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Lin M, Williams D, Vitcov G, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. Parent Preferences and Experiences in Advance Care Planning in the Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:e1783-e1791. [PMID: 37201532 DOI: 10.1055/s-0043-1768960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Our objective was to evaluate the preferences and experiences of bereaved parents around advance care planning (ACP) in the neonatal intensive care unit (NICU). STUDY DESIGN Single-center cross-sectional survey of bereaved parents who experienced the death of a child in the Boston Children's Hospital NICU between 2010 and 2021 was carried out. Chi-square, Fisher's exact, Fisher Freeman Halton, and Wilcoxin rank sum tests were used to evaluate differences between parents who did and did not receive ACP. RESULTS Out of eligible parents, 40 out of 146 (27%) responded to our survey. Most parents (31 out of 33, 94%) rated ACP as being very important and 27 out of 33 (82%) reported having ACP discussions during their child's admission. Parents preferred initial ACP discussions to occur early in their child's illness trajectory with members of the primary NICU team, with most parents' experiences aligning with these preferences. CONCLUSION Parents value ACP discussions suggesting a further role for ACP in the NICU. KEY POINTS · NICU parents value and participate in advance care planning discussions. · Parents prefer advance care planning with members of the primary NICU, specialty, and palliative care teams. · Parents prefer advance care planning early in their child's illness trajectory.
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Affiliation(s)
- Matthew Lin
- Division of Hospital Medicine, Department of Pediatrics, Children's National Medical Center, Pediatric Palliative Care Program, Washington, District of Columbia
| | - David Williams
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Giselle Vitcov
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sadath Sayeed
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - Christy Cummings
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
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Quinn M, Gephart S, Crist J. Exploring Parent Experiences With Early Palliative Care Practices in the NICU. Adv Neonatal Care 2024; 24:98-109. [PMID: 38324727 DOI: 10.1097/anc.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND The anxiety and uncertain outcome of an admission of a seriously ill infant to the neonatal intensive care unit (NICU) can cause great stress for parents and contribute to poor mental health outcomes. Early implementation of family-centered palliative care (PC) may provide support for NICU parents. Key concepts of early PC in the NICU include shared decision-making, care planning, and support for coping with distress. PURPOSE The purpose of this study was to explore parent experiences during their child's NICU admission with the early PC practices of shared decision-making, care planning, and coping with distress. METHODS Qualitative descriptive methodology was used. Strategies of reflexive journaling, peer debriefing, and data audits were used to enhance trustworthiness. Parents (N = 16) were interviewed, and data were analyzed by conventional content analysis. Targeted recruitment of fathers occurred to ensure they comprised 25% of sample. RESULTS Parents' descriptions of decision-making were contextualized in gathering information to make a decision, the emotional impact of the decision, and influences on their decision-making. In experiences with care planning, parents described learning to advocate, having a spectator versus participant role, and experiencing care planning as communication. Key themes expressed regarding parental coping were exposure to trauma, survival mode, and a changing support network. IMPLICATIONS FOR PRACTICE AND RESEARCH These findings highlight key areas for practice improvement: providing more support and collaboration in decision-making, true engagement of parents in care planning, and encouraging peer support and interaction in the NICU and in online communities.
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Affiliation(s)
- Megan Quinn
- Author Affiliations: Oregon Health Sciences University, Portland (Dr Quinn); and University of Arizona, Tucson (Drs Gephart and Crist)
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Uveges MK, Hamilton JB, Pados BF, Thayer WM, Hinds PS, Nolan MT. Being a "Good Parent" to a NICU Infant With a Major Congenital Anomaly. Adv Neonatal Care 2024; 24:14-26. [PMID: 38232327 DOI: 10.1097/anc.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND In the United States, up to one-third of infants with a congenital anomaly require neonatal intensive care unit (NICU) hospitalization. Parents of these infants may have different decision-making priorities, which may be influenced by the timing of the infant's diagnosis. PURPOSE (1) To compare the ranked importance of decision-making beliefs for parents of infants who received a prenatal versus postnatal congenital diagnosis and (2) explore how parents describe their decision-making beliefs. METHODS A cross-sectional, sequential mixed-methods pilot design was applied to collect quantitative data using the Good Parent Ranking Exercise and further explore parents' decision-making beliefs through qualitative interviews. Maximum difference scaling/hierarchical Bayes estimation and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS Forty mothers completed the Good Parent Ranking Exercise and 20 mothers completed qualitative interviews. Four of the top 5 ranked parenting beliefs were shared by mothers in the prenatal and postnatal groups. Mothers in the postnatal group ranked "focusing on my child's quality of life" higher. Qualitative interviews revealed that previously identified decision-making beliefs were consistent in this NICU parent population, with 1 additional belief identified. Mixed-methods analysis revealed high concordance between the prenatal and postnatal groups. IMPLICATIONS FOR PRACTICE NICU nurses need to know that decision-making beliefs for parents who receive a prenatal versus postnatal congenital diagnosis, while largely similar, may have differences. IMPLICATIONS FOR RESEARCH Future research should explore decision-making beliefs in demographically diverse parent groups (ie, fathers, partnered vs nonpartnered couples) and effective strategies for promoting NICU parents' decision-making beliefs.
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Affiliation(s)
- Melissa K Uveges
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Uveges); Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia (Dr Hamilton); Infant Feeding Care, Wellesley Hills, Massachusetts (Dr Pados); School of Nursing, Johns Hopkins University, Baltimore, Maryland (Mr Thayer); Children's National Health System, Washington, District of Columbia (Dr Hinds); Department of Pediatrics, The George Washington University, Washington, District of Columbia (Dr Hinds); and Conway School of Nursing, The Catholic University of America, Washington, District of Columbia (Dr Nolan)
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Zhang WW, Wang S, Li Y, Dong X, Zhao L, Li Z, Liu Q, Liu M, Zhang F, Yao G, Zhang J, Liu X, Liu G, Zhang X, Reddy S, Yu YH. Development and validation of a model to predict mortality risk among extremely preterm infants during the early postnatal period: a multicentre prospective cohort study. BMJ Open 2023; 13:e074309. [PMID: 38154879 PMCID: PMC10759098 DOI: 10.1136/bmjopen-2023-074309] [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: 04/05/2023] [Accepted: 12/06/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND Recently, with the rapid development of the perinatal medical system and related life-saving techniques, both the short-term and long-term prognoses of extremely preterm infants (EPIs) have improved significantly. In rapidly industrialising countries like China, the survival rates of EPIs have notably increased due to the swift socioeconomic development. However, there is still a reasonably lower positive response towards the treatment of EPIs than we expected, and the current situation of withdrawing care is an urgent task for perinatal medical practitioners. OBJECTIVE To develop and validate a model that is practicable for EPIs as soon as possible after birth by regression analysis, to assess the risk of mortality and chance of survival. METHODS This multicentre prospective cohort study used datasets from the Sino-Northern Neonatal Network, including 46 neonatal intensive care units (NICUs). Risk factors including maternal and neonatal variables were collected within 1 hour post-childbirth. The training set consisted of data from 41 NICUs located within the Shandong Province of China, while the validation set included data from 5 NICUs outside Shandong Province. A total of 1363 neonates were included in the study. RESULTS Gestational age, birth weight, pH and lactic acid in blood gas analysis within the first hour of birth, moderate-to-severe hypothermia on admission and adequate antenatal corticosteroids were influencing factors for EPIs' mortality with important predictive ability. The area under the curve values for internal validation of our prediction model and Clinical Risk Index for Babies-II scores were 0.81 and 0.76, and for external validation, 0.80 and 0.51, respectively. Moreover, the Hosmer-Lemeshow test showed that our model has a constant degree of calibration. CONCLUSIONS There was good predictive accuracy for mortality of EPIs based on influencing factors prenatally and within 1 hour after delivery. Predicting the risk of mortality of EPIs as soon as possible after birth can effectively guide parents to be proactive in treating more EPIs with life-saving value. TRIAL REGISTRATION NUMBER ChiCTR1900025234.
