Burgos, Spain
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Zhang WW, Yu YH, Dong XY, Reddy S. Treatment status of extremely premature infants with gestational age < 28 weeks in a Chinese perinatal center from 2010 to 2019. World J Pediatr 2022; 18:67-74. [PMID: 34767193 PMCID: PMC8761149 DOI: 10.1007/s12519-021-00481-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/28/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND There is a paucity of studies conducted in China on the outcomes of all live-birth extremely premature infants (EPIs) and there is no unified recommendation on the active treatment of the minimum gestational age in the field of perinatal medicine in China. We aimed to investigate the current treatment situation of EPIs and to provide evidence for formulating reasonable treatment recommendations. METHODS We established a real-world ambispective cohort study of all live births in delivery rooms with gestational age (GA) between 24+0 and 27+6 weeks from 2010 to 2019. RESULTS Of the 1163 EPIs included in our study, 241 (20.7%) survived, while 849 (73.0%) died in the delivery room and 73 (6.3%) died in the neonatal intensive care unit. Among all included EPIs, 862 (74.1%) died from withholding or withdrawal of care. Regardless of stratification according to GA or birth weight, the proportion of total mortality attributable to withdrawal of care is high. For infants with the GA of 24 weeks, active treatment did not extend their survival time (P = 0.224). The survival time without severe morbidity of the active treatment was significantly longer than that of withdrawing care for infants older than 25 weeks (P < 0.001). Over time, the survival rate improved, and the withdrawal of care caused by socioeconomic factors and primary nonintervention were reduced significantly (P < 0.001). CONCLUSIONS The mortality rate of EPIs is still high. Withdrawal of care is common for EPIs with smaller GA, especially in the delivery room. It is necessary to use a multi-center, large sample of real-world data to find the survival limit of active treatment based on our treatment capabilities.
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Affiliation(s)
- Wen-Wen Zhang
- grid.460018.b0000 0004 1769 9639Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021 China
| | - Yong-Hui Yu
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
| | - Xiao-Yu Dong
- grid.508193.6Department of Neonatology, Shandong Maternal and Child Health Hospital, Jinan, 250021 China
| | - Simmy Reddy
- grid.27255.370000 0004 1761 1174Cheeloo College of Medicine, Shandong University, Jinan, China
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Schouten ES, Beyer MF, Flemmer AW, de Vos MA, Kuehlmeyer K. Conversations About End-of-Life Decisions in Neonatology: Do Doctors and Parents Implement Shared Decision-Making? Front Pediatr 2022; 10:897014. [PMID: 35676897 PMCID: PMC9168986 DOI: 10.3389/fped.2022.897014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/20/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Advances in perinatal medicine have contributed to significantly improved survival of newborns. While some infants die despite extensive medical treatment, a larger proportion dies following medical decision-making (MDM). International guidelines about end-of-life (EOL) MDM for neonates unify in their recommendation for shared decision-making (SDM) between doctors and parents. Yet, we do not know to what extent SDM is realized in neonatal practice. OBJECTIVE We aim at examining to which extent SDM is implemented in the NICU setting. METHODS By means of Qualitative Content Analysis, audio-recorded conversations between neonatologists and parents were analyzed. We used a framework by de Vos that was used to analyze similar conversations on the PICU. RESULTS In total we analyzed 17 conversations with 23 parents of 12 NICU patients. SDM was adopted only to a small extent in neonatal EOL-MDM conversations. The extent of sharing decreased considerably over the stages of SDM. The neonatologists suggested finding a decision together with parents, while at the same time seeking parents' agreement for the intended decision to forgo life-sustaining treatment. CONCLUSIONS Since SDM was only realized to a small extent in the NICU under study, we propose evaluating how parents in this unit experience the EOL-MDM process and whether they feel their involvement in the process acceptable and beneficial. If parents evaluate their involvement in the current approach beneficial, the need for implementation of SDM to the full extent, as suggested in the guidelines, may need to be critically re-assessed.
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Affiliation(s)
- Esther S Schouten
- Division of Neonatology, LMU University Children's Hospital, Dr. v. Hauner, Munich, Germany
| | - Maria F Beyer
- Division of Neonatology, LMU University Children's Hospital, Dr. v. Hauner, Munich, Germany
| | - Andreas W Flemmer
- Division of Neonatology, LMU University Children's Hospital, Dr. v. Hauner, Munich, Germany
| | - Mirjam A de Vos
- Department of Paediatrics, Emma Children's Hospital, Amsterdam University Medical Centre, Amsterdam, Netherlands
| | - Katja Kuehlmeyer
- Institute of Ethics, History and Theory of Medicine, Medical Faculty, LMU Munich, Munich, Germany
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Alexander D, Eustace-Cook J, Brenner M. Approaches to the initiation of life-sustaining technology in children: A scoping review of changes over time. J Child Health Care 2021; 25:509-522. [PMID: 32966106 DOI: 10.1177/1367493520961884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is understood about the dynamic circumstances within which the initiation of technology dependence takes place in children. The aim of this scoping review was to identify the influences on the initiation of technology dependence and the issues that require further exploration and consideration. Scientific literature that directly or indirectly discussed the initiation of technology dependence in children was identified. A three-stage screening process of title and abstract scrutiny, full-text scanning and in-depth full-text reading resulted in 63 relevant articles from 1133 initially reviewed. These were then subjected to descriptive and thematic analysis. Articles ranged from the 1970s to the present, reflecting the evolution of ethical debates around the approaches to clinical practice and changes in cultural and societal attitudes. Three themes emerged: how technology alters the meaning of futile care, dissonance in the perspectives of decision makers and increasing support for joint decision-making. Only articles in English and predominantly from the clinician's rather than the patient's perspective were included. Societal and cultural factors as well as the structural, financial and cultural environment influence the initiation of technology dependence in children. However, to what extent these overt and implicit influences guide decision-makers in this field remains largely unknown.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, 8809Trinity College Dublin, Ireland
| | | | - Maria Brenner
- School of Nursing and Midwifery, 8809Trinity College Dublin, Ireland
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29
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Inter-center variation in autopsy practices among regional neonatal intensive care units (NICUs). J Perinatol 2021; 41:2820-2825. [PMID: 34983934 DOI: 10.1038/s41372-021-01286-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/11/2021] [Accepted: 11/24/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To characterize infants who underwent autopsy in regional neonatal intensive care units (NICUs) and examine inter-center variability in autopsy completion. STUDY DESIGN Retrospective cohort study of infants who died between 2010 and 2016 from 32 participating hospitals in the Children's Hospital Neonatal Database (CHND). Maternal/infant demographics and hospital stay data were collected, along with autopsy rates by center, year, and region. Data analysis utilized bivariate and multivariable statistics. RESULT Of 6299 deaths, 1742 (27.7%) completed autopsy. Infants who underwent autopsy had higher median birth weight (2 124 g vs. 1 655 g) and gestational age (34 vs. 32 weeks). No differences were seen in sex, length of stay, or primary cause of death. Marked inter-center variability was observed, with 17-fold adjusted difference (p < 0.001) in autopsy rates. CONCLUSION Patient characteristics do not account for variability in autopsy practices across regional NICUs. Factors such as provider practices and parental preferences should be investigated.
