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Guillén Ú, Zupancic JAF, Litt JS, Kaempf J, Fanaroff A, Polin RA, Martin R, Eichenwald E, Wilson-Costello D, Edwards AD, Hallman M, Bührer C, Fanaroff J, Albersheim S, Embleton ND, Shah PS, Dennery PA, Discenza D, Jobe AH, Kirpalani H. Community Considerations for Aggressive Intensive Care Therapy for Infants <24+0 Weeks of Gestation. J Pediatr 2024; 268:113948. [PMID: 38336203 DOI: 10.1016/j.jpeds.2024.113948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 01/20/2024] [Accepted: 02/04/2024] [Indexed: 02/12/2024]
Affiliation(s)
| | - John A F Zupancic
- Division of Newborn Medicine, Harvard Medical School, Boston, MA; Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jonathan S Litt
- Division of Newborn Medicine, Harvard Medical School, Boston, MA; Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA; Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA
| | - Joseph Kaempf
- Women and Children's Services, Providence St. Vincent Medical Center, Portland, OR
| | - Avroy Fanaroff
- Emeritus, Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Cleveland, OH
| | | | - Richard Martin
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Eric Eichenwald
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - A David Edwards
- Centre for the Developing Brain, King's College London, London, United Kingdom
| | - Mikko Hallman
- Department of Pediatrics and Adolescence, Oulu University Hospital, Oulu, Finland
| | - Christoph Bührer
- Department of Neonatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jonathan Fanaroff
- Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Susan Albersheim
- Division of Neonatology, University of British Columbia, Vancouver, BC, Canada
| | | | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada
| | - Phyllis A Dennery
- Warren Alpert School of Medicine of Brown University, Providence, RI
| | | | - Alan H Jobe
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, and University of Cincinnati, Cincinnati, OH
| | - Haresh Kirpalani
- Emeritus, Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, and Emeritus Department Pediatrics, McMaster University, Hamilton, ON, Canada
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2
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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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3
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Haward MF, Lorenz JM, Janvier A, Fischhoff B. Antenatal consultation and deliberation: adapting to parental preferences. J Perinatol 2023; 43:895-902. [PMID: 36725985 DOI: 10.1038/s41372-023-01605-8] [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: 09/25/2022] [Revised: 12/28/2022] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To analyze and compare perspectives on antenatal consultation and decision-making from participants with varying degrees of prematurity experience and clinician-experts. STUDY DESIGN Open-ended interviews structured around topics previously identified by recognized clinician-experts were conducted with participants having different levels of prematurity experience. Analysis used mixed methods (thematic and mental models analysis). Secondary sub-group comparisons were performed, based on degree of experience. RESULTS Non-clinician participants' (n = 80) perspectives differed regarding: amount and content of information desired, decision-making strategies, and who - parent or clinician - should direct consultations. Most wanted to retain decisional authority, all recognized their emotional limitations and many advocated for deliberation support. Participants worried parents' would regret choosing palliative care contrary to clinicians. Bereaved parents often saw issues differently. CONCLUSIONS Parents approach risk and decision-making for extremely premature infants in a personal fashion. They need personalized support tailored to their unique circumstances, decision-making preferences, and emotions.
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Affiliation(s)
- Marlyse F Haward
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - John M Lorenz
- Department of Pediatrics, Morgan Stanley Children Hospital of New York and Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Annie Janvier
- Department of Pediatrics, Bureau de l'Éthique Clinique, Université de Montréal and Division of Neonatology, Research Center, Clinical Ethics Unit, Palliative Care Unit, Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine, Montréal, QC, Canada
| | - Baruch Fischhoff
- Institute for Politics and Strategy, and Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, USA
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Scheinerman N, Callahan KP. Legal Discrepancies and Expectations of Women: Abortion, Fetal Therapy, and NICU Care. Hastings Cent Rep 2023; 53:36-43. [PMID: 37092649 PMCID: PMC10352933 DOI: 10.1002/hast.1472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Over the past several decades in which access to abortion has become increasingly restricted, parents' autonomy in medical decision-making in the realms of fetal care and neonatal intensive care has expanded. Today, parents can decide against invasive medical interventions at gestational ages where abortions are forbidden, even in cases where neonates are expected to be seriously ill. Although a declared state interest in protecting the lives of fetuses and newborns contributes to justifications for restricting women's autonomy with regards to abortion, it does not fully explain this discrepancy. We believe that social portrayals of women as complying with or shirking their reproductive function play a major role in explaining it. The growing divide between a woman's rights as a reproductive being and as a parent suggest that abortion restriction is rooted in a historical societal desire for women to serve as reproducers and in the corresponding fear of them abandoning this allotted role in pursuit of social equality. The Dobbs v. Jackson (2022) decision is not based in a view of abortion as a medical act occurring between a doctor and patient, as Roe v. Wade (1973) did, but decision-making about fetal therapy or NICU care is still viewed as occurring between a doctor and patient or surrogate because in this act a woman is seen as fulfilling her role as mother.