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Affiliation(s)
- Wen-Wen Zhang
- Jinan Maternity and Child Care Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shaofeng Wang
- Jinan Maternity and Child Care Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yuxin Li
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaoyu Dong
- Shandong University Affiliated to Shandong Province Maternal and Child Health Care Hospital, Jinan, Shandong, China
| | - Lili Zhao
- Liaocheng People's Hospital, Liaocheng City, Shandong, China
| | - Zhongliang Li
- Weifang Maternal and Child Health Hospital, Weifang, China
| | - Qiang Liu
- Linyi People's Hospital, Linyi, Shandong, China
| | - Min Liu
- Linyi Maternal and Child Health Care Hospital, Linyi, Shandong, China
| | - Fengjuan Zhang
- The First Affiliated Hospital of Shandong First Medical University, Jinan, Shandong, China
| | - Guo Yao
- Taian City Central Hospital, Taian, Shandong, China
| | - Jie Zhang
- Hebei Medical University Petroleum Clinical Medical College, Langfang, Hebei, China
| | - Xiaohui Liu
- Shi Jiazhuang Maternity and Child Health Care Hospital, Shi Jiazhuang, China
| | - Guohua Liu
- Linfen Maternal and Child Health Hospital, Linfen, China
| | - Xiaohui Zhang
- Qindao University Medical College Affiliated to Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Simmy Reddy
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yong-Hui Yu
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Moore CM, O'Sullivan S, Curley AE. Parents' understanding and experiences of blood component transfusion in the neonatal intensive care unit: A qualitative study. Acta Paediatr 2023; 112:2493-2502. [PMID: 37615240 DOI: 10.1111/apa.16952] [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: 05/22/2023] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
AIM Blood component transfusion is a common intervention in the neonatal intensive care unit (NICU). Parents consent on their babies' behalf. This study aimed to explore parents' understandings and experiences of consenting and the subsequent blood transfusion. METHODS A "low inference" qualitative descriptive semi-structured interview approach was utilised. Grounded theory was employed. Parents described their memories of babies' transfusions, their responses to the consent process and assessed the written information they were given. RESULTS A purposive sample of 17 parents whose babies required blood transfusion in the NICU participated. Parents talked about their initial fears of transfusion, later replaced by confidence in the process and results of transfusion and trust in the healthcare professional team. The main themes elicited by the interviews were parents' expectations and outcomes of transfusion, parents' prior and current opinions of transfusion, parents trust in healthcare professionals and how parents would like to receive information about transfusions in the NICU. CONCLUSION Parents in our study trust information from the healthcare professionals caring for their baby and would like more specific information about how blood transfusion will impact their baby, in a variety of means. Parents felt that blood transfusions were beneficial for their babies.
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Affiliation(s)
- Carmel Maria Moore
- School of Medicine, University College Dublin, Dublin 4, Ireland
- Neonatology, National Maternity Hospital, Dublin 2, Ireland
| | - Sara O'Sullivan
- School of Sociology, University College Dublin, Dublin 4, Ireland
| | - Anna E Curley
- School of Medicine, University College Dublin, Dublin 4, Ireland
- Neonatology, National Maternity Hospital, Dublin 2, Ireland
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Vidiella-Martin J, Been JV. Maternal Migration Background and Mortality Among Infants Born Extremely Preterm. JAMA Netw Open 2023; 6:e2347444. [PMID: 38091041 PMCID: PMC10719757 DOI: 10.1001/jamanetworkopen.2023.47444] [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] [Received: 08/01/2023] [Accepted: 10/30/2023] [Indexed: 12/17/2023] Open
Abstract
Importance Extremely preterm infants require care provided in neonatal intensive care units (NICUs) to survive. In the Netherlands, a decision is made regarding active treatment between 24 weeks 0 days and 25 weeks 6 days after consultation with the parents. Objective To investigate the association between maternal migration background and admissions to NICUs and mortality within the first year among extremely preterm infants. Design, Setting, and Participants This cross-sectional study linked data of registered births in the Netherlands with household-level income tax records and municipality and mortality registers. Eligible participants were households with live births at 24 weeks 0 days to 25 weeks 6 days gestation between January 1, 2010, and December 31, 2017. Data linkage and analysis was performed from March 1, 2020, to June 30, 2023. Exposure Maternal migration background, defined as no migration background vs first- or second-generation migrant mother. Main Outcomes and Measures Admissions to NICUs and mortality within the first week, month, and year of life. Logistic regressions were estimated adjusted for year of birth, maternal age, parity, household income, sex, gestational age, multiple births, and small for gestational age. NICU-specific fixed effects were also included. Results Among 1405 live births (768 male [54.7%], 546 [38.9%] with maternal migration background), 1243 (88.5%) were admitted to the NICU; 490 of 546 infants (89.7%) born to mothers with a migration background vs 753 of 859 infants (87.7%) born to mothers with no migration background were admitted to NICU (fully adjusted RR, 1.03; 95% CI, 0.99-1.08). A total of 652 live-born infants (46.4%) died within the first year of life. In the fully adjusted model, infants born to mothers with a migration background had lower risk of mortality within the first week (RR, 0.81; 95% CI, 0.66-0.99), month (RR, 0.84; 95% CI, 0.72-0.97), and year of life (RR, 0.85; 95% CI, 0.75-0.96) compared with infants born to mothers with no migration background. Conclusions In this nationally representative cross-sectional study, infants born to mothers with a migration background at 24 weeks 0 days to 25 weeks 6 days of gestation in the Netherlands had lower risk of mortality within the first year of life than those born to mothers with no migration background, a result that was unlikely to be explained by mothers from different migration backgrounds attending different NICUs or differential preferences for active obstetric management across migration backgrounds. Further research is needed to understand the underlying mechanisms driving these disparities, including parental preferences for active care of extremely preterm infants.
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Affiliation(s)
- Joaquim Vidiella-Martin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Erasmus School of Economics, Tinbergen Institute and Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jasper V. Been
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Department of Obstetrics and Gynaecology, Erasmus MC Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Friedrich AB. Ethical Consequences of Technological Mediation on Parental Decision-Making Experiences in the Neonatal Intensive Care Unit. QUALITATIVE HEALTH RESEARCH 2023; 33:259-269. [PMID: 36704925 DOI: 10.1177/10497323231151816] [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: 06/18/2023]
Abstract
The neonatal intensive care unit (NICU) is a morally charged space in which parents may be confronted with difficult decisions about the treatment of their newborns, decisions often complicated and created by the increasing use of technologies. This paper adopts a postphenomenological approach to explore the ethical consequences of technological mediation on parental treatment decision-making in the NICU. Semi-structured interviews were conducted with parents of children who received invasive technological support in the NICU to better understand how they made treatment decisions or decisions about specific interventions during their child's hospitalization. The findings suggest that technological mediation-or the various ways in which humans can interact with their world via technologies-contributes to experiences of ambiguity, ambivalence, and alienation in parental decision-making. The ambiguity of invasive NICU technologies can create uncertainty in a decision, which can then lead to internal ambivalence about which decision to make. Ultimately, this ambiguity and ambivalence may lead to alienation from one's child, as parents are disconnected physically and emotionally from the decision and thus their child. Articulating the effects of technological mediation on parental decision-making is a key step in addressing decisional conflict in neonatal intensive care settings and better supporting parents in their decision-making roles.
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Affiliation(s)
- Annie B Friedrich
- Center for Bioethics and Medical Humanities, Institute for Health & Equity, 5506Medical College of Wisconsin, Milwaukee, WI, USA
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Sapp C, McCreery R, Holte L, Oleson J, Walker E. Descriptions of Hearing Loss Severity Differentially Influence Parental Concern about the Impact of Childhood Hearing Loss. Ear Hear 2023; 44:287-299. [PMID: 36314965 PMCID: PMC10810141 DOI: 10.1097/aud.0000000000001280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
PURPOSE The purpose of this study was to measure how parent concern about childhood hearing loss varies under different description conditions: classification-based, audibility-based, and simulation-based descriptions. METHOD We randomly allocated study participants (n = 143) to complete an online survey about expected child difficulties with listening situations with hearing loss. Our participants were parents of children with typical hearing in the 0- to 12-month age range. Participants were exposed to one type of description (classification-based, audibility-based, or simulation-based) and one level of hearing loss (slight, mild, and moderate or their audibility and simulation equivalents), producing nine total groups. Participants rated the level of expected difficulty their child would experience performing age-appropriate listening tasks with the given hearing loss. They also selected what they perceived as the most appropriate intervention from a list of increasingly intense options. RESULTS Our findings revealed that audibility-based descriptions elicited significantly higher levels of parent concerns about hearing loss than classification-based strategies, but that simulation-based descriptions elicited the highest levels of concern. Those assigned to simulation-based and audibility-based groups also judged relatively more intense intervention options as appropriate compared to those assigned to classification-based groups. CONCLUSIONS This study expands our knowledge base about descriptive factors that impact levels of parent concern about hearing loss after diagnosis. This has potentially cascading effects on later intervention actions such as fitting hearing technology. It also provides a foundation for developing and testing clinical applications of audibility-based counseling strategies.