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30
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Assaad M, Lapointe A, Thivierge É, Janvier A. Mortality and Morbidity rounds in neonatology: Providers' experiences and perspectives. Acta Paediatr 2021; 110:2737-2744. [PMID: 34133791 DOI: 10.1111/apa.15986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/28/2021] [Accepted: 06/15/2021] [Indexed: 11/27/2022]
Abstract
AIM To describe how Canadian level III neonatal intensive care units (NICU) organise mortality and morbidity rounds (M&MR) and explore clinicians' perspectives. METHODS This questionnaire study, including open-ended questions, examined the following domains: (1) M&MR format, (2) ethical issues and (3) limitations and perceived effectiveness. RESULTS Sixteen out of twenty (80%) level III NICUs participated. All deaths and 64% of morbidities were discussed. M&MR occurred monthly (69%) with 3-5 patients discussed hourly (63%) and usually (75%) physician led. Wide variations of practice between centres existed for practical issues, such as administrative support and attendance. 44% of centres allowed nurses to participate. Goals reported by participants were also heterogeneous: reducing medical error (56%), educational (50%), improving communication (44%) and peer review (23%). Practical barriers were time (75%) and lack of resources/structure (25%). Four main themes were as follows: the role of M&MR, the ongoing blame culture, communication issues and the distinction between mortality and morbidity. CONCLUSION Goals and format of M&MR vary widely. M&MR remains physician-centric, where the blame culture still endures. Neonatal M&MR models should be adapted to the modern NICU to ensure the M&MR stays relevant. It could also benefit from lessons learned in quality improvement.
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Affiliation(s)
- Michael‐Andrew Assaad
- Department of Paediatrics Division of Neonatology Sainte‐Justine HospitalUniversity of Montreal Montreal QC Canada
| | - Anie Lapointe
- Department of Paediatrics Division of Neonatology Sainte‐Justine HospitalUniversity of Montreal Montreal QC Canada
| | - Émilie Thivierge
- Department of Paediatrics Sainte‐Justine HospitalUniversity of Montreal Montreal QC Canada
| | - Annie Janvier
- Department of Paediatrics Division of Neonatology Sainte‐Justine HospitalUniversity of Montreal Montreal QC Canada
- Clinical Ethics Unit, Palliative Care Unit, Research Centre and Unité de Recherche en Éthique Clinique et Partenariat Famille Sainte‐Justine Hospital Montreal QC Canada
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31
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Dame C, von der Hude K, Kliemann M, Rösner B, Bührer C, Garten L. [... because We Should not Forget! Neonatal Organ Donation]. Z Geburtshilfe Neonatol 2021; 225:366-370. [PMID: 34384134 DOI: 10.1055/a-1509-3688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Obwohl sich fast 40% aller Todesfälle im Kindes- und Jugendalter während der Neugeborenenperiode ereignen, kommt es in der Neonatologie nur selten zur Organspende. Wir berichten über ein Neugeborenes, bei dem nach perinataler Asphyxie der endgültige, nicht behebbare Ausfall der Gesamtfunktion des Großhirns, des Kleinhirns und des Hirnstamms ("Hirntod") gemäß Transplantationsgesetz diagnostiziert wurde. Das Herz wurde nach der sogenannten zweiten richtliniengemäßen "Hirntoddiagnostik" zur Organspende entnommen und erfolgreich transplantiert. Besondere juristische Herausforderungen ergaben sich aus dem Umstand der anonymen Geburt, den notwendigen Regelungen der Vormundschaft sowie der Zuordnung des Totenfürsorgerechts. Medizinisch standen die speziellen Regelungen der Diagnostik des irreversiblen Hirnfunktionsausfalls bei Neugeborenen und der optimale Erhalt der Organfunktion vor Entnahme im Vordergrund. Für die Pflegenden stellte sich der Ablauf grundlegend anders dar als bei einer Therapiezieländerung mit anschließender palliativen Versorgung in Anwesenheit der Eltern. Angesichts der großen emotionalen Herausforderungen erwiesen sich die Einbindung aller Beteiligten in die Entscheidungsabläufe und die Übernahme der besonderen Verantwortung als hilfreich.Although almost 40% of all deaths prior to 18 years of age occur within the neonatal period, organ donation is rare in neonatology. Herein we report about a newborn infant with perinatal asphyxia and permanent, irreversible loss of brain function (cerebrum, cerebellum and brain stem), managed according to the criteria and instructions defined by the German law of donor organ transplantation. After confirmation of irreversible loss of brain function, the heart was successfully transplanted. Specific legal challenges resulted from the instance of an anonymous birth, the guardianship required, and the specific regulations of welfare of the deceased individual. The most prominent medical challenges consisted in the specific regulatory purposes for the diagnosis of the irreversible loss of brain function in neonates and the optimal maintenance of organ functions prior to donation. From the nursing point of view, the proceeding differed entirely compared to redirection of care into palliation while parents are present. Involving all stakeholders in every step of decision making was regarded as emotionally helpful.