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Affiliation(s)
- Naomi Scheinerman
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
| | - Katharine Press Callahan
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania; Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia; Philadelphia, Pennsylvania
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Sullivan A, Arzuaga B, Luff D, Young V, Schnur M, Williams D, Cummings C. A Qualitative Study of Parental Perspectives on Prenatal Counseling at Extreme Prematurity. J Pediatr 2022; 251:17-23.e2. [PMID: 36096177 PMCID: PMC9729443 DOI: 10.1016/j.jpeds.2022.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/30/2022] [Accepted: 09/06/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine parental preferred language, terminology, and approach after prenatal counseling for an anticipated extremely preterm delivery. STUDY DESIGN Pregnant persons (and their partners) admitted at 220/7-256/7 weeks of estimated gestation participated in post antenatal-counseling semistructured interviews to explore preferred language and decision-making approaches of their antenatal counseling session. Interviews were audio-recorded and transcribed, and thematic analysis of the data was performed. RESULTS Thirty-nine interviews were conducted representing 28 total prenatal consults. Analysis identified 2 overarching themes impacting the whole counseling experience: the need for reassurance and compassionate communication, while parents traveled along a dynamic decision-making journey they described as fluid and ever-changing. Related themes included the following: (1) Finding Balance: parents reported the importance of balancing positivity and negativity as well as tailoring the amount of information, (2) The Unspoken: parents described assumptions and inferences surrounding language, resuscitation options, and values that can cloud the counseling process, (3) Making the Intangible Tangible: parents reported the importance of varied communication strategies, for example, visuals to better anticipate and prepare, and (4) Team Synergism: Parents expressed desire for communication and consistency among and between teams, which increased trust. CONCLUSIONS Parents facing extremely premature delivery generally did not report remembering specific terminology used during prenatal consultation but rather how the language and counseling approach made them feel and affected the decision-making process. These findings have implications for further research and educational intervention design to improve clinicians' counseling practices to better reflect parental preferences and ultimately improve counseling outcomes.
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Affiliation(s)
- Anne Sullivan
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Bonnie Arzuaga
- Harvard Medical School, Boston, MA; South Shore Hospital, Weymouth, MA
| | - Donna Luff
- Harvard Medical School, Boston, MA; Division of Anesthesia and SimPeds, Boston Children's Hospital, Boston, MA
| | - Vanessa Young
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Maureen Schnur
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - David Williams
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Christy Cummings
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Krick JA, Feltman DM, Arnolds M. Decision-Making for Extremely Preterm Infants: A Qualitative Systematic Review. J Pediatr 2022; 251:6-16. [PMID: 35940293 DOI: 10.1016/j.jpeds.2022.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To synthesize and describe important elements of decision-making during antenatal consultation for threatened preterm delivery at the margin of gestational viability. STUDY DESIGN Data sources including PubMed, EMBASE, Web of Science, and CINAHL Plus were searched. We included all qualitative literature published on decision-making from 1990 to July 2021. Two authors independently screened and evaluated each study using the Critical Appraisal Skills Programme checklist; studies reaching moderate and high quality were included. We developed an extraction tool to collect and categorize data from each qualitative article, then used thematic analysis to analyze and describe the findings. RESULTS Twenty-five articles incorporating the views of 504 providers and 352 parents were included for final review. Thematic analysis revealed 4 main themes describing the experience of health care providers and parents participating in decision-making: factors that influence decision-making, information sharing, building a partnership, and making the decision. Parents and providers were not always in agreement upon which elements were most essential to the process of decision-making. Articles published in languages other than English were excluded. CONCLUSIONS Qualitative literature highlighting key factors which are important during antenatal counseling can inform and guide providers through the process of shared decision-making. Communicating clear, honest, and balanced information; avoiding artificially dichotomized options; and focusing on partnership building with families will help providers use the antenatal consultation to reach personalized decisions for each infant.
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Affiliation(s)
- Jeanne A Krick
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, TX.
| | - Dalia M Feltman
- Division of Neonatology, Department of Pediatrics, Evanston Hospital, NorthShore University Health System, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Marin Arnolds
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI
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7
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Cavolo A. Embrace the Gray: How Tackling the Clinical Complexities of the Gray Zone Will Improve Decision-making. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:40-43. [PMID: 36332041 DOI: 10.1080/15265161.2022.2123982] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Personalized support of parents of extremely preterm infants before, during and after birth. Semin Fetal Neonatal Med 2022; 27:101335. [PMID: 35780043 DOI: 10.1016/j.siny.2022.101335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The emotional turmoil associated with extremely preterm birth is inescapable parents. How each parent handles the unexpected, makes sense of the unknown and learns to parent their child is uniquely personal. A rigid standardized approach to support families through their journey before and during neonatal intensive care disregards this individuality. This article reviews general concepts and practices that can be learned and applied by clinicians to promote resiliency and help parents cope adaptively. This review will describe how to personalize parenting support during the antenatal consultation and hospitalization for parents of extremely premature infants. To facilitate this, mindsets and care delivery models need to shift from inflexible standardized protocols to flexible guidelines that enable personalized communications, support structures and care delivery models tailored to each person's characteristics, preferences, and values.