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Affiliation(s)
- Caitlin Sapp
- Department of Pediatric Audiology, University of North Carolina Medical Center, Chapel Hill, NC
| | | | - Lenore Holte
- Department of Communication Sciences and Disorders, University of Iowa, Iowa City, IA
| | - Jacob Oleson
- Department of Biostatistics, University of Iowa, Iowa City, IA
| | - Elizabeth Walker
- Department of Communication Sciences and Disorders, University of Iowa, Iowa City, IA
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Tadros HJ, Saidi A, Rawlinson AR, Cattier C, Black EW, Rackley J, Breault L, Pietra BA, Fricker FJ, Gupta D. Assessment of parental decision making in congenital heart disease, cardiomyopathy and heart transplantation: an observational study analysing decisional characteristics and preferences. Arch Dis Child 2023:archdischild-2022-324373. [PMID: 36732035 DOI: 10.1136/archdischild-2022-324373] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE We explore shared decision making (DM) in guardians of children with heart disease by assessing the desired weight of influence on DM and factors that may alter the relative weight of parent or medical team influence. METHODS Guardians of patients <21 years and admitted >1 week in the paediatric cardiac intensive care unit (PCICU) were recruited. Twelve vignettes were designed including technical (antibiotic selection, intubation, peripherally inserted central catheter placement, ventricular assist device placement, heart transplant, organ rejection, heart rhythm abnormalities and resuscitation effort) and non-technical vignettes (cessation of life-sustaining therapies, depression treatment, obesity and palliative care referral). Participants responded to questions on DM characteristics and one question querying preference for relative weight of parent or medical team influence on DM. RESULTS Of 209 participants approached, 183 were included. Most responded with equal desire of medical team and parental influence on DM in all vignettes (range 41.0%-66.7%). Technical scenarios formed one cluster based on DM characteristics, compared with non-technical scenarios. Factors that increase the relative weight of parental influence on DM include desired input and involvement in big-picture goals (OR 0.274, CI [0.217 to 0.346]; OR 0.794, CI [0.640 to 0.986]). Factors that increase the relative weight of medical team influence on DM include perception of medical expertise needed (OR 1.949 [1.630 to 2.330]), urgency (OR 1.373 [1.138 to 1.658]), benefit (OR 1.415 [1.172 to 1.710]), number of PCICU admissions (OR 1.134 [1.024 to 1.256]) and private insurance (OR 1.921 [1.144 to 3.226]). CONCLUSION Although factors may alter the weight of influence on DM, most parents desire equal parental and medical team influence on DM.
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Affiliation(s)
- Hanna J Tadros
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Arwa Saidi
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Alana R Rawlinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Celine Cattier
- Department of Palliative Care, University of Florida, Gainesville, Florida, USA
| | - Erik W Black
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Jennifer Rackley
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Leah Breault
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Biagio A Pietra
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Fredrick J Fricker
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Dipankar Gupta
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA .,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
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Pellikka HK, Axelin A, Sankilampi U, Kangasniemi M. Shared responsibility for decision-making in NICU: A scoping review. Nurs Ethics 2023; 30:462-476. [PMID: 36688269 DOI: 10.1177/09697330221134948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Shared responsibility is an essential part of family-centred care and it characterizes the relationship between parents and healthcare professionals. Despite this, little is known about their shared responsibility for decision-making in neonatal intensive care units. AIM The aim of this scoping review was to identify previous studies on the subject and to summarize the knowledge that has been published so far. METHOD The review was conducted using electronic searches in the CINAHL, PubMed, Scopus and PsycINFO databases and manual searches of the reference lists of the selected papers. The searches were limited to peer-reviewed papers that had been published in English from 2010 to September 2021. The data were selected based on inclusion and exclusion criteria and the findings were inductively summarized. We identified eight papers that met the inclusion criteria. ETHICAL CONSIDERATIONS The scoping review was conducted according to good scientific practice by respecting authorship and reporting the study processes accurately, honestly and transparently. RESULTS The results showed that shared responsibility for decision-making was based on the parents' intentions, but the degree to which they were willing to take responsibility varied. The facilitating and inhibiting factors for shared responsibility for decision-making were related to the communication between parents and professionals. The impact was related to the parents' emotions. CONCLUSION It is essential that parents and professionals negotiate how both parties will contribute to their shared responsibility for decision-making. This will enable them to reach a mutual understanding of what is in the infants' best interests and to mitigate the emotional burden of decisions in neonatal intensive care units. More research is needed to clarify the concept of shared responsibility for decision-making in this intensive care context.
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Affiliation(s)
| | | | - Ulla Sankilampi
- 60650Kuopio University Hospital, Finland; University of Eastern Finland, Finland
| | - Mari Kangasniemi
- 60654University of Turku, Finland; Satakunta Hospital District, Finland
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Abdin S, Heath G, Neilson S, Byron‐Daniel J, Hooper N. Decision-making experiences of health professionals in withdrawing treatment for children and young people: A qualitative study. Child Care Health Dev 2022; 48:531-543. [PMID: 34994015 PMCID: PMC9306775 DOI: 10.1111/cch.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/20/2021] [Accepted: 12/31/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore factors that influence professionals in deciding whether to withdraw treatment from a child and how decision making is managed amongst professionals as an individual and as a team. STUDY DESIGN Semi-structured interviews were conducted with a purposive sample of health professionals working at a UK Children's Hospital, with children with life-limiting illnesses whose treatment has been withdrawn. Data were transcribed verbatim, anonymized and analysed using a thematic framework method. RESULTS A total of 15 participants were interviewed. Five interrelated themes with associated subthemes were generated to help understand the experiences of health professionals in decision making on withdrawing a child's treatment: (1) understanding the child's best interests, (2) multidisciplinary approach, (3) external factors, (4) psychological well-being and (5) recommendations to support shared decision making. CONCLUSION A shared decision-making approach should be adopted to support professionals, children and their families to make decisions collectively.
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Affiliation(s)
- Shanara Abdin
- Faculty of Health and Applied SciencesUniversity of the West of EnglandBristolUK,Public Health and WellbeingCity of Wolverhampton CouncilWolverhamptonUK
| | - Gemma Heath
- School of PsychologyAston UniversityBirminghamUK
| | - Susan Neilson
- School of NursingUniversity of BirminghamBirminghamUK
| | - James Byron‐Daniel
- Faculty of Health and Applied SciencesUniversity of the West of EnglandBristolUK
| | - Nic Hooper
- School of PsychologyCardiff UniversityCardiffUK
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Parish O, Williams D, Odd D, Joseph-Williams N. Barriers and facilitators to shared decision-making in neonatal medicine: A systematic review and thematic synthesis of parental perceptions. PATIENT EDUCATION AND COUNSELING 2022; 105:1101-1114. [PMID: 34503868 DOI: 10.1016/j.pec.2021.08.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 07/14/2021] [Accepted: 08/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Systematically review parental perceptions of shared decision-making (SDM) in neonatology, identifying barriers and facilitators to implementation. METHODS Electronic database (Medline, PsycINFO, CINAHL and Scopus) and follow-up searches were conducted to identify qualitative studies. Data were extracted, thematically analysed and synthesised. RESULTS Searches yielded 2445 papers, of which 25 were included. Thematic analysis identified six key themes. Key barriers included emotional crises experienced in the NICU setting, lack of medical information provided to parents to inform decision-making, inadequate communication of information, poor relationships with caregivers, lack of continuity in care, and perceived power imbalances between HCPs and parents. Key facilitators included clear, honest and compassionate communication of medical information, caring and empathetic caregivers, continuity in care, and tailored approaches that reflected parent's desired level of involvement. CONCLUSION The highly specialised environment, and the emotional crises experienced by parents impact significantly on their perceived capacity to engage in surrogate decision-making. PRACTICE IMPLICATIONS Complex and multi-factorial interventions that address the training needs of HCPs, and the emotional, informational and decision support needs of parents are needed. SDM skills training, improved information delivery, and integrated emotional and decisional support could help parents to become more involved in SDM for their infant.
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Affiliation(s)
- Olivia Parish
- Cardiff University, School of Medicine, Cardiff, UK.
| | - Denitza Williams
- Cardiff Metropolitan University, Cardiff School of Sport and Health Sciences, Cardiff, UK
| | - David Odd
- Cardiff University, School of Medicine, Cardiff, UK
| | - Natalie Joseph-Williams
- Cardiff University, School of Medicine, Cardiff, UK; PRIME Centre Wales, School of Medicine, Cardiff, UK
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13
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Catholic Perspective on Decision-Making for Critically Ill Newborns and Infants. CHILDREN 2022; 9:children9020207. [PMID: 35204927 PMCID: PMC8870660 DOI: 10.3390/children9020207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
In this paper, we discuss the foundational values informing the Catholic perspective on decision-making for critically ill newborns and infants, particularly focusing on the prudent use of medical technologies. Although the Church has consistently affirmed the general good of advances in scientific research and medicine, the technocratic paradigm of medicine may, particularly in cases with severely ill infants, lead to decision-making conflicts and breakdowns in communication between parents and providers. By exploring two paradigm cases, we offer specific practices in which providers can engage to connect with parents and avoid common technologically mediated decision-making conflicts. By focusing on the inherent relationality of all human persons, regardless of debility, and the Christian hope in the life to come, we can make decisions in the midst of the technocratic paradigm without succumbing to it.