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Affiliation(s)
- Christof Dame
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Kerstin von der Hude
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Markus Kliemann
- Region Nord-Ost, Deutsche Stiftung Organtransplantation, Frankfurt, Deutschland
| | - Bianka Rösner
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Christoph Bührer
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Lars Garten
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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32
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Prentice TM, Janvier A, Gillam L, Donath S, Davis PG. Moral Distress in Neonatology. Pediatrics 2021; 148:peds.2020-031864. [PMID: 34285081 DOI: 10.1542/peds.2020-031864] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To longitudinally examine the nature of moral distress (MoD) experienced by clinicians caring for extremely low gestational age neonates. METHODS Neonatologists, medical trainees, and nurses were surveyed at regular intervals on their experience of MoD and their preferred level of care in relation to 99 neonates born <28 weeks' gestational age managed from birth until discharge or death in 2 tertiary NICUs. Clinicians reporting significant distress (≥6 of 10 on Wocial's Moral Distress Thermometer) were asked to provide open-ended responses on why they experienced MoD. Descriptive statistics were used to analyze frequency and intensity of MoD across different clinician characteristics. Open-ended responses were analyzed by using mixed methods. RESULTS Over 18 months, 4593 of 5332 surveys (86% response rate) were collected. MoD was reported on 687 (15%) survey occasions; 91% of neonates elicited MoD during their hospitalization. In their open-ended answers, clinicians invoked 5 main themes to explain their distress: (1) infant-centered reasons (83%), including illness severity, predicted outcomes, and disproportionate care; (2) management plans (26%); (3) family-centered reasons (19%); (4) parental decision-making (16%); and (5) provider-centered reasons (15%). MoD was strongly associated with the perception of "parents wanting too much." Neonatologists experienced less distress and were more likely than nurses and trainees to align preferred levels of care with family wishes. CONCLUSIONS The majority of preterm infants will generate some MoD; however, it is rarely shared and of a sustained nature. The main constraint reported by clinicians was "parents wanting too much," leading to disproportionate care.
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Affiliation(s)
- Trisha M Prentice
- Department of Neonatal Medicine .,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Departments of Paediatrics
| | - Annie Janvier
- Clinical Ethics and Palliative Care Units, Unité de Recherche en Éthique Clinique et Partenariat Famille, Division of Neonatology, Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada.,Department of Pediatrics and Clinical Ethics, Université de Montréal, Montreal, Quebec, Canada
| | - Lynn Gillam
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Departments of Paediatrics
| | - Peter G Davis
- Newborn Research, Royal Women's Hospital, Melbourne, Victoria, Australia.,Obstetrics and Gynaecology, Melbourne Medical School
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33
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McCauley KE, Carey EC, Weaver AL, Mara KC, Clark RH, Carey WA, Collura CA. Survival of Ventilated Extremely Premature Neonates With Severe Intraventricular Hemorrhage. Pediatrics 2021; 147:e20201584. [PMID: 33727247 PMCID: PMC8015160 DOI: 10.1542/peds.2020-1584] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Severe intraventricular hemorrhage (IVH) is a leading mortality risk factor among extremely premature neonates. Because other life-threatening conditions also occur in this population, it is unclear whether severe IVH is independently associated with death. The existence and potential implications of regional variation in severe IVH-associated mortality are unknown. METHODS We performed a retrospective cohort study of mechanically ventilated neonates born at 22 to 29 weeks' gestation who received care in 242 American NICUs between 2000 and 2014. After building groups composed of propensity score-matched and center-matched pairs, we used the Cox proportional hazards analysis to test our hypothesis that severe IVH would be associated with greater all-cause in-hospital mortality, defined as death before transfer or discharge. We also performed propensity score-matched subgroup analyses, comparing severe IVH-associated mortality among 4 geographic regions of the United States. RESULTS In our analysis cohort, we identified 4679 patients with severe IVH. Among 2848 matched pairs, those with severe IVH were more likely to die compared with those without severe IVH (hazard ratio 2.79; 95% confidence interval 2.49-3.11). Among 1527 matched pairs still hospitalized at 30 days, severe IVH was associated with greater risk of death (hazard ratio 2.03; 95% confidence interval 1.47-2.80). Mortality associated with severe IVH varied substantially between geographic regions. CONCLUSIONS The early diagnosis of severe IVH is independently associated with all-cause in-hospital mortality in extremely premature neonates. Regional variation in severe IVH-associated mortality suggests that shared decision-making between parents and neonatologists is strongly influenced by ultrasound-based IVH assessment and classification.
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Affiliation(s)
| | | | - Amy L Weaver
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Kristin C Mara
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota; and
| | - Reese H Clark
- Center for Research, Education and Quality, Pediatrix Medical Group, Sunrise, Florida
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34
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Akyempon AN, Aladangady N. Neonatal and perinatal palliative care pathway: a tertiary neonatal unit approach. BMJ Paediatr Open 2021; 5:e000820. [PMID: 33537461 PMCID: PMC7852922 DOI: 10.1136/bmjpo-2020-000820] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/24/2020] [Accepted: 12/14/2020] [Indexed: 12/27/2022] Open
Abstract
A lack of well-structured guideline or care pathway results in inadequate, inconsistent and fragmented palliative care (PC) for babies and their families. The impact on the families could be emotionally and psychologically distressing. Not all neonatal units have specialist PC clinicians or teams, and such units will benefit from a well-planned perinatal PC pathway. In this article, we discuss a tertiary neonatal unit perinatal care pathway which provides guidance from the point of diagnosis and establishment of eligibility of a baby for PC through to care after death and bereavement support for families. Planning PC with families which encourages family-centred and individualised approach is also discussed.