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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: 18] [Impact Index Per Article: 9.0] [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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10
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Abstract
Decision-making at extreme prematurity remains ethically and practically challenging and can result in parental and clinician distress. It is vital that clinicians learn the necessary skills integral to counseling and decision-making with families in these situations. A pedagogical approach to teaching counseling should incorporate adult learning theory, emphasize multidisciplinary team in-situ simulation that links to counseling clinicians' daily practice, and includes critical reflection, debriefing, and program assessment. Multiple educational strategies that train clinicians in advanced communication and decision-making offer promising results to optimize antenatal counseling and shared decision-making for families facing possible delivery at extreme prematurity. Continued process evaluation and innovation in these educational domains are needed while also assessing the effect on patient-centered outcomes.
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Affiliation(s)
- Anne Sullivan
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Center for Bioethics, Harvard Medical School, Boston, MA, USA.
| | - Christy L. Cummings
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA,Center for Bioethics, Harvard Medical School, Boston, MA,Department of Pediatrics, Harvard Medical School, Boston, MA
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Personalized communication with parents of children born at less than 25 weeks: Moving from doctor-driven to parent-personalized discussions. Semin Perinatol 2022; 46:151551. [PMID: 34893335 DOI: 10.1016/j.semperi.2021.151551] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Communication with parents is an essential component of neonatal care. For extremely preterm infants born at less than 25 weeks, this process is complicated by the substantial risk of mortality or major morbidity. For some babies with specific prognostic factors, the majority die. Although many of these deaths occur after admission to the intensive care unit, position statements have focused on communication during the prenatal consultation. This review takes a more comprehensive approach and covers personalized and parent-centered communication in the clinical setting during three distinct yet inter-related phases: the antenatal consultation, the neonatal intensive care hospitalization, and the dying process (when this happens). We advocate that a 'one-size-fits-all' communication model focused on standardizing information does not lead to partnerships. It is possible to standardize personalized approaches that recognize and adapt to parental heterogeneity. This can help clinicians and parents build effective partnerships of trust and affective support to engage in personalized decision-making. These practices begin with self-reflection on the part of the clinician and continue with practical frameworks and stepwise approaches supporting personalization and parent-centered communication.
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12
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Seifart C, Falch M, Wege M, Maier RF, Pedrosa Carrasco AJ. NEO-SPEAK: A conceptual framework that underpins breaking bad news in neonatology. Front Pediatr 2022; 10:1044210. [PMID: 36440326 PMCID: PMC9681898 DOI: 10.3389/fped.2022.1044210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/19/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Breaking bad news in neonatology is a frequent and difficult challenge. Although there are guidelines for communicating with parents in pediatrics and neonatology, the specific framework for breaking bad news in neonatology has not been studied in more detail. Therefore, we aimed to identify determinants that are important for successful managing breaking bad news in neonatology from professionals' perspective and to develop a conceptual framework that underpins this challenging task. METHODS We conducted seventeen semi-structured interviews with senior neonatologists of six perinatal centers of the highest level of care in Germany. The transcripts were analyzed according to Mayring's method of qualitative content analysis using inductive and deductive coding. RESULTS Eight determinants of breaking bad news in neonatology could be identified from the interviews. From these, we developed the conceptual framework NEO-SPEAK. The first three determinants, Neonatal prognostic uncertainty, Encounter in (triangular-)partnerships, Organization and teamwork (NEO) are directly related to the specific care situation in neonatology, whereas the others, Situational stress, Processuality, Emotional burden, Attention to individuality, Knowledge and experience, play a role for difficult conversations in general, but are subject to special modifications in neonatology (SPEAK). In addition, the results show that the context in neonatology as well as reciprocal effects on the team and the individual level of the physicians are important influencing factors in breaking bad news. CONCLUSION On the one hand, the constitutional framework NEO-SPEAK shows which special aspects play a role in neonatology for the delivery of bad news, and on the other hand, it can help to identify and consider these aspects in clinical routine and training. Considering or reinforcing each NEO-SPEAK element when planning or delivering bad news may guide healthcare professionals through communication with parents of critically ill or premature newborns and support the resilience of the caring team.
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Affiliation(s)
- Carola Seifart
- Faculty of Medicine, Dean's Office, Research Group Medical Ethics (AGEM), Philipps-University of Marburg, Marburg, Germany
| | - Mirjam Falch
- Faculty of Medicine, Dean's Office, Research Group Medical Ethics (AGEM), Philipps-University of Marburg, Marburg, Germany
| | - Mirjam Wege
- Children's Hospital, University Hospital of Marburg, Marburg, Germany
| | - Rolf F Maier
- Faculty of Medicine, Philipps University of Marburg, Marburg, Germany
| | - Anna J Pedrosa Carrasco
- Faculty of Medicine, Dean's Office, Research Group Medical Ethics (AGEM), Philipps-University of Marburg, Marburg, Germany
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Fortin S, Le Gall J, Richer J, Payot A, Duval M. Decision-Making in the Era of New Medical Technologies in Pediatric Hematology-Oncology: The Death of Palliative Care? J Pediatr Hematol Oncol 2021; 43:271-276. [PMID: 33480652 DOI: 10.1097/mph.0000000000002058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/06/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent advances in immunology, genomics, and cellular therapy have opened numerous therapeutic possibilities in pediatric hematology-oncology, generating new hope in poor prognosis situations. How decisions are made when it comes to treatments and aims needs to be explored in this new technologic context. In particular, their impact on the gold standard of early referral to palliative care must be assessed. MATERIALS AND METHODS Stemming from an ethnographic study combining semistructured interviews and observations carried out in a hematopoietic stem cell transplant unit in a Montréal Pediatric Hospital, we discuss the decision-making process when a patient faces poor prognosis. RESULTS AND DISCUSSION Although health care providers individually envisioned that palliative care may be the best course of action for patients receiving emergent therapy, they remained collectively in the curative mode. The intricate relationship between science, hope, caregiver, and care receiver sustains this perspective even when (near) death is the probable outcome. When proven treatment fails, emerging therapeutic possibilities offer new hope that can delay the referral to the palliative care team.