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Jonas D, Scanlon C, Bogetz JF. Parental Decision-Making for Children With Medical Complexity: An Integrated Literature Review. J Pain Symptom Manage 2022; 63:e111-e123. [PMID: 34363953 DOI: 10.1016/j.jpainsymman.2021.07.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
CONTEXT Children with medical complexity (CMC) have multiple significant chronic health conditions that result in functional limitations and high health care utilization. The population of CMC is increasing and parent decision-making for this population is nuanced. OBJECTIVES To review the literature specifically related to the parent experience of medical decision-making for CMC from the parent perspective. METHODS A comprehensive, systematic approach was undertaken with the goal of identifying emergent themes in the existing literature as well as implications for clinical practice and future research. PubMed and PsycInfo databases were searched for English-language articles published between 1995-2020 that focused on parent experiences/perspectives using the search terms: children with medical complexity, children with serious illness, parent decision-making, parent experience, goals of care, parental priorities, advance care planning, and shared decision-making. RESULTS The search yielded 300 unique manuscripts; including 32 empirical articles incorporated in this review. The synthesized findings were broken down into three main sections: 1. types of decisions that parents of CMC face, 2. key factors that influence parental decision-making for CMC, and 3. reasons that the decision-making process for parents of CMC is unique. The findings suggest that parents should be considered experts in their child's care and should be incorporated in shared decision-making in a culturally appropriate manner. CMC should have their personhood valued and providers require specialized training in communication. CONCLUSIONS Parents of CMC have unique needs in their decision-making process and benefit from shared decision-making, continuity of care, collaborative communication and tailored, individualized care.
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Affiliation(s)
- Danielle Jonas
- Silver School of Social Work, New York University, New York, New York, USA.
| | - Caitlin Scanlon
- Pediatric Palliative Care Team, Riley Hospital For Children, Indiana University Health, Indianapolis, Indiana, USA
| | - Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
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15
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Vidiella-Martin J, Been JV, Van Doorslaer E, García-Gómez P, Van Ourti T. Association Between Income and Perinatal Mortality in the Netherlands Across Gestational Age. JAMA Netw Open 2021; 4:e2132124. [PMID: 34726746 PMCID: PMC8564582 DOI: 10.1001/jamanetworkopen.2021.32124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/30/2021] [Indexed: 12/15/2022] Open
Abstract
Importance The association between household income and perinatal health outcomes has been understudied. Examining disparities in perinatal mortality within strata of gestational age and before and after adjusting for birth weight centile can reveal how the income gradient is associated with gestational age, birth weight, and perinatal mortality. Objectives To investigate the association between household income and perinatal mortality, separately by gestational age strata and time of death, and the potential role of birth weight centile in mediating this association. Design, Setting, and Participants This cross-sectional study used individually linked data of all registered births in the Netherlands with household-level income tax records. Singletons born between January 1, 2004, and December 31, 2016, at 24 weeks to 41 weeks 6 days of gestation with complete information on birth outcomes and maternal characteristics were studied. Data analysis was performed from March 1, 2018, to August 30, 2021. Exposures Household income rank (adjusted for household size). Main Outcomes and Measures Perinatal mortality, stillbirth (at ≥24 weeks of gestation), and early neonatal mortality (at ≤7 days after birth). Disparities were expressed as bottom-to-top ratios of projected mortality among newborns with the poorest 1% of households vs those with the richest 1% of households. Generalized additive models stratified by gestational age categories, adjusted for potential confounding by maternal age at birth, maternal ethnicity, parity, sex, and year of birth, were used. Birth weight centile was included as a potential mediator. Results Among 2 036 431 singletons in this study (1 043 999 [51.3%] males; 1 496 579 [73.5%] with mother of Dutch ethnicity), 121 010 (5.9%) were born before 37 weeks of gestation, and 8720 (4.3 deaths per 1000) died during the perinatal period. Higher household income was positively associated with higher rates of perinatal survival, with an unadjusted bottom-to-top ratio of 2.18 (95% CI, 1.87-2.56). The bottom-to-top ratio decreased to 1.30 (95% CI, 1.22-1.39) after adjustment for potential confounding factors and inclusion of birth weight centile as a possible mediator. The fully adjusted ratios were lower for stillbirths (1.27; 95% CI, 1.20-1.36) than for early neonatal deaths (1.35; 95% CI, 1.14-1.66). Inequalities in perinatal mortality were found for newborns at greater than 26 weeks of gestation but not between 24 and 26 weeks of gestation (fully adjusted bottom-to-top ratio, 0.89; 95% CI, 0.77-1.04). Conclusions and Relevance The results of this large nationally representative cross-sectional study suggest that a large part of the increased risk of perinatal mortality among low-income women is mediated via a lower birth weight centile. The absence of disparities at very low gestational ages suggests that income-related risk factors for perinatal mortality are less prominent at very low gestational ages. Further research should aim to understand which factors associated with preterm birth and lower birth weight can reduce inequalities in perinatal mortality.
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Affiliation(s)
- Joaquim Vidiella-Martin
- Erasmus School of Economics, Tinbergen Institute and Erasmus Centre for Health Economics Rotterdam, Rotterdam, the Netherlands
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jasper V. Been
- Division of Neonatology, Department of Paediatrics, Erasmus MC Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, the Netherlands
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Eddy Van Doorslaer
- Erasmus School of Economics, Tinbergen Institute and Erasmus Centre for Health Economics Rotterdam, Rotterdam, the Netherlands
- Erasmus School of Health Policy and Management, Rotterdam, the Netherlands
| | - Pilar García-Gómez
- Erasmus School of Economics, Tinbergen Institute and Erasmus Centre for Health Economics Rotterdam, Rotterdam, the Netherlands
| | - Tom Van Ourti
- Erasmus School of Economics, Tinbergen Institute and Erasmus Centre for Health Economics Rotterdam, Rotterdam, the Netherlands
- Erasmus School of Health Policy and Management, Rotterdam, the Netherlands
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16
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Lorié ES, Wreesmann WJW, van Veenendaal NR, van Kempen AAMW, Labrie NHM. Parents' needs and perceived gaps in communication with healthcare professionals in the neonatal (intensive) care unit: A qualitative interview study. PATIENT EDUCATION AND COUNSELING 2021; 104:1518-1525. [PMID: 33423822 DOI: 10.1016/j.pec.2020.12.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/21/2020] [Accepted: 12/13/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore parents' needs and perceived gaps concerning communication with healthcare professionals during their preterm infants' admission to the neonatal (intensive) care unit (NICU) after birth. METHODS Semi-structured, retrospective interviews with 20 parents of preterm infants (March 2020), admitted to a Dutch NICU (level 2-4) minimally one week, one to five years prior. The interview guide was developed using Epstein and Street's Framework for Patient-Centered Communication. Online interviews were audio-taped and transcribed verbatim. Deductive and inductive thematic analysis was performed by two independent coders. RESULTS Communication needs and gaps emerged across four main functions of NICU communication: Building/maintaining relationships, exchanging information, (sharing) decision-making, and enabling parent self-management. Communication gaps included: lack of supportive physician communication, disregard of parents' views and agreements, missing communication about decisions, and the absence of written (discharge) information. CONCLUSION This study improves our understanding and conceptualization of adequate NICU communication by revealing persisting gaps in parent-provider interaction. Also, this study provides a steppingstone for further integration of parents as equal partners in neonatal care and communication. PRACTICE IMPLICATIONS The results are relevant to practitioners in the field of neonatal and pediatric care, providing suggestions for tangible improvements in NICU care in the Netherlands and beyond.
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Affiliation(s)
- Esther S Lorié
- Athena Institute, Vrije Universiteit Amsterdam, the Netherlands
| | | | - Nicole R van Veenendaal
- Department of Pediatrics and Neonatology, OLVG Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, the Netherlands
| | | | - Nanon H M Labrie
- Athena Institute, Vrije Universiteit Amsterdam, the Netherlands; Department of Pediatrics and Neonatology, OLVG Amsterdam, the Netherlands.
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17
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Wreesmann WJW, Lorié ES, van Veenendaal NR, van Kempen AAMW, Ket JCF, Labrie NHM. The functions of adequate communication in the neonatal care unit: A systematic review and meta-synthesis of qualitative research. PATIENT EDUCATION AND COUNSELING 2021; 104:1505-1517. [PMID: 33341329 DOI: 10.1016/j.pec.2020.11.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To assess the main functions of parent-provider communication in the neonatal (intensive) care unit (NICU) and determine what adequate communication entails according to both parents and health professionals. METHODS A systematic review and meta-synthesis of qualitative research. PubMed, Ebsco/PsycINFO, Wiley/Cochrane Library, Ebsco/CINAHL, Clarivate Analytics/Web of Science Core Collection, and Elsevier/Scopus were searched in October-November 2019 for records on interpersonal communication between parents and providers in neonatal care. Title/abstract screening and full-text analysis were conducted by multiple, independent coders. Data from included articles were analyzed using deductive and inductive thematic analysis. RESULTS 43 records were included. Thematic analysis of data resulted in the development of the NICU Communication Framework, including four functions of communication (1. building/maintaining relationships, 2. exchanging information, 3. (sharing) decision-making, 4. enabling parent self-management) and five factors that contribute to adequate communication across these functions (topic, aims, location, route, design) and, thereby, to tailored parent-provider communication. CONCLUSION The NICU Communication Framework fits with the goals of Family Integrated Care to encourage parent participation in infants' care. This framework forms a first step towards the conceptualization of (adequate) communication in NICU settings. PRACTICE IMPLICATIONS Findings can be used to improve NICU communication in practice, in particular through the mnemonic TAILORED.