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Affiliation(s)
- Abena N Akyempon
- Neonatology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Narendra Aladangady
- Neonatology, Homerton University Hospital NHS Foundation Trust, London, UK.,Pediatrics, Centre for Paediatrics, Bart's and the London School of Medicine and Dentistry, London, UK
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35
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Lemmon ME, Bonifacio SL, Shellhaas RA, Wusthoff CJ, Greenberg RG, Soul JS, Chang T, Chu CJ, Bates S, Massey SL, Abend NS, Cilio MR, Glass HC. Characterization of Death in Infants With Neonatal Seizures. Pediatr Neurol 2020; 113:21-25. [PMID: 32980743 PMCID: PMC7669564 DOI: 10.1016/j.pediatrneurol.2020.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/15/2020] [Accepted: 08/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neonatal seizures are associated with death and neurological morbidity; however, little is known about how neonates with seizures die. METHODS This was a prospective, observational cohort study of neonates with seizures treated at seven sites of the Neonatal Seizure Registry. We characterized the mode of death, evaluated the association between infant characteristics and mode of death, and evaluated predictors of death or transfer to hospice. RESULTS We enrolled 611 consecutive neonates with seizures, and 90 neonates (15%) died before hospital discharge at a median age of 11 days (range: 1 to 163 days); 32 (36%) died in the first postnatal week. An additional 19 neonates (3%) were transferred to hospice. The most common mode of in-hospital death was death after extubation amidst concerns for poor neurological prognosis, in the absence of life-threatening physiologic instability (n = 43, 48%). Only one infant died while actively receiving cardiopulmonary resuscitation. In an adjusted analysis, premature birth (odds ratio: 3.06, 95% confidence interval 1.59 to 5.90) and high seizure burden (odds ratio: 4.33, 95% confidence interval 1.88 to 9.95) were associated with increased odds of death or transfer to hospice. CONCLUSION In a cohort of neonates with seizures, death occurred predominantly after decisions to withdraw or withhold life-sustaining intervention(s). Future work should characterize how these decisions occur and develop optimized approaches to support families and clinicians caring for newborns with seizures.
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Affiliation(s)
- Monica E. Lemmon
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Dr, Durham, NC 27710, United States
| | - Sonia L. Bonifacio
- Departments of Pediatrics, Stanford University, 291 Campus Dr, Palo Alto, CA 94305, United States
| | - Renée A. Shellhaas
- Department of Pediatrics, University of Michigan, 1540 E Hospital Dr, Ann Arbor, MI 48109, United States
| | - Courtney J. Wusthoff
- Departments of Pediatrics, Stanford University, 291 Campus Dr, Palo Alto, CA 94305, United States;,Departments of Neurology, Stanford University, 291 Campus Dr, Palo Alto, CA 94305, United States
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Dr, Durham, NC 27710, United States;,Duke Clinical Research Institute, 301 W Morgan St, Durham, NC 27701, United States
| | - Janet S. Soul
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, United States
| | - Taeun Chang
- Department of Neurology, Children’s National Hospital, George Washington University School of Medicine, 111 Michigan Ave NW, Washington, DC 20010, United States
| | - Catherine J. Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02115, United States
| | - Sara Bates
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02115, United States
| | - Shavonne L. Massey
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA 19104 United States
| | - Nicholas S. Abend
- Departments of Neurology and Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA 19104 United States;,Department of Anesthesia & Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104 United States
| | - M. Roberta Cilio
- Department of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Hannah C. Glass
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California San Francisco, 1975 4th St, San Francisco, CA 94158, United States;,Department of Epidemiology & Biostatistics; University of California San Francisco, 1701 Divisadero St, San Francisco, CA 94115, United States;,Department of Neurology; UCSF Benioff Children’s Hospital, University of California San Francisco, 1975 4th St, San Francisco, CA 94158, United States
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Chatziioannidis I, Iliodromiti Z, Boutsikou T, Pouliakis A, Giougi E, Sokou R, Vidalis T, Xanthos T, Marina C, Iacovidou N. Physicians' attitudes in relation to end-of-life decisions in Neonatal Intensive Care Units: a national multicenter survey. BMC Med Ethics 2020; 21:121. [PMID: 33225943 PMCID: PMC7681959 DOI: 10.1186/s12910-020-00555-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND End-of-life decisions for neonates with adverse prognosis are controversial and raise ethical and legal issues. In Greece, data on physicians' profiles, motivation, values and attitudes underlying such decisions and the correlation with their background are scarce. The aim was to investigate neonatologists' attitudes in Neonatal Intensive Care Units and correlate them with self-reported practices of end-of-life decisions and with their background data. METHODS A structured questionnaire was distributed to all 28 Neonatal Intensive Care Units in Greece. One hundred and sixty two out of 260 eligible physicians answered anonymously the questionnaire (response rate 66%). Demographic and professional characteristics, self-reported practices and opinions were included in the questionnaire, along with a questionnaire of 12 items measuring physicians' attitude and views ranging from value of life to quality of life approach (scale 1-5). RESULTS Continuation of treatment in neonates with adverse prognosis without adding further therapeutic interventions was the most commonly reported EoL practice, when compared to withdrawal of mechanical ventilation. Physicians with a high attitude score (indicative of value of quality-of-life) were more likely to limit, while those with a low score (indicative of value of sanctity-of-life) were more likely for continuation of intensive care. Physicians' educational level (p:0.097), involvement in research (p:0.093), religion (p:0.024) and position on the existing legal framework (p < 0.001) were factors that affected the attitude score. CONCLUSIONS Physicians presented with varying end-of-life practices. Limiting interventions in neonates with poor prognosis was strongly related to their attitudes. The most important predictors for physicians' attitudes were religiousness and belief for Greek legal system reform.
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Affiliation(s)
- Ilias Chatziioannidis
- 2nd Neonatal Department and Neonatal Intensive Care Unit, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece.
| | - Zoi Iliodromiti
- Neonatal Department, School of Medicine, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, School of Medicine, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Abraham Pouliakis
- 2nd Department of Pathology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Rozeta Sokou
- Neonatal Department, School of Medicine, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Takis Vidalis
- Hellenic National Bioethics Commission, Athens, Greece
| | | | - Cuttini Marina
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicoletta Iacovidou
- Neonatal Department, School of Medicine, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Al Amrani F, Racine E, Shevell M, Wintermark P. Death after Birth Asphyxia in the Cooling Era. J Pediatr 2020; 226:289-293. [PMID: 32682749 DOI: 10.1016/j.jpeds.2020.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 11/19/2022]
Abstract
In asphyxiated newborn infants treated with hypothermia, 31 of 50 (62%) deaths occurred in unstable infants electively extubated before completing hypothermia treatment. Later deaths occurred after consultation with palliative care (13/19) or clinical ethics (6/19) services, suggesting these decisions were challenging and required support, particularly if nutrition and hydration were withdrawn (n = 4).