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Affiliation(s)
- Sylvie Fortin
- Departments of Anthropology
- Pediatrics, Université de Montréal
| | - Josiane Le Gall
- Departments of Anthropology
- The Integrated Health and Social Services University Network for West-Central Montreal
| | - Johanne Richer
- Mother and Child University Hospital Center CHU Sainte-Justine, Université de Montréal
| | | | - Michel Duval
- Department of Pediatrics (Head of Hematology-Oncology Unit), Palliative Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Canada
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Elternzentrierte ethische Entscheidungsfindung für Frühgeborene im Grenzbereich der Lebensfähigkeit – Reflexion über die Bedeutung probabilistischer Prognosen als Entscheidungsgrundlage. Ethik Med 2021. [DOI: 10.1007/s00481-021-00653-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungFrühgeborene im Grenzbereich der Lebensfähigkeit befinden sich in einer prognostischen Grauzone. Das bedeutet, dass deren Prognose zwar schlecht, aber nicht hoffnungslos ist, woraus folgt, dass nach Geburt lebenserhaltende Behandlungen nicht obligatorisch sind. Die Entscheidung für oder gegen lebenserhaltende Maßnahmen ist wertbeladen und für alle Beteiligten enorm herausfordernd. Sie sollte eine zwischen Eltern und Ärzt*innen geteilte Entscheidung sein, wobei sie unbedingt mit den Präferenzen der Eltern abgestimmt sein sollte. Bei der pränatalen Beratung der Eltern legen die behandelnden Ärzt*innen üblicherweise numerische Schätzungen der Prognose vor und nehmen in der Regel an, dass die Eltern ihre Behandlungspräferenzen davon ableiten. Inwieweit probabilistische Daten die Entscheidungen der Eltern in prognostischen Grauzonen tatsächlich beeinflussen, ist noch unzureichend untersucht. In der hier vorliegenden Arbeit wird eine Studie reflektiert, in welcher die Hypothese geprüft wurde, dass numerisch bessere oder schlechtere kindliche Prognosen die Präferenzen werdender Mütter für lebenserhaltende Maßnahmen nicht beeinflussen. In dieser Studie zeigte sich, dass die elterlichen Behandlungspräferenzen eher von individuellen Einstellungen und Werten als von Überlegungen zu numerischen Ergebnisschätzungen herzurühren scheinen. Unser Verständnis, welche Informationen werdende Eltern, die mit einer extremen Frühgeburt konfrontiert sind, wünschen und brauchen, ist noch immer unvollständig. Bedeutende medizinische Entscheidungen werden keineswegs nur rational und prognoseorientiert gefällt. In der vorliegenden Arbeit wird diskutiert, welchen Einfluss der Prozess der Entscheidungsfindung auf das Beratungsergebnis haben kann und welche Implikationen sich aus den bisher vorliegenden Studienergebnissen ergeben – klinisch-praktisch, ethisch und wissenschaftlich.
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Haward MF, Lorenz JM, Janvier A, Fischhoff B. Bereaved Parents: Insights for the Antenatal Consultation. Am J Perinatol 2021; 40:874-882. [PMID: 34255335 DOI: 10.1055/s-0041-1731651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The study aimed to explore experiences of extremely preterm infant loss in the delivery room and perspectives about antenatal consultation. STUDY DESIGN Bereaved participants were interviewed, following a semi-structured protocol. Personal narratives were analyzed with a mixed-methods approach. RESULTS In total, 13 participants, reflecting on 17 pregnancies, shared positive, healing and negative, harmful interactions with clinicians and institutions: feeling cared for or abandoned, doubted or believed, being treated rigidly or flexibly, and feeling that infant's life was valued or not. Participants stressed their need for personalized information, individualized approaches, and affective support. Their decision processes varied; some wanted different things for themselves than what they recommended for others. These interactions shaped their immediate experiences, long-term well-being, healing, and regrets. All had successful subsequent pregnancies; few returned to institutions where they felt poorly treated. CONCLUSION Antenatal consultations can be strengthened by personalizing them, within a strong caregiver relationship and supportive institutional practices. KEY POINTS · Personalized antenatal consultations should strive to balance cognitive and affective needs.. · Including perspectives from bereaved parents can strengthen antenatal consultations.. · Trusting provider-parent partnerships are pivotal for risk communication..