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Affiliation(s)
| | - Esther S Lorié
- Athena Institute, Vrije Universiteit Amsterdam, the Netherlands
| | - Nicole R van Veenendaal
- Department of Pediatrics and Neonatology, OLVG, Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, the Netherlands
| | | | | | - Nanon H M Labrie
- Athena Institute, Vrije Universiteit Amsterdam, the Netherlands; Department of Pediatrics and Neonatology, OLVG, Amsterdam, the Netherlands.
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18
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Mitra S, Dorling J, Johnston BC. Optimizing practice guidelines through incorporating patient and family values and preferences. Semin Fetal Neonatal Med 2021; 26:101194. [PMID: 33504465 DOI: 10.1016/j.siny.2021.101194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Neonatal care largely follows clinical practice guidelines and position statements developed locally by respective institutions as well as by national and international organizations. One might expect that adoption of clinical guidelines based on best available research evidence would make neonatal care practices mostly uniform. However, wide variation in clinical practice is still noted in neonatal care. Neonatal clinical guidelines are developed almost exclusively by healthcare professionals, with little or no input from families of the infants being cared for. Therefore, such variation in practice may stem not only from how the evidence is interpreted but also how caregivers and families value different outcomes that are affected by particular interventions. Acknowledging and incorporating the variability in patient and family values and preferences in clinical guidelines is an important step towards allowing shared decision making while reducing unwarranted practice variation, and thereby helping clinicians practice family-centered evidence-based medicine.
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Affiliation(s)
- Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada.
| | - Jon Dorling
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada.
| | - Bradley C Johnston
- Department of Nutrition, Texas A&M University, College Station, TX, USA.
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19
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Weiss EM, Olszewski AE, Guttmann KF, Magnus BE, Li S, Shah AR, Juul SE, Wu YW, Ahmad KA, Bendel-Stenzel E, Isaza NA, Lampland AL, Mathur AM, Rao R, Riley D, Russell DG, Salih ZNI, Torr CB, Weitkamp JH, Anani UE, Chang T, Dudley J, Flibotte J, Havrilla EM, Kathen CM, O'Kane AC, Perez K, Stanley BJ, Wilfond BS, Shah SK. Parental Factors Associated With the Decision to Participate in a Neonatal Clinical Trial. JAMA Netw Open 2021; 4:e2032106. [PMID: 33433595 PMCID: PMC7804922 DOI: 10.1001/jamanetworkopen.2020.32106] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE It remains poorly understood how parents decide whether to enroll a child in a neonatal clinical trial. This is particularly true for parents from racial or ethnic minority populations. Understanding factors associated with enrollment decisions may improve recruitment processes for families, increase enrollment rates, and decrease disparities in research participation. OBJECTIVE To assess differences in parental factors between parents who enrolled their infant and those who declined enrollment for a neonatal randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS This survey study conducted from July 2017 to October 2019 in 12 US level 3 and 4 neonatal intensive care units included parents of infants who enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial or who were eligible but declined enrollment. Data were analyzed October 2019 through July 2020. EXPOSURE Parental choice of enrollment in neonatal clinical trial. MAIN OUTCOMES AND MEASURES Percentages and odds ratios (ORs) of parent participation as categorized by demographic characteristics, self-assessment of child's medical condition, study comprehension, and trust in medical researchers. Survey questions were based on the hypothesis that parents who enrolled their infant in HEAL differ from those who declined enrollment across 4 categories: (1) infant characteristics and parental demographic characteristics, (2) perception of infant's illness, (3) study comprehension, and (4) trust in clinicians and researchers. RESULTS Of a total 387 eligible parents, 269 (69.5%) completed the survey and were included in analysis. This included 183 of 242 (75.6%) of HEAL-enrolled and 86 of 145 (59.3%) of HEAL-declined parents. Parents who enrolled their infant had lower rates of Medicaid participation (74 [41.1%] vs 47 [55.3%]; P = .04) and higher rates of annual income greater than $55 000 (94 [52.8%] vs 30 [37.5%]; P = .03) compared with those who declined. Black parents had lower enrollment rates compared with White parents (OR, 0.35; 95% CI, 0.17-0.73). Parents who reported their infant's medical condition as more serious had higher enrollment rates (OR, 5.7; 95% CI, 2.0-16.3). Parents who enrolled their infant reported higher trust in medical researchers compared with parents who declined (mean [SD] difference, 5.3 [0.3-10.3]). There was no association between study comprehension and enrollment. CONCLUSIONS AND RELEVANCE In this study, the following factors were associated with neonatal clinical trial enrollment: demographic characteristics (ie, race/ethnicity, Medicaid status, and reported income), perception of illness, and trust in medical researchers. Future work to confirm these findings and explore the reasons behind them may lead to strategies for better engaging underrepresented groups in neonatal clinical research to reduce enrollment disparities.
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Affiliation(s)
- Elliott Mark Weiss
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Aleksandra E Olszewski
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Katherine F Guttmann
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brooke E Magnus
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, Massachusetts
| | - Sijia Li
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Anita R Shah
- Division of Neonatology, Children's Hospital of Orange County, Orange, California
| | - Sandra E Juul
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Yvonne W Wu
- Departments of Neurology and Pediatrics, University of California San Francisco School of Medicine, San Francisco
| | - Kaashif A Ahmad
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas
| | | | - Natalia A Isaza
- Division of Neonatology, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Andrea L Lampland
- Department of Neonatology, Children's Minnesota Hospital, Minneapolis
| | - Amit M Mathur
- Department of Pediatrics, St Louis University School of Medicine, St Louis, Missouri
| | - Rakesh Rao
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - David Riley
- Department of Pediatrics, Cook Children's Medical Center, Fort Worth, Texas
| | - David G Russell
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Zeynep N I Salih
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Carrie B Torr
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | | | - Uchenna E Anani
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Juanita Dudley
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John Flibotte
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erin M Havrilla
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Alexandra C O'Kane
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Krystle Perez
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | | | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Seema K Shah
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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20
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Goals of Parents Whose Infant Is in the Neonatal Intensive Care Unit: An Explorative Study. Adv Neonatal Care 2020; 20:499-505. [PMID: 32243323 DOI: 10.1097/anc.0000000000000725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of many neonatal intensive care units (NICU) today is to promote a family-centered practice that addresses parental concerns and needs. However, the specific goals of parents are often unaddressed by the healthcare team. The aim of this study was to understand the goals of parents whose infant was in the NICU to enhance collaboration and communication between parents and health professionals. METHODS A written questionnaire was disseminated to parents whose infant was in the NICU at the Kingston Health Sciences Centre. A thematic analysis of the goals was completed to identify key emergent themes and their implications. RESULTS A total of 23 questionnaires were disseminated to parents and 13 (57%) were returned. Returned questionnaires were most often completed by the mother (n = 9, 70%), and a total of 40 goals were recorded. Three key emergent themes were identified, which included feeding and weight gain, eliminating medical equipment, and successful hospital discharge. IMPLICATIONS FOR PRACTICE Understanding the goals of parents whose infant was in the NICU can enhance communication between parents and their healthcare team, thus aiding the implementation of a family-centered practice. IMPLICATIONS FOR RESEARCH Future larger sample sizes studies across several NICUs would increase the generalizability of results and garner a larger volume of data to establish significant trends between specific infant and parent demographic data and the associated goals.
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21
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van Veenendaal NR, van der Schoor SRD, Heideman WH, Rijnhart JJM, Heymans MW, Twisk JWR, van Goudoever JB, van Kempen AAMW. Family integrated care in single family rooms for preterm infants and late-onset sepsis: a retrospective study and mediation analysis. Pediatr Res 2020; 88:593-600. [PMID: 32241017 DOI: 10.1038/s41390-020-0875-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND During hospital stay after birth, preterm infants are susceptible to late-onset sepsis (LOS). OBJECTIVE To study the effect of family integrated care in single family rooms (SFRs) compared to standard care in open bay units (OBUs) on LOS. Peripheral or central venous catheters (PVCs/CVCs) and parenteral nutrition (PN) were investigated as potential mediators. Secondary outcomes were length of stay, exclusive breastfeeding at discharge, and weight gain during hospital stay. METHODS Single-center retrospective before-after study with preterm infants admitted ≥3 days. RESULTS We studied 1,046 infants (468 in SFRs, 578 in OBUs, median gestational age 35 weeks). SFRs were associated with less LOS (adjusted odds ratio (OR) 0.486, 95% confidence interval (CI): 0.293; 0.807, p = 0.005). PVCs (indirect effect -1.757, 95% CI: -2.738; -1.068), CVCs (indirect effect -1.002, 95% CI: -2.481; 0.092), and PN (indirect effect -1.784, 95% CI: -2.688; -1.114) were possible mediators of the effect. PN was the main mediator of the effect of SFRs on LOS. We found shorter length of stay (median length of stay in SFRs 10 days and in OBUs 12 days, adjusted β -0.088, 95% CI: -0.159; -0.016, p = 0.016), but no differences in weight gain or exclusive breastfeeding at discharge. CONCLUSIONS SFRs were associated with decreased incidences of LOS and shorter length of hospital stay. The positive effect of SFRs on LOS was mainly mediated through a decreased use of PN in SFRs. IMPACT Family integrated care (FICare) in single family rooms for preterm infants was associated with less late-onset sepsis events during hospital stay and a shorter length of hospital stay after birth. FICare in single family rooms was associated with less use of peripheral or central venous catheters and parenteral nutrition. Mediation analysis provided insights into the mechanisms underlying the effect of FICare in single family rooms on late-onset sepsis and helped explain the differences observed in late-onset sepsis between FICare in single family rooms and open bay units. The reduction in late-onset sepsis in FICare in single family rooms was mediated by a reduced use of intravenous catheters and parenteral nutrition.