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Affiliation(s)
- Fatema Al Amrani
- Division of Pediatric Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Eric Racine
- Department of Medicine and Social and Preventive Medicine, University of Montreal, Montreal, Canada; Department of Neurology and Neurosurgery and Medicine, and Biomedical Ethics Unit, McGill University, Montreal, Canada
| | - Michael Shevell
- Division of Pediatric Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Pia Wintermark
- Division of Newborn Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Canada.
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Bourque CJ, Dahan S, Mantha G, Reichherzer M, Janvier A. My child's legacy: a mixed methods study of bereaved parents and providers' opinions about collaboration with NICU teams in quality improvement initiatives. BMJ Open 2020; 10:e034817. [PMID: 32895262 PMCID: PMC7476470 DOI: 10.1136/bmjopen-2019-034817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 05/22/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Although stakeholders' participation in healthcare is increasingly recommended, bereaved parents are often excluded for perceived potential risks to them. The objective of this study is to describe the ongoing involvement and the perspectives of bereaved parents engaged in different types of activities in Neonatal Intensive Care Units and providers who work with them. DESIGN/METHODS Mixed methods convergent analysis. SETTING Canadian paediatric tertiary care university hospital. PARTICIPANTS All bereaved members of the resource parents group (n=8) and most providers who work with them (n=16) answered a satisfaction/needs questionnaires. RESULTS Since 2011, eight bereaved parents were involved in a large number of activities mostly related to palliative care (research, education or clinical care initiatives). Three engaged in peer-to-peer support activities while the others preferred activities outside of clinical units and/or without direct interactions with other families. All of them reported that their participation had positive impacts, but two parents also reported a reactivation of traumatic experiences during a medical simulation activity. All participants expressed a desire for further collaboration. Motivation to contribute gravitated around two central themes: helping others and helping themselves. Many wanted to give back, help other families, improve the system and meet with providers who had cared for their child. All stated that this kind of involvement empowered them and gave meaning to their experiences. Providers and researchers all reported positive experiences, mainly due to the unique perspectives of bereaved parents who took part in their projects. CONCLUSIONS With careful recruitment and supervision, some bereaved parents can become resource parents involved in different types of activities. It is important to understand the positive impacts this type of engagement can have on their healing process and to control the risks related to their participation. Research is needed to develop pertinent tools and measures to evaluate the outcomes and impacts of their participation.
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Affiliation(s)
- Claude Julie Bourque
- CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Quebec, Canada
- Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Sonia Dahan
- Pediatrics, Université de Montréal, Montreal, Quebec, Canada
- Division of Neonatology, CHU Sainte-Justine, Montréal, Quebec, Canada
| | | | | | - Annie Janvier
- CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Quebec, Canada
- Pediatrics, Université de Montréal, Montreal, Quebec, Canada
- Division of Neonatology, CHU Sainte-Justine, Montréal, Quebec, Canada
- Québec Research Network on Palliative and End-of-Life Care, RQSPAL, Montréal, Québec, Canada
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Chen SJ, Lee YS, Tsao PC, Wang C, Chou CS, Jeng MJ. Neonatal hospice care utilization in a tertiary hospital in Taiwan before and after the legalization of life-sustaining treatment withdrawal. J Chin Med Assoc 2020; 83:774-778. [PMID: 32433346 DOI: 10.1097/jcma.0000000000000346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The advancements in neonatal critical care have not only improved the outcomes of extreme prematurity but also prolonged the process of death in terminally ill neonates. This study analyzed the characteristics of neonates who died at a single tertiary center in Taiwan. The utilization of neonatal hospice care before and after the legalization of life-sustaining treatment (LST) withdrawal in Taiwan in 2013 was also compared. METHODS This study enrolled the neonatal mortality cases in the Taipei Veterans General Hospital during January 2008 to December 2017 through chart review. Data on birth history, primary diagnosis, complications, and death circumstances were recorded and analyzed. RESULTS In total, 105 neonatal deaths were analyzed. The circumstances of death were as follows: 22 (21%) cases of full LST and cardiopulmonary resuscitation (CPR) performed until death; 63 (60%) cases of LST initiated but no more CPR after do-not-resuscitate (DNR) consents signed; 8 (7.6%) cases of LST withdrawn; 4 (3.8%) cases of DNR signed without LST initiation; 3 (2.9%) cases of CPR not performed, although no DNR signed; and 5 (4.8%) cases of discharge against medical advice under critical condition. The incidence of written DNR consents (57.9% in 2008-2009 vs 93.8% in 2016-2017; p = 0.02) showed an increasing trend. Regarding the incidence of comorbidities, renal failure rate was higher in the DNR group than in the non-DNR group (p = 0.002). CONCLUSION There was an increasing trend for written DNR consent and the utilization of neonatal hospice care. Renal failure, as a comorbidity, was significantly associated with the written DNR consent in the neonates. Further studies to evaluate the factors associated with neonatal hospice care utilization are suggested.
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Affiliation(s)
- Szu-Jung Chen
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Hsinchu Branch, Hsinchu, Taiwan, ROC
| | - Yu-Sheng Lee
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Pei-Chen Tsao
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
| | - Chi Wang
- Department of Nursing, Taipei Veteran General Hospital, Taipei, Taiwan, ROC
| | - Chia-Sui Chou
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
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Aghion A, Hussey-Gardner B, Davis NL, Falck AJ. Patient and provider factors impacting referral for neonatal organ donation. Pediatr Transplant 2020; 24:e13744. [PMID: 32478967 DOI: 10.1111/petr.13744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/28/2020] [Accepted: 03/05/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND As determination of brain death is infrequent in neonates, the AAP endorses donation after circulatory determination of death as an acceptable alternative. Despite this recommendation, neonatal organ donation is infrequent. Timely referral to OPOs is a vital first step in the organ donation process. The aim of this study was to identify patient and provider factors impacting timely referral for neonatal organ donation. METHODS Medical records were reviewed for deaths occurring in a Level IV NICU from 2007 to 2017. Clinical and demographic factors, provider type, timing of OPO referral (before or after death), and outcome were assessed. Bivariate and multivariable logistic regression models were utilized to identify predictors of OPO referral characteristics. RESULTS Between 2007 and 2017, 329 deaths occurred in the NICU or delivery room. Of the 265 infants meeting inclusion criteria, 96% had late referrals (after death) and were declined for organ donation. Frequency of timely referrals (before death) improved when OPO contact was by an attending neonatologist, when withdrawal of life support was planned, and with increasing birthweight, gestational age, and PMA. Factors associated with decreased OPO referral included male sex, lower weight at death, earlier PMA, and deaths occurring while receiving maximal intensive care support. No organs or tissues were donated. CONCLUSIONS This study is the first to report NICU referral patterns for organ donation. We found that timely provider referral of neonates to the OPO was rare. Exploration of provider knowledge will guide future educational interventions aimed to improve the referral process.