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Affiliation(s)
- Marlyse F Haward
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - John M Lorenz
- Department of Pediatrics, Morgan Stanley Children Hospital of New York, Columbia University Vagelos College of Physicians and Surgeons, New York City, New York
| | - Annie Janvier
- Department of Pediatrics, Bureau de l'Éthique Clinique, Université de Montréal, Montréal, Canada.,Division of Neonatology, Research Center, Clinical Ethics Unit, Palliative Care Unit, Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine, Montréal, Canada
| | - Baruch Fischhoff
- Department of Engineering and Public Policy and Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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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: 24] [Impact Index Per Article: 8.0] [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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Kaemingk BD, Carroll K, Thorvilson MJ, Schaepe KS, Collura CA. Uncertainty at the Limits of Viability: A Qualitative Study of Antenatal Consultations. Pediatrics 2021; 147:peds.2020-1865. [PMID: 33658319 DOI: 10.1542/peds.2020-1865] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Antenatal consultation between a neonatologist and expectant parent(s) may determine if resuscitation is provided for or withheld from neonates born in the gray zone of viability. In this study, we sought to gain a deeper understanding of uncertainties present and neonatologists' communication strategies regarding such uncertainties in this shared decision-making. METHODS A prospective, qualitative study using transcriptions of audio-recorded antenatal consultations between a neonatologist and expectant parent(s) was conducted. Pregnant women were eligible if anticipating delivery in the gray zone of viability (22 0/7-24 6/7 weeks' gestation). Over 18 months, 25 of 28 pregnant women approached consented to participate. Applied thematic analysis was used to inductively derive and examine conceptual themes. RESULTS Inductive analysis of consult transcripts revealed uncertainty as a central theme. Several subthemes relating to uncertainty were also derived, including the timing of delivery, NICU course, individual characteristics (of physician, expectant parent(s), and fetus or neonate), and consequences of the decision for the expectant parent(s). Analysis revealed that uncertainty was actively managed by neonatologists through a variety of strategies, including providing more information, acknowledging the limits of medicine, acknowledging and accepting uncertainty, holding hope, and relationship building. CONCLUSIONS Uncertainty is pervasive within the antenatal consultation for periviable neonates and likely plays a significant role in decision-making toward postnatal resuscitative efforts. Uncertainty complicated, or even paralyzed, decision-making efforts while also providing reassurance toward a positive outcome. Directions for future study should consider whether advanced communication training modulates the impact that uncertainty plays in the shared decision-making encounter.
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Affiliation(s)
- Bethany D Kaemingk
- Division of Neonatal Medicine, .,Department of Pediatric and Adolescent Medicine and
| | - Katherine Carroll
- School of Sociology, College of Arts and Social Sciences, Australian National University, Canberra, Australia
| | | | - Karen S Schaepe
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; and
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18
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Exploring implicit bias in the perceived consequences of prematurity amongst health care providers in North Queensland - a constructivist grounded theory study. BMC Pregnancy Childbirth 2021; 21:55. [PMID: 33441110 PMCID: PMC7805144 DOI: 10.1186/s12884-021-03539-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 01/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background A study was done to explore the attitudes of relevant health care professionals (HCP) towards the provision of intensive care for periviable and extremely premature babies. Methods/design Applying a constructivist grounded theory methodology, HCP were interviewed about their attitudes towards the provision of resuscitation and intensive care for extremely premature babies. These babies are at increased risk of death and neurodisability when compared to babies of older gestations. Participants included HCP of varying disciplines at a large tertiary centre, a regional centre and a remote centre. Staff with a wide range of experience were interviewed. Results Six categories of i) who decides, ii) culture and context of families, iii) the life ahead, iv) to treat a bit or not at all, v) following guidelines and vi) information sharing, emerged. Role specific implicit bias was found as a theoretical construct, which depended on the period for which care was provided relative to the delivery of the baby. This implicit bias is an underlying cause for the negativity seen towards extreme prematurity and is presented in this paper. HCP caring for women prior to delivery have a bias towards healthy term babies that involves overestimation of the risks of extreme prematurity, while neonatal staff were biased towards suffering in the neonatal period and paediatricians recognise positivity of outcomes regardless of neurological status of the child. The implicit bias found may explain negativity towards intensive care of periviable neonates. Conclusion Understanding the presence and origins of role specific implicit bias may enable HCP to work together to improve care for parents preparing for the delivery of extremely premature babies. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03539-5.
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Tavares PDAJ, Ukawa TB, Hamamoto Filho PT, de Avila MAG. Evaluating Educational Material from the Perspective of Informal Caregivers of Children with Hydrocephalus: A Qualitative Study. World Neurosurg 2020; 139:427-433. [DOI: 10.1016/j.wneu.2020.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/28/2022]
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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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21
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Lomotey AY, Bam V, Diji AK, Asante E, Asante HB, Osei J. Experiences of mothers with preterm babies at a Mother and Baby Unit of a tertiary hospital: A descriptive phenomenological study. Nurs Open 2020; 7:150-159. [PMID: 31871698 PMCID: PMC6917974 DOI: 10.1002/nop2.373] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 08/10/2019] [Accepted: 08/22/2019] [Indexed: 11/08/2022] Open
Abstract
Aim To describe the lived experiences of mothers with preterm babies at a Mother and Baby Unit (MBU) of a tertiary hospital. Design A descriptive phenomenological approach. Method Ten mothers were purposively sampled during the month of May, 2017 to describe their experiences of having preterm babies. Recorded in-depth individual interviews were transcribed verbatim; codes were generated and inductively organised into themes. Results Four themes were actively generated: 'Emotional experiences of mothers', 'Mother-baby interaction', 'Perception on care and support' and 'Challenges within Mother and Baby Unit environment'. Mothers were anxious about the premature delivery and were afraid of possible infant's death. They cherished interactions with their babies during kangaroo mother care and breastfeeding. Mothers applauded the nurses for their professional competence. They expressed concerns about inadequate accommodation, high cost of care, the frequency and duration of mother-baby interactions.