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Affiliation(s)
- Nicole R van Veenendaal
- Department of Neonatology, OLVG, Amsterdam, The Netherlands.,Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
| | | | - Wieke H Heideman
- Department of Research and Epidemiology, OLVG, Amsterdam, The Netherlands
| | - Judith J M Rijnhart
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Johannes B van Goudoever
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
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Stanak M. Neonatology in Austria: ethics to improve practice. MEDICINE, HEALTH CARE AND PHILOSOPHY 2020; 23:361-369. [PMID: 32144643 PMCID: PMC7426316 DOI: 10.1007/s11019-020-09943-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In the world of Austrian neonatal intensive care units, the role of ethics is recognized only partially. The normatively tense cases that are at the backdrop of this essay concern the situations around the limit of viability (weeks 22 + 0 days to 25 + 6 days of gestation), which is the point in the development of an extremely preterm infant at which there are chances of extra-uterine survival. This essay first outlines the key explicit ethical challenges that are mainly concerned with notions of uncertainty and best interest. Then, it attempts to elucidate the less explicit ethical challenges related to the notion of nudging in the neonatal practice and argue that the role of ethics needs to be recognized more—with the focus on the role of virtue ethics—in order to improve the practice of neonatal medicine.
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Berkowitz I, Garrett JR. Legal and Ethical Considerations for Requiring Consent for Apnea Testing in Brain Death Determination. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:4-16. [PMID: 32441596 DOI: 10.1080/15265161.2020.1754501] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The past decade has witnessed escalating legal and ethical challenges to the diagnosis of death by neurologic criteria (DNC). The legal tactic of demanding consent for the apnea test, if successful, can halt the DNC. However, US law is currently unsettled and inconsistent in this matter. Consent has been required in several trial cases in Montana and Kansas but not in Virginia and Nevada. In this paper, we analyze and evaluate the legal and ethical bases for requiring consent before apnea testing and defend such a requirement by appealing to ethical and legal principles of informed consent and battery and the right to refuse medical treatment. We conclude by considering and rebutting two major objections to a consent requirement for apnea testing: (1) a justice-based objection to allocate scarce resources fairly and (2) a social utility objection that halting the diagnosis of brain death will reduce the number of organ donors.
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Abstract
The ethical dilemmas and predominant frameworks surrounding decision making for critically ill newborns have evolved substantially over the last 40 years. A shared decision-making approach is now favored, involving an exchange of information between parents and clinicians that emphasizes parental values and preferences, resulting in a personalized approach to decision making. In this review, we summarize the history of clinical decision making with a focus on the NICU, highlight different models of decision making, describe the advantages and current limitations of shared decision making, and discuss the ongoing and future challenges of decision making in the NICU amidst medical innovations and emerging technologies.
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Affiliation(s)
- Anne Sullivan
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Christy Cummings
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
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Early for Everyone: Reconceptualizing Palliative Care in the Neonatal Intensive Care Unit. Adv Neonatal Care 2020; 20:109-117. [PMID: 31990696 DOI: 10.1097/anc.0000000000000707] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Palliative care (PC) in the neonatal intensive care unit (NICU) is often provided exclusively to infants expected to die. Standards of care support providing PC early after diagnosis with any condition likely to impact quality of life. PURPOSE To determine the state of early PC practice across populations to derive elements of early PC applicable to neonates and their families and demonstrate their application in practice. SEARCH STRATEGY Multiple literature searches were conducted from 2016 to 2019. Common keywords used were: palliative care; early PC; end of life, neonate; NICU; perinatal PC; pediatric PC; family-centered care; advanced care planning; palliative care consultant; and shared decision-making. FINDINGS Early PC is an emerging practice in adult, pediatric, and perinatal populations that has been shown to be helpful for and recommended by families. Three key elements of early PC in the NICU are shared decision-making, care planning, and coping with distress. A hypothetical case of a 24-week infant is presented to illustrate how findings may be applied. Evidence supports expansion of neonatal PC to include infants and families without terminal diagnoses and initiation earlier in care. IMPLICATIONS FOR PRACTICE Involving parents more fully in care planning activities and decision-making and providing structured support for them to cope with distress despite their child's prognosis are essential to early PC. IMPLICATIONS FOR RESEARCH As early PC is incorporated into practice, strategies should be evaluated for feasibility and efficacy to improve parental and neonatal outcomes. Researchers should consider engaging NICU parent stakeholders in leading early PC program development and research.
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Garrity B, Berry J, Crofton C, Ward E, Cox J, Glader L, Bastianelli L, Emans J, Glotzbecker M, Emara N, Salem J, Jabur T, Higgins S, Shapiro J, Singer S. Parent-to-Parent Advice on Considering Spinal Fusion in Children with Neuromuscular Scoliosis. J Pediatr 2019; 213:149-154. [PMID: 31253410 DOI: 10.1016/j.jpeds.2019.05.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 05/03/2019] [Accepted: 05/21/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To convey advice from families whose children recently underwent spinal fusion to families whose children are under consideration for initial spinal fusion for neuromuscular scoliosis and to providers who counsel families on this decision. STUDY DESIGN We interviewed 18 families of children who underwent spinal fusion between August 2017 and January 2019 at a freestanding children's hospital. We conducted phone interviews a median of 65 (IQR 51-77) days after surgery. We audio recorded, transcribed, and coded (line-by-line) interviews using grounded theory by 2 independent reviewers, and discussed among investigators to induce themes associated with surgical decision making and preparation. RESULTS Six themes emerged about decision making and preparation for spinal fusion: (1) simplify risks and benefits; it is easy to get lost in the details; (2) families prolonging the decision whether or not to pursue spinal fusion surgery may not benefit the child; (3) anticipate anxiety and fear when making a decision about spinal fusion; (4) realize that your child might experience a large amount of pain; (5) anticipate a long recovery and healing process after spinal fusion; and (6) be engaged and advocate for your child throughout the perioperative spinal fusion process. CONCLUSIONS Parents of children who had recently undergone spinal fusion had strong perceptions about what information to convey to families considering surgery, which may improve communication between future parents and physicians. Further investigation is needed to assess how best to incorporate the wisdom and experiences of parent peers into shared decision making and preparation for spinal fusion in children with neuromuscular scoliosis.
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Affiliation(s)
- Brigid Garrity
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jay Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Charis Crofton
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Erin Ward
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Joanne Cox
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Laurie Glader
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - John Emans
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | | | - Norah Emara
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Joseph Salem
- Healthcare Systems Engineering Institute, Northeastern University, Boston, MA; North Shore Medical Center, Salem, MA
| | - Tiago Jabur
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | | | - Jillian Shapiro
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Sara Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
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27
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Abstract
Neonatal professionals encounter many ethical challenges especially when it comes to interventions at the limit of viability (weeks 22-25 of gestation). At times, these challenges make the moral dilemmas in neonatology tragic and they require a particular set of intellectual and moral virtues. Intellectual virtues of episteme and phronesis, together with moral virtues of courage, compassion, keeping fidelity to trust, and integrity were highlighted as key virtues of the neonatal professional. Recognition of the role of ethics requires a recognition that answering the obvious question (what shall we do?) does not always suffice. Acknowledging the tragic question (is any of the alternatives open to us free from serious moral wrongdoing) and recognizing the ethical dilemmas, where the lines between right and wrong are blurred, leads to actions taken towards establishing ethics frameworks to support decision-making. In neonatology units, such organizational support can help in allowing the team members to recognize the ethical dilemmas, avoid moral distress, and improve team cohesion and the quality of care provided. Only when the organizational structure allows ethical dilemmas to be recognized, adequate decisions can be made.
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Affiliation(s)
- Michal Stanak
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria.
- Department of Philosophy, University of Vienna, Vienna, Austria.