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Affiliation(s)
- Abigail Aghion
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brenda Hussey-Gardner
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie L Davis
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alison J Falck
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
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Bioethical Decisions in Neonatal Intensive Care: Neonatologists' Self-Reported Practices in Greek NICUs. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17103465. [PMID: 32429230 PMCID: PMC7277706 DOI: 10.3390/ijerph17103465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 01/27/2023]
Abstract
This study presents, for the first time, empirical data on practices regarding bioethical decision-making in treatment of preterm and ill newborns in Greece. The aim of the study was to: (a) record self-reported practices and involvement of Greek physicians in decisions of withholding and withdrawing neonatal intensive care, and (b) explore the implication of cultural, ethical, and professional parameters in decision-making. Methods: 71 physicians, employed fulltime in all public Neonatal Intensive Care Units (NICUs) (n = 17) in Greece, completed an anonymous questionnaire between May 2009 and May 2011. Results: One-third of the physicians in our sample admitted that they have, at least once in the past, decided the limitation of intensive care of a newborn close to death (37.7%) and/or a newborn with unfavorable neurological prognosis (30.8%). The higher the physicians’ support towards the value of quality of human life, the more probable it was that they had taken a decision to withhold or withdraw neonatal intensive care (p < 0.05). Conclusions: Our research shows that Greek NICU physicians report considerably lower levels of ethical decision-making regarding preterm and ill newborns compared to their counterparts in other European countries. Clinical practices and attitudes towards ethical decision-making appear to be influenced mainly by the Greek physicians’ values.
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Comparison of End-of-Life Care Practices Between Children With Complex Chronic Conditions and Neonates Dying in an ICU Versus Non-ICUs: A Substudy of the Pediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) Project. Pediatr Crit Care Med 2020; 21:e236-e246. [PMID: 32091504 DOI: 10.1097/pcc.0000000000002259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe and compare characteristics of care provided at the end of life for children with chronic complex conditions and neonates who died in an ICU with those who died outside an ICU. DESIGN Substudy of a nation-wide retrospective chart review. SETTING Thirteen hospitals, including 14 pediatric and neonatal ICUs, two long-term institutions, and 10 community-based organizations in the three language regions of Switzerland. PATIENTS One hundred forty-nine children (0-18 yr) who died in the years 2011 or 2012. Causes of death were related to cardiac, neurologic, oncological, or neonatal conditions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and clinical characteristics, therapeutic procedures, circumstances of death, and patterns of decisional processes were extracted from the medical charts. Ninety-three (62%) neonates (median age, 4 d) and children (median age, 23 mo) died in ICU, and 56 (38%) with a median age of 63 months outside ICU. Generally, ICU patients had more therapeutic and invasive procedures, compared with non-ICU patients. Changes in treatment plan in the last 4 weeks of life, such as do-not-resuscitate orders occurred in 40% of ICU patients and 25% of non-ICU patients (p < 0.001). In the ICU, when decision to withdraw life-sustaining treatment was made, time to death in children and newborns was 4:25 and 3:00, respectively. In institutions where it was available, involvement of specialized pediatric palliative care services was recorded in 15 ICU patients (43%) and in 18 non-ICU patients (78%) (p = 0.008). CONCLUSIONS This nation-wide study demonstrated that patients with a complex chronic condition who die in ICU, compared with those who die outside ICU, are characterized by fast changing care situations, including when to withdraw life-sustaining treatment. This highlights the importance of early effective communication and shared decision making among clinicians and families.
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Silberberg A, Herich LC, Croci I, Cuttini M, Villar MJ, Requena Meana P. Limitation of life-sustaining treatment in NICU: Physicians' beliefs and attitudes in the Buenos Aires region. Early Hum Dev 2020; 142:104955. [PMID: 32006786 DOI: 10.1016/j.earlhumdev.2020.104955] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To explore the ethical beliefs and attitudes of Argentinean neonatologists regarding limitation of life-sustaining treatment (LST) for very sick infants. METHODS We used an anonymous questionnaire including direct questions and hypothetical clinical cases (inevitable demise and anticipated survival with severe long-term disability). Multivariable analysis was carried out to assess the relation between type of clinical case and physicians' LST attitudes. RESULTS Overall, 315 neonatologists in 34 units in the Buenos Aires region participated (response rate 54%). Most responders would agree with decisions to start or continue LST. In both clinical cases, continuing current treatment with no therapeutic escalation was the only form of LST limitation acceptable to a substantial proportion (about 60%) of neonatologists. Agreement with LST limitation was slightly but significantly more likely when death was inevitable. CONCLUSION Argentinean neonatologists showed a conservative attitude regarding LST limitation. Patient prognosis and options of non-treatment decision significantly influenced their choices.
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Affiliation(s)
- Agustín Silberberg
- Department of Bioethics, Hospital Universitario Austral and Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina.
| | - Lena Carolin Herich
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Ileana Croci
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Marcelo José Villar
- Institute of Translational Research, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina.
| | - Pablo Requena Meana
- Department of Moral Theology, Pontificia Università della Santa Croce, Rome, Italy.