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Affiliation(s)
| | - Victoria Bam
- Department of NursingP. M. B., U. P. O.KNUST‐KumasiGhana
| | | | - Ernest Asante
- Department of NursingP. M. B., U. P. O.KNUST‐KumasiGhana
| | | | - Joyce Osei
- Department of NursingP. M. B., U. P. O.KNUST‐KumasiGhana
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22
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Abstract
BACKGROUND Neonatologists, legal experts and ethicists extensively discuss the ethical challenges of decision-making when a child is born at the limit of viability. The voices of parents are less heard in this discussion. In Norway, parents are actively shielded from the burden of decision-making responsibility. In an era of increasing patient autonomy, is this position still defendable? RESEARCH QUESTION In this article, we discuss the role of parents in neonatal decision-making, based on the following research question: Should parents decide whether to provide lifesaving treatment when their child is born at the limit of viability? RESEARCH DESIGN We conducted eight interviews with 12 parents, 4 individuals and 4 couples, all having experienced prenatal counselling at the limit of viability. The interviews took place at different university locations in Norway in the years 2014-2018. ETHICAL CONSIDERATIONS All study participants gave their written informed consent. The Regional Committee for Medical Research Ethics approved the study. FINDINGS We identified six main themes in parents' responses to the research question. Parents (1) experienced an emotional turmoil confronted with birth at the border of viability, (2) emphasized the importance of being involved in decision-making, (3) described and reflected on the need to balance the parental instinct of saving, (4) were concerned about the dilemmas involved in protecting the family, (5) were worried about the burden of overwhelming responsibility and (6) called for guideline relief. CONCLUSION The perceived parental instinct of saving the life of their child makes it hard for parents to step away from a call for 'everything to be done'. Involvement of an interprofessional periviability team drawing on the experiences and viewpoints of nurses and neonatologists in decision-making is needed to protect both infants and parents against undue parental push for treatment and enable parents to make good decisions regarding their child.
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Affiliation(s)
- Lars Ursin
- Norwegian University of Science and Technology, Norway
| | - Janicke Syltern
- St. Olav's University Hospital, Norway; Norwegian University of Science and Technology, Norway
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Levaillant C, Caeymaex L, Béhal H, Kaminski M, Diguisto C, Tosello B, Azria E, Claris O, Bétrémieux P, Foix L’Hélias L, Truffert P. Prenatal parental involvement in decision for delivery room management at 22-26 weeks of gestation in France - The EPIPAGE-2 Cohort Study. PLoS One 2019; 14:e0221859. [PMID: 31465428 PMCID: PMC6715208 DOI: 10.1371/journal.pone.0221859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 08/18/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Our main objective was to examine if parental prenatal preferences predict delivery-room management of extremely preterm periviable infants. The secondary objectives were to describe parental involvement and the content of prenatal counseling given to parents for this prenatal decision. DESIGN Prospective study of neonates liveborn between 22 and 26 weeks of gestation in France in 2011 among the neonates included in the EPIPAGE-2 study. SETTING 18 centers participating in the "Extreme Prematurity Group" substudy of the EPIPAGE-2 study. PATIENTS 302 neonates liveborn between 22-26 weeks among which 113 with known parental preferences while parental preferences were unknown or unavailable for 186 and delivery room management was missing for 3. RESULTS Data on prenatal counseling and parental preferences were collected by a questionnaire completed by professionals who cared for the baby at birth; delivery room (DR) management, classified as stabilization or initiation of resuscitation (SIR) vs comfort care (CC). The 113 neonates studied had a mean (SD) gestational age of 24 (0.1) weeks. Parents of neonates in the CC group preferred SIR less frequently than those with neonates in the SIR group (16% vs 88%, p < .001). After multivariate analysis, preference for SIR was an independent factor associated with this management. Professionals qualified decisions as shared (81%), exclusively medical (16%) or parental (3%). Information was described as medical with no personal opinion (71%), complete (75%) and generally pessimistic (54%). CONCLUSION Parental involvement in prenatal decision-making did not reach satisfying rates in the studied setting. When available, prenatal parental preference was a determining factor for DR management of extremely preterm neonates. Potential biases in the content of prenatal counselling given to parents need to be evaluated.