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28
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Weiss EM, Magnus BE, Coughlin K. Factors associated with decision-making preferences among parents of infants in neonatal intensive care. Acta Paediatr 2019; 108:967-968. [PMID: 30715746 DOI: 10.1111/apa.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Elliott Mark Weiss
- Division of Neonatology Department of Pediatrics University of Washington School of Medicine Seattle WA USA
- Treuman Katz Center for Pediatric Bioethics Seattle Children's Hospital & Research Institute Seattle WA USA
| | | | - Katherine Coughlin
- Division of Neonatology Department of Pediatrics The Children's Hospital of Philadelphia Philadelphia PA USA
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Weiss EM, Clark JD, Heike CL, Rosenberg AR, Shah SK, Wilfond BS, Opel DJ. Gaps in the Implementation of Shared Decision-making: Illustrative Cases. Pediatrics 2019; 143:peds.2018-3055. [PMID: 30824603 DOI: 10.1542/peds.2018-3055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2018] [Indexed: 11/24/2022] Open
Abstract
Shared decision-making (SDM) has emerged as the preferred decision-making model in the clinician-patient relationship. Through collaboration, SDM helps to facilitate evidence-based medical decisions that are closely aligned with patient or surrogate preferences, values, and goals. How to implement SDM in clinical pediatric practice, however, remains elusive, in part because SDM in pediatrics is complicated by the involvement of parents as a special class of surrogate decision-maker. A provisional framework for the process of SDM in pediatrics was recently proposed by Opel to help facilitate its implementation. To identify aspects of the framework that require refinement, we applied it across a diverse range of clinical cases from multiple pediatric specialties. In doing so, several questions surfaced that deserve further scrutiny: (1) For which medical decisions is consideration of SDM required? (2) What is considered medically reasonable when there is variability in standard practice? (3) Can an option that is not consistent with standard practice still be medically reasonable? (4) How should public health implications be factored into SDM? (5) How should variability in preference sensitivity be approached? (6) How should the developing autonomy of adolescents be integrated into SDM?; and (7) How should SDM address parental decisional burden for emotionally charged decisions? We conduct a brief analysis of each question raised to illustrate key areas for future research.
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Affiliation(s)
- Elliott Mark Weiss
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington; .,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Jonna D Clark
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Carrie L Heike
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Abby R Rosenberg
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Seema K Shah
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
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Nudging in Neonatology: Practical Wisdom and Accountability for Reasonableness. Int J Technol Assess Health Care 2019; 35:5-9. [PMID: 30744713 DOI: 10.1017/s0266462318003732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The way choice is presented has an impact on decision-making. This is the case also in the context of neonatal intensive care units (NICUs), particularly in the challenging cases that concern the limit of viability. The objective of this article is to examine the role of nudging in the shared decision-making in neonatology and elaborate on the respective moral challenges. RESULTS Nudging is not morally neutral. There are two key sources of ethical issues at the heart of nudging. The first one concerns the lack of transparency, while the second concerns the background value judgments that are imminent whenever nudging is used for achieving a particular end. To solve the underlying conflict, a virtue ethics approach combined with the accountability for reasonableness framework is suggested to guide the use of the tool of nudging. CONCLUSIONS NICU professionals ought to use the tool of nudging transparently in line with their act of profession and their practically wise judgment.
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Ayres S, Gallacher L, Stark Z, Brett GR. Genetic counseling in pediatric acute care: Reflections on ultra-rapid genomic diagnoses in neonates. J Genet Couns 2019; 28:273-282. [DOI: 10.1002/jgc4.1086] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 09/11/2018] [Accepted: 12/02/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Samantha Ayres
- Australian Genomics Health Alliance; Melbourne Australia
- Melbourne Genomics Health Alliance; Melbourne Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute; Melbourne Australia
| | - Lyndon Gallacher
- Australian Genomics Health Alliance; Melbourne Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute; Melbourne Australia
- Department of Paediatrics; University of Melbourne; Melbourne Australia
| | - Zornitza Stark
- Australian Genomics Health Alliance; Melbourne Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute; Melbourne Australia
- Department of Paediatrics; University of Melbourne; Melbourne Australia
| | - Gemma R. Brett
- Australian Genomics Health Alliance; Melbourne Australia
- Melbourne Genomics Health Alliance; Melbourne Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute; Melbourne Australia
- Department of Paediatrics; University of Melbourne; Melbourne Australia
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32
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Hagen IH, Iversen VC, Nesset E, Orner R, Svindseth MF. Parental satisfaction with neonatal intensive care units: a quantitative cross-sectional study. BMC Health Serv Res 2019; 19:37. [PMID: 30646901 PMCID: PMC6332571 DOI: 10.1186/s12913-018-3854-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients and users experiences are useful for monitoring the quality of the hospital provisions and to improve health care delivery. Research results on associations between parental satisfaction and their socio-demographic status are inconclusive. We have also found a scarcity of research on the associations between parental satisfaction and standards of neonatal intensive care (NICU) services. We used the Neonatal Satisfaction Survey (NSS-8) to collect data to explore associations between parental satisfaction and socio-demographic variables and, associations between parents' satisfaction and NICU care-services. METHODS A total of 568 parents from six different NICUs geographically dispersed in Norway completed the (NSS-8). All responses were rated and analysed using nonparametric analyses and logistic regression. RESULTS Support from families and friends is the most important sociodemographic area which links to reported levels of parental satisfaction. The most important areas for parents' satisfaction with NICU care services include the decision making processes regarding the infant, respect and empathy from staff, and the continuity of treatment and care. Parents were least satisfied with how NICUs facilitate ongoing care for siblings, parents and infants during later stages of their hospital stay. Parents reported being in need of more guidance and training in meeting their child's needs. CONCLUSION To increase and sustain parents' satisfaction with NICU care considerations should be given to separate elements of the total provision made for affected families. This study suggests that health personnel could address the needs of all family members as these evolve through phases of their stays in hospitals; be more attentive to parents with very preterm infants and parents with long NICU admissions; provide support to siblings; and give more attention to parents' needs for continuity of care, follow-up, and information.
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Affiliation(s)
- Inger Hilde Hagen
- NTNU Norwegian University of Science and Technology, Postbox 1517, 6025 Aalesund, Norway
| | - Valentina Cabral Iversen
- St Olav’s University Hospital HF, Tiller District Psychiatric Center, Trondheim, Norway
- Norwegian of Science and Technology, Faculty of Medicine and Health Science, 7491 Trondheim, Norway
| | - Erik Nesset
- NTNU Norwegian University of Science and Technology, Postbox 1517, 6025 Aalesund, Norway
| | - Roderick Orner
- College of Social Science. University of Lincoln, Brayford Pool, Lincoln, Lincolnshire LN6 7TS UK
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Barker C, Dunn S, Moore GP, Reszel J, Lemyre B, Daboval T. Shared decision making during antenatal counselling for anticipated extremely preterm birth. Paediatr Child Health 2018; 24:240-249. [PMID: 31239813 DOI: 10.1093/pch/pxy158] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 07/24/2018] [Indexed: 01/08/2023] Open
Abstract
Objectives To explore health care providers' (HCPs) perceptions of using shared decision making (SDM) and to identify facilitators of and barriers to its use with families facing the anticipated birth of an extremely preterm infant at 22+0 to 25+6 weeks gestational age. Study Design Qualitative descriptive study design: we conducted interviews with 25 HCPs involved in five cases at a tertiary care centre and completed qualitative content analysis of their responses. Results Nine facilitators and 16 barriers were identified. Facilitators included: a correct understanding of this process and how to apply it, a belief that parents should be the decision makers in these situations, and a positive outlook toward using SDM during antenatal counselling. Barriers included: HCPs' misunderstandings of how and when to apply SDM during antenatal counselling, challenges using the process for cases at the lower end of the gestational age range, fear of the negative emotions and stress parents face when making decisions, and HCPs' uncertainty about their ability to properly apply SDM. Conclusions This study identified facilitators and barriers to use of SDM during antenatal counselling for anticipated birth of extremely preterm infants that can be used to inform development of tailored strategies to facilitate future implementation of shared decision making in this area.
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Affiliation(s)
- Conor Barker
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario
| | - Sandra Dunn
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario.,Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute (CHEORI)
| | - Gregory P Moore
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario.,Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute (CHEORI).,Department of Obstetrics Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario.,The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario
| | - Jessica Reszel
- Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario
| | - Brigitte Lemyre
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario.,Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute (CHEORI).,Department of Obstetrics Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario.,The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario
| | - Thierry Daboval
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario.,Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute (CHEORI).,Department of Obstetrics Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario.,The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario
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Morrison W, Clark JD, Lewis-Newby M, Kon AA. Titrating Clinician Directiveness in Serious Pediatric Illness. Pediatrics 2018; 142:S178-S186. [PMID: 30385625 DOI: 10.1542/peds.2018-0516i] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 11/24/2022] Open
Abstract
Shared decision-making in pediatrics is based on a trusting partnership between parents, clinicians, and sometimes patients, wherein all stakeholders explore values and weigh options. Within that framework, clinicians often have an obligation to provide guidance. We describe a range of ethically justifiable clinician directiveness that could be appropriate in helping families navigate serious pediatric illness. The presentation of "default" options and informed nondissent as potential strategies are discussed. The degree of clinician directiveness may vary even for decisions that are equally "shared." A myriad of factors affect how directive a clinician can or should be. Some of the most important factors are the degree of prognostic certainty and the family's desire for guidance, but others are important as well, such as the urgency of the decision; the relationship between the clinician, patient, and family; the degree of team consensus; and the burdens and benefits of therapy. Directiveness should be considered an important tool in a clinician's armamentarium and is one that can be used to support families in stressful and emotionally difficult situations.