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Yotani N, Nabetani M, Feudtner C, Honda J, Kizawa Y, Iijima K. Withholding and withdrawal of life-sustaining treatments for neonate in Japan: Are hospital practices associated with physicians' beliefs, practices, or perceived barriers? Early Hum Dev 2020; 141:104931. [PMID: 31810052 DOI: 10.1016/j.earlhumdev.2019.104931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the current status of withholding or withdrawal of life-sustaining interventions (LSI) for neonates in Japan and to identify physician- and institutional-related factors that may affect advance care planning (ACP) practices with parents. STUDY DESIGN A self-reported questionnaire was administered to assess frequency of withholding and withdrawing intensive care at the respondent's facility, the physician's degree of affirming various beliefs about end-of-life care that was compared to 7 European countries, their self-reported ACP practices and perceived barriers to ACP. Three neonatologists at all 298 facilities accredited by the Japan Society for Neonatal Health and Development were surveyed, with 572 neonatologists at 217 facilities responding. RESULTS At 76% of facilities, withdrawing intensive care treatments was "never" done, while withholding intensive care had been done "sometimes" or more frequently at 82% of facilities. Japanese neonatologists differed from European neonatologists regarding their degree of affirmation of 3 out of 7 queried beliefs about end-of-life care. In hospitals that were more likely to "sometimes" (or more often) withdraw treatments, respondents were less likely to affirm beliefs about doing "everything possible" or providing the "maximum of intensive care". Self-reported ACP practices did not vary between neonatologists based on their hospital's overall pattern of withholding or withdrawing treatments. CONCLUSION Among NICU facilities in Japan, 21% had been sometimes withdrawing LSI and 82% had been "sometimes" withholding LSI. Institutional treatment practices may have a strong association with physicians' beliefs that then affect end-of-life discussions, but not with self-reported ACP practices.
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Affiliation(s)
- Nobuyuki Yotani
- Department of Palliative Medicine, National Centre for Child Health and Development, Tokyo, Japan.
| | | | - Chris Feudtner
- Department Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Junko Honda
- College of Nursing Art and Science, University of Hyogo, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Lizotte MH, Barrington KJ, Sultan S, Pennaforte T, Moussa A, Lachance C, Sureau M, Zao Y, Janvier A. Techniques to Communicate Better With Parents During End-of-Life Scenarios in Neonatology. Pediatrics 2020; 145:peds.2019-1925. [PMID: 31988171 DOI: 10.1542/peds.2019-1925] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Clinicians are urged to optimize communication with families, generally without empirical practical recommendations. The objective of this study was to identify core behaviors associated with good communication during and after an unsuccessful resuscitation, including parental perspectives. METHODS Clinicians from different backgrounds participated in a standardized, videotaped, simulated neonatal resuscitation in the presence of parent actors. The infant remained pulseless; participants communicated with the parent actors before, during, and after discontinuing resuscitation. Twenty-one evaluators with varying expertise (including 6 bereaved parents) viewed the videos. They were asked to score clinician-parent communication and identify the top communicators. In open-ended questions, they were asked to describe 3 aspects that were well done and 3 that were not. Answers to open-ended questions were coded for easily reproducible behaviors. All the videos were then independently reviewed to evaluate whether these behaviors were present. RESULTS Thirty-one participants' videos were examined by 21 evaluators (651 evaluations). Parents and actors agreed with clinicians 81% of the time about what constituted optimal communication. Good communicators were more likely to introduce themselves, use the infant's name, acknowledge parental presence, prepare the parents (for the resuscitation, then death), stop resuscitation without asking parents, clearly mention death, provide or enable proximity (clinician-parent, infant-parent, clinician-infant, mother-father), sit down, decrease guilt, permit silence, and have knowledge about procedures after death. Consistently, clinicians who displayed such behaviors had evaluations >9 out of 10 and were all ranked top 10 communicators. CONCLUSIONS During a neonatal end-of-life scenario, many simple behaviors, identified by parents and providers, can optimize clinician-parent communication.
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Affiliation(s)
- Marie-Hélène Lizotte
- Centre de Recherche.,Department of Pediatrics, Hôpital de Rimouski, Rimouski, Canada
| | | | - Serge Sultan
- Centre de Recherche.,Departments of Pediatrics.,Psychology, and
| | - Thomas Pennaforte
- Centre de Recherche.,Education, Université de Montréal, Montréal, Canada; and
| | - Ahmed Moussa
- Centre de Recherche.,Mother-Child Simulation Center.,Division of Neonatology.,Soins Palliatifs, and.,Centre de Pédagogie Appliquée aux Sciences de la Santé, and.,Departments of Pediatrics
| | | | | | | | - Annie Janvier
- Centre de Recherche, .,Division of Neonatology.,Unités des Éthique Clinique and.,Soins Palliatifs, and.,Bureau du Partenariat Patients-Familles-Soignants, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada.,Bureau de L'éthique Clinique.,Departments of Pediatrics
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Fry JT, Matoba N, Datta A, DiGeronimo R, Coghill CH, Natarajan G, Brozanski B, Leuthner SR, Niehaus JZ, Schlegel AB, Shah A, Zaniletti I, Bartman T, Murthy K, Sullivan KM. Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units. J Pediatr 2020; 217:86-91.e1. [PMID: 31831163 DOI: 10.1016/j.jpeds.2019.10.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/12/2019] [Accepted: 10/14/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs). STUDY DESIGN We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6 hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation. RESULTS Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28 weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death. CONCLUSIONS From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.