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Affiliation(s)
- Cerise Levaillant
- CHU Lille Neonatal unit, EA Epidemiology and Quality of Care, Lille, France
- * E-mail:
| | - Laurence Caeymaex
- Department of Neonatology, Centre Hospitalier Intercommunal de Creteil, Créteil, France
- CEDITEC, University Paris Est Creteil, France
| | - Hélène Béhal
- Department of biostatistics, Univ. Lille, CHU Lille, Lille, France
| | - Monique Kaminski
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Caroline Diguisto
- Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, France
| | - Barthélémy Tosello
- Department of Neonatology, Assistance Publique-Hôpitaux de Marseille, Nord Hospital, Marseille, France
- Aix-Marseille University, CNRS, EFS, ADES, Marseille, France
| | - Elie Azria
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
- Maternity Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Olivier Claris
- Department of Neonatology, Hospices Civils de Lyon, Hôpital Femme Mère Enfants
- Claude Bernard University, EAM, France
| | | | - Laurence Foix L’Hélias
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
- Sorbonne Université Paris, France, Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Patrick Truffert
- CHU Lille Neonatal unit, EA Epidemiology and Quality of Care, Lille, France
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Geurtzen R, van Heijst A, Draaisma J, Ouwerkerk L, Scheepers H, Hogeveen M, Hermens R. Prenatal counseling in extreme prematurity - Insight into preferences from experienced parents. PATIENT EDUCATION AND COUNSELING 2019; 102:1541-1549. [PMID: 30948203 DOI: 10.1016/j.pec.2019.03.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE In-depth analysis of parental preferences in prenatal counseling in extreme prematurity. METHODS A nationwide qualitative interview study among experienced parents of extremely premature babies born at 24+0/7 - 24+6/7 weeks of gestation. Semi-structured interviews were held until saturation, transcribed and qualitatively analyzed to search for parental counseling preferences. RESULTS Thirteen parents were included, most parents decided on active care. Organisation: Parents wanted counseling as soon as possible, and for various reasons they wanted more than one conversation. Supportive material to help visualize complex information was suggested to be helpful, preferably with adjustable levels of detail. An empathetic, honest style with commitment of the counselor was regarded important. CONTENT Understandable statistics should be used for those who want it. Parents needed different information with respect to the decision-making as opposed to being prepared for future situations. Decision-making: The preferred share of parents' and doctors' input in decision-making varied among parents and among situations. Parents expressed that their roles were to take responsibility for and protect their infant. CONCLUSIONS Various parental preferences for prenatal counseling were found. PRACTICE IMPLICATIONS Common parental preferences for the organisation, content and decision-making elements can provide a starting point for personalized prenatal counseling.
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Affiliation(s)
- Rosa Geurtzen
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands.
| | - Arno van Heijst
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | - Jos Draaisma
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | - Laura Ouwerkerk
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | | | - Marije Hogeveen
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | - Rosella Hermens
- Scientific Institute for Quality of Care, Radboud university medical center, Nijmegen, the Netherlands
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Caring for or caring with?Production of different caring relationships and the construction of time. Soc Sci Med 2019; 233:78-86. [DOI: 10.1016/j.socscimed.2019.05.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 01/31/2023]
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Guillén Ú, Mackley A, Laventhal N, Kukora S, Christ L, Derrick M, Batza J, Ghavam S, Kirpalani H. Evaluating the Use of a Decision Aid for Parents Facing Extremely Premature Delivery: A Randomized Trial. J Pediatr 2019; 209:52-60.e1. [PMID: 30952510 PMCID: PMC6625526 DOI: 10.1016/j.jpeds.2019.02.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/30/2019] [Accepted: 02/14/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To assess decisional conflict and knowledge about prematurity among mothers facing extreme premature delivery when the counseling clinicians were randomized to counsel using a validated decision aid compared with usual counseling. STUDY DESIGN In this randomized trial, clinicians at 5 level III neonatal intensive care units in the US were randomized to supplement counseling using the decision aid or to counsel mothers in their usual manner. We enrolled mothers with threatened premature delivery at 220/7 to 256/7 weeks of gestation within 7 days of their counseling. The primary outcome was the Decisional Conflict Scale (DCS) score. One hundred mothers per group were enrolled to detect a clinically relevant effect size of 0.4 in the Decisional Conflict Scale. Secondary outcomes included knowledge about prematurity; scores on the Preparedness for Decision Making scale; and acceptability. RESULTS Ninety-two clinicians were randomized and 316 mothers were counseled. Of these, 201 (64%) mothers were enrolled. The median gestational age was 24.1 weeks (IQR 23.7-24.9). In both groups, DCS scores were low (16.3 ± 18.2 vs 16.8 ± 17, P = .97) and Preparedness for Decision Making scores were high (73.4 ± 28.3 vs 70.5 ± 31.1, P = .33). There was a significantly greater knowledge score in the decision aid group (66.2 ± 18.5 vs 57.2 ± 18.8, P = .005). Most clinicians and parents found the decision aid useful. CONCLUSIONS For parents facing extremely premature delivery, use of a decision aid did not impact maternal decisional conflict, but it significantly improved knowledge of complex information. A structured decision aid may improve comprehension of complex information. TRIAL REGISTRATION Clinicaltrials.gov: NCT01713894.