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Affiliation(s)
- Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Jonna D Clark
- Divisions of Pediatric Critical Care Medicine and Pediatric Bioethics, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Mithya Lewis-Newby
- Divisions of Pediatric Critical Care Medicine and Pediatric Bioethics, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Alexander A Kon
- Department of Pediatrics, University of California, San Diego, San Diego, California
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35
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Madrigal VN, Kelly KP. Supporting Family Decision-making for a Child Who Is Seriously Ill: Creating Synchrony and Connection. Pediatrics 2018; 142:S170-S177. [PMID: 30385624 PMCID: PMC6220653 DOI: 10.1542/peds.2018-0516h] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 11/24/2022] Open
Abstract
The families of children with chronic or serious illness are sometimes faced with difficult decisions never previously imagined. We offer a stepwise approach in building a human connection with these families to support them through the decision-making process. We encourage the clinician to stop talking and to actively listen and find common ground. We suggest that offering open and honest information begins with an invitation. We encourage clinicians to explore concepts with the family, including their fears and hopes. We discuss nurturing an emotional connection between the child and family and describe ways to discover a family's preference for involvement in the decision-making process. Central to supporting a family is to place infinite value on the life of their child. We argue that attention to these matters will help the clinician remain in sync with the family to ensure meaningful and high-quality decision-making during highly vulnerable times for families.
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Affiliation(s)
- Vanessa N. Madrigal
- Division of Critical Care Medicine, Departments of Pediatrics and,Associate Professor of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Katherine Patterson Kelly
- Nursing Science, Professional Practice, and Quality, Children’s National Health System, Washington, District of Columbia; and,Director of Pediatric Ethics Program, Assistant Professor and
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Abstract
Shared decision-making (SDM) is a well-established component of patient-centered care, and yet, its application in pediatrics is poorly understood. Common features of pediatric decision-making are not completely addressed in current SDM models, such as the fact that the principal SDM participant is the patient's surrogate, who, unlike competent adult patients deciding for themselves, has limitations on decision-making authority. To address this gap and improve the practice of SDM in pediatrics, a practical 4-step framework is presented. In step 1, physicians are posed the following question for any discrete decision: does the decision include >1 medically reasonable option? If the answer is no, SDM is not indicated. If the answer is yes, physicians proceed to step 2 and answer the following question: does 1 option have a favorable medical benefit-burden ratio compared with other options? If yes, physician-guided SDM is appropriate. If no, parent-guided SDM is appropriate. For each SDM approach, the physician proceeds to step 3 and answers the following question: how preference sensitive are the options? This helps to determine the specific SDM approach in step 4, which ranges from a strong or weak version of physician-guided SDM to a strong or weak version of parent-guided SDM. Several decisional characteristics, if present, can also help calibrate the version of SDM used. Additional analyses are needed to consider the inclusion of adolescents into this SDM framework.
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Affiliation(s)
- Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute; and Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
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Weiss EM, Xie D, Cook N, Coughlin K, Joffe S. Characteristics Associated With Preferences for Parent-Centered Decision Making in Neonatal Intensive Care. JAMA Pediatr 2018; 172:461-468. [PMID: 29554176 PMCID: PMC5875325 DOI: 10.1001/jamapediatrics.2017.5776] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/21/2017] [Indexed: 11/14/2022]
Abstract
Importance Little is known about how characteristics of particular clinical decisions influence decision-making preferences by patients or their surrogates. A better understanding of the factors underlying preferences is essential to improve the quality of shared decision making. Objective To identify the characteristics of particular decisions that are associated with parents' preferences for family- vs medical team-centered decision making across the spectrum of clinical decisions that arise in the neonatal intensive care unit (NICU). Design, Setting, and Participants This cross-sectional survey assessed parents' preferences for parent- vs medical team-centered decision making across 16 clinical decisions, along with parents' assessments of 7 characteristics of those decisions. Respondents included 136 parents of infants in 1 of 3 academically affiliated hospital NICUs in Philadelphia, Pennsylvania, from January 7 to July 8, 2016. Respondents represented a wide range of educational levels, employment status, and household income but were predominantly female (109 [80.1%]), white (68 [50.0%]) or African American (53 [39.0%]), and married (81 of 132 responding [61.4%]). Main Outcomes and Measures Preferences for parent-centered decision making. For each decision characteristic (eg, urgency), multivariable analyses tested whether middle and high levels of that characteristic (compared with low levels) were associated with a preference for parent-centered decision making, resulting in 2 odds ratios (ORs) per decision characteristic. Results Among the 136 respondents (109 women [80.1%] and 27 men [19.9%]; median age, 30 years [range, 18-43 years]), preferences for parent-centered decision making were positively associated with decisions that involved big-picture goals (middle OR, 2.01 [99% CI, 0.83-4.86]; high OR, 3.38 [99% CI, 1.48-7.75]) and that had the potential to harm the infant (middle OR, 1.32 [99% CI, 0.84-2.08]; high OR, 2.62 [99% CI, 1.67-4.11]). In contrast, preferences for parent-centered decision making were inversely associated with the following 4 decision characteristics: technical decisions (middle OR, 0.82 [99% CI, 0.45-1.52]; high OR, 0.48 [99% CI, 0.25-0.93]), the potential to benefit the infant (middle OR, 0.42 [99% CI, 0.16-1.05]; high OR, 0.21 [99% CI, 0.08-0.52]), requires medical expertise (middle OR, 0.48 [99% CI, 0.22-1.05]; high OR, 0.21 [99% CI, 0.10-0.48]), and a high level of urgency (middle OR, 0.47 [99% CI, 0.24-0.92]; high OR, 0.42 [99% CI, 0.22-0.83]). Conclusions and Relevance Preferences for parent-centered vs medical team-centered decision making among parents of infants in the NICU may vary systematically by the characteristics of particular clinical decisions. Incorporating this variation into shared decision making and endorsing models that allow parents to cede control to physicians in appropriate clinical circumstances might improve the quality and outcomes of medical decisions.
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Affiliation(s)
- Elliott Mark Weiss
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital and Research Institute, Seattle, Washington
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Noah Cook
- Division of Neonatology, Children’s Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, Philadelphia
| | - Katherine Coughlin
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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In Response. J Obstet Gynecol Neonatal Nurs 2018; 47:416-417. [DOI: 10.1016/j.jogn.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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On "End-of-Life Decision Making for Parents of Extremely Preterm Infants". J Obstet Gynecol Neonatal Nurs 2018; 47:415-416. [PMID: 29453954 DOI: 10.1016/j.jogn.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2018] [Indexed: 11/22/2022] Open
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Kon AA. Integrating Informed Nondissent Into Informed Consent Standards. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:20-21. [PMID: 29111943 DOI: 10.1080/15265161.2017.1378761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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End-of-Life Decision Making for Parents of Extremely Preterm Infants. J Obstet Gynecol Neonatal Nurs 2017; 46:727-736. [DOI: 10.1016/j.jogn.2017.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 11/23/2022] Open
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Vasu V. Pilot evaluation of parental and professional views regarding consent in neonatal medicine by telephone interviews and questionnaires. BMJ Paediatr Open 2017; 1:e000128. [PMID: 29637148 PMCID: PMC5862204 DOI: 10.1136/bmjpo-2017-000128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/20/2017] [Accepted: 10/16/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The objectives of the study were to determine (1) parental and professional views regarding the type of consent required for common neonatal interventions and (2) whether there has been a change in professional understanding regarding the requirements of consent since the last UK survey in 2003. DESIGN Cohort study of (1) parents of babies admitted to a single-centre tertiary neonatal unit and (2) healthcare professionals. METHODS The views of 8 parents of former neonatal patients and 69 neonatal professionals were sought using online and telephone survey methodology regarding 20 neonatal interventions and whether implied consent, explicit verbal consent or explicit written consent should be obtained. RESULTS Agreement, defined as both parental and professional consensus on the type of consent required, was present in 12/20 of the interventions. Comparison between professional views in 2003 demonstrated a change regarding type of consent for 50% of interventions with a shift towards obtaining explicit written consent certain treatments. CONCLUSIONS The study indicates areas of consensus that exist between parents and professionals regarding consent for common neonatal interventions and a change in professional views regarding consent since the last UK survey in 2003. These data might help inform the development of national guidance for how professionals should obtain consent in neonatology.
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Affiliation(s)
- Vimal Vasu
- Department of Neonatal Medicine, William Harvey Hospital, Kent, UK
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