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Affiliation(s)
- Jessica T Fry
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Nana Matoba
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ankur Datta
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Robert DiGeronimo
- Department of Pediatrics, University of Washington, Seattle, WA; Division of Neonatology, Seattle Children's Hospital, Seattle, WA
| | - Carl H Coghill
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL; Division of Neonatology, Children's of Alabama, Birmingham, AL
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, MI; Division of Neonatology, Children's Hospital of Michigan, Detroit, MI
| | - Beverly Brozanski
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA; Division of Newborn Medicine, UPMC Children's Hospital, Pittsburgh, PA
| | - Steven R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; Division of Neonatology, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Jason Z Niehaus
- Department of Pediatrics, Indiana University, Indianapolis, IN; Division of Neonatology, Riley Hospital for Children, Indianapolis, IN
| | - Amy Brown Schlegel
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Anita Shah
- Division of Neonatology, Children's Hospital of Orange County, Orange, CA
| | | | - Thomas Bartman
- Department of Pediatrics, The Ohio State College of Medicine, Columbus, OH; Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
| | - Karna Murthy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Kevin M Sullivan
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; Division of Neonatology, Nemours/AI duPont Hospital for Children, Wilmington, DE
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- Children's Hospitals Neonatal Consortium, Kansas City, MO
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Abdel Razeq NM, Alduraidi H, Halasa S, Cuttini M. Clinicians' Self-Reported Practices Related to End-of-Life Care for Infants in NICUs in Jordan. J Obstet Gynecol Neonatal Nurs 2019; 49:78-90. [PMID: 31811824 DOI: 10.1016/j.jogn.2019.11.005] [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] [Accepted: 11/01/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To examine how clinical decisions are made at the end of life for infants born with specific fatal and disabling conditions in NICUs in Jordan from the perspectives of neonatal health care providers. DESIGN A cross-sectional survey of neonatal nurses and physicians. SETTING Twenty-four NICUs in Jordan. PARTICIPANTS Participants included 213 nurses and 75 physicians who provided direct care for infants in NICUs. METHODS Using the EURONIC questionnaire, we asked participants to recall the last experiences of end-of-life decision making in which they were involved. The participants described factors and outcomes related to those experiences, and we used descriptive and inferential statistics to examine these factors. RESULTS In 83% of the recalled situations, the physicians in charge of the infants' care or who were on duty were the primary decision makers. Parents, nurses, ethics committees, and NICU heads were less involved. The infants' primary diagnoses were significantly associated with the nature of decisions regarding end-of-life care (p < .001). Age, importance of religion, having their own children, and involvement in research activities were factors that significantly predicted nurses' perceived levels of involvement in decision making (χ2[4] = 23.140, p < .001). CONCLUSION Our results suggest the need to improve clinical approaches to decision making regarding end-of-life care for infants in NICUs in Jordan to be more family focused and team based. This process should include parents, physicians, neonatal nurses, and ethics committees.
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Comparison of family centered care with family integrated care and mobile technology (mFICare) on preterm infant and family outcomes: a multi-site quasi-experimental clinical trial protocol. BMC Pediatr 2019; 19:469. [PMID: 31791285 PMCID: PMC6886221 DOI: 10.1186/s12887-019-1838-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/15/2019] [Indexed: 12/12/2022] Open
Abstract
Background Family Centered Care (FCC) has been widely adopted as the framework for caring for infants in the Neonatal Intensive Care Unit (NICU) but it is not uniformly defined or practiced, making it difficult to determine impact. Previous studies have shown that implementing the Family Integrated Care (FICare) intervention program for preterm infants in the NICU setting leads to significant improvements in infant and family outcomes. Further research is warranted to determine feasibility, acceptability and differential impact of FICare in the US context. The addition of a mobile application (app) may be effective in providing supplemental support for parent participation in the FICare program and provide detailed data on program component uptake and outcomes. Methods This exploratory multi-site quasi-experimental study will compare usual FCC with mobile enhanced FICare (mFICare) on growth and clinical outcomes of preterm infants born at or before 33 weeks gestational age, as well as the stress, competence and self-efficacy of their parents. The feasibility and acceptability of using mobile technology to gather data about parent involvement in the care of preterm infants receiving FCC or mFICare as well as of the mFICare intervention will be evaluated (Aim 1). The effect sizes for infant growth (primary outcome) and for secondary infant and parent outcomes at NICU discharge and three months after discharge will be estimated (Aim 2). Discussion This study will provide new data about the implementation of FICare in the US context within various hospital settings and identify important barriers, facilitators and key processes that may contribute to the effectiveness of FICare. It will also offer insights to clinicians on the feasibility of a new mobile application to support parent-focused research and promote integration of parents into the NICU care team in US hospital settings. Trial registration ClinicalTrials.gov, ID NCT03418870. Retrospectively registered on December 18, 2017.
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Abdel Razeq NM. Physicians' standpoints on end-of-life decisions at the neonatal intensive care units in Jordan. J Child Health Care 2019; 23:579-595. [PMID: 30606043 DOI: 10.1177/1367493518814926] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The purpose of this cross-sectional descriptive study is to explore pediatricians' and neonatologists' attitudes and standpoints on end-of-life (EOL) decision-making in neonates. Seventy-five physicians, employed fulltime to care for newborns in 23 hospitals in Jordan, completed internationally accepted questionnaires. Most physicians (75%) were supportive of using life-sustaining interventions, irrespective of the severity of the newborns' prognosis and the potential burden of the neonates' disabilities on their families. The general attitude of the physicians (59-88%) was against making decisions that limit life support at EOL; even those infants with what are, in fact, untreatable and disabling medical conditions (56-88%). Most physicians (77%) indicated that ethics committees should be involved in EOL decision-making based on requests from parents, physicians, or both. The results of this study indicate strong pro-life attitudes among the physicians whose role is to take care of infants in Jordan. The results also emphasize the need for (1) the creation of clear EOL-focused regulations and guidelines, (2) the establishment of special ethical committees to inform and assist healthcare providers' efforts during EOL care, and (3) raised awareness and competencies regarding EOL and ethical decision-making among physicians taking care of newborns in Jordan's intensive care units.
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Affiliation(s)
- Nadin M Abdel Razeq
- Department of Maternal and Child Health Nursing, School of Nursing, The University of Jordan, Amman, Jordan
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Shafer G, Singh H, Suresh G. Diagnostic errors in the neonatal intensive care unit: State of the science and new directions. Semin Perinatol 2019; 43:151175. [PMID: 31488330 DOI: 10.1053/j.semperi.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Diagnostic errors remain understudied in neonatology. The limited available evidence, however, suggests that diagnostic errors in the neonatal intensive care unit (NICU) result in significant and long-term consequences. In this narrative review, we discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. We then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error. This multifactorial causation has limited the development of methodology to measure diagnostic errors as well as strategies to mitigate and prevent their adverse effects. We recommend research focused on the frequency and etiology of diagnostic error in the NICU as well as potential mitigation strategies to advance this important field in neonatal intensive care.
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Affiliation(s)
- Grant Shafer
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, 6621 Fanning Street, Suite W6104, Houston, TX 77020, United States.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, United States
| | - Gautham Suresh
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, United States
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