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Affiliation(s)
- Úrsula Guillén
- Division of Neonatology, Christiana Care Health System, Newark, DE.
| | - Amy Mackley
- Division of Neonatology, Christiana Care Health System, Newark, DE
| | - Naomi Laventhal
- Division of Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, MI
| | - Stephanie Kukora
- Division of Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, MI
| | - Lori Christ
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Matthew Derrick
- Division of Neonatology, NorthShore University Health System, Evanston, IL
| | - Jennifer Batza
- Division of Neonatology, NorthShore University Health System, Evanston, IL
| | - Sarvin Ghavam
- Division of Neonatology, Virtua Voorhees Hospital, Voorhees Township, NJ
| | - Haresh Kirpalani
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
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Edmonds BT, Savage TA, Kimura RE, Kilpatrick SJ, Kuppermann M, Grobman W, Kavanaugh K. Prospective parents' perspectives on antenatal decision making for the anticipated birth of a periviable infant. J Matern Fetal Neonatal Med 2019; 32:820-825. [PMID: 29103318 PMCID: PMC6810652 DOI: 10.1080/14767058.2017.1393066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine prospective parents' perceptions of management options and outcomes in the context of threatened periviable delivery, and the values they apply in making antenatal decisions during this period. STUDY DESIGN Qualitative analysis of 46 antenatal interviews conducted at three tertiary-care hospitals with 54 prospective parents (40 pregnant women, 14 partners) who had received counseling for threatened periviable delivery (40 cases). RESULTS Participants most often recalled being involved in resuscitation, cerclage, and delivery mode decisions. Over half (63.0%) desired a shared decision-making role. Most (85.2%) recalled hearing about morbidity and mortality, with many reiterating terms like "brain damage", "disability", and "handicap". The potential for disability influenced decision making to variable degrees. In describing what mattered most, participant spoke of giving their child a "fighting chance"; others voiced concerns about "best interest", a "healthy baby", "pain and suffering", and religious faith. CONCLUSIONS Our findings underscore the importance of presenting clear information on disability and eliciting the factors that parents deem most important in making decisions about periviable birth.
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Affiliation(s)
- Brownsyne Tucker Edmonds
- Indiana University School of Medicine, Department of Obstetrics and Gynecology, Indianapolis, IN
| | - Teresa A. Savage
- University of Illinois at Chicago, Department of Women, Children & Family Health Science, Chicago, IL
| | - Robert E. Kimura
- Rush University Medical Center, Department of Pediatrics, Chicago, IL
| | - Sarah J. Kilpatrick
- Cedars-Sinai Medical Center, Department of Obstetrics and Gynecology, Los Angeles, CA
| | - Miriam Kuppermann
- University of California, San Francisco, Department of Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA
| | - William Grobman
- Northwestern University Medical School, Obstetrics and Gynecology-Maternal Fetal Medicine, Chicago, IL
| | - Karen Kavanaugh
- Wayne State University College of Nursing and the Children’s Hospital of Michigan, Detroit, MI
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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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Geurtzen R, Draaisma J, Hermens R, Scheepers H, Woiski M, van Heijst A, Hogeveen M. Various experiences and preferences of Dutch parents in prenatal counseling in extreme prematurity. PATIENT EDUCATION AND COUNSELING 2018; 101:2179-2185. [PMID: 30029812 DOI: 10.1016/j.pec.2018.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/28/2018] [Accepted: 07/03/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate experienced and preferred prenatal counseling among parents of extremely premature babies. METHODS A Dutch nationwide, multicenter, cross-sectional study using an online survey. Surveys were sent to all parents of extremely premature babies born between 2010 and 2013 at 24+0/7-24+6/7 weeks of gestation. RESULTS Sixty-one out of 229 surveys were returned. A minority (14%) had no counseling conversation. Conversations were done more often by neonatologists (90%) than by obstetricians (39%) and in 37% by both these experts. Supportive material was rarely used (19%). Mortality (92%) and short-term morbidity (88%) were discussed the most, and more frequently than long-term morbidity (65%), practical items (63%) and delivery mode (52%). Most decisions on active care or palliative comfort care were perceived as decisions by doctor and parents together (61%). 80% felt they were involved in decision-making. The preferred way of involvement in decision-making varied among parents. CONCLUSION The vast majority of parents were counseled: mostly by neonatologists, and mainly about mortality and short-term morbidity. Parents wanted to be involved in the decision-making process but differed on the preferred extent of involvement. Practice implications Understanding of shared decision-making may contribute to meet the various preferences of parents.
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Affiliation(s)
- Rosa Geurtzen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands.
| | - Jos Draaisma
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| | - Rosella Hermens
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of IQ Healthcare, Nijmegen, The Netherlands
| | | | - Mallory Woiski
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Gynecology, Nijmegen, The Netherlands
| | - Arno van Heijst
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
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Schrijvers NM, Geurtzen R, Draaisma JM, Halamek LP, Yamada NK, Hogeveen M. Perspectives on periviability counselling and decision-making differed between neonatologists in the United States and the Netherlands. Acta Paediatr 2018; 107:1710-1715. [PMID: 29603788 DOI: 10.1111/apa.14347] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 12/27/2017] [Accepted: 03/23/2018] [Indexed: 11/28/2022]
Abstract
AIM American guidelines suggest that neonatal resuscitation be considered at 23 weeks of gestation, one week earlier than in the Netherlands, but how counselling practices differ at the threshold of viability is unknown. This pilot study compared prenatal periviability counselling in the two countries. METHODS In 2013, a cross-sectional survey was sent to 121 Dutch neonatologists as part of a nationwide evaluation of prenatal counselling. In this pilot study, the same survey was sent to a convenience sample of 31 American neonatologists in 2014. The results were used to compare the organisation, content and decision-making processes in prenatal counselling at 24 weeks of gestation between the two countries. RESULTS The survey was completed by 17 (55%) American and 77 (64%) Dutch neonatologists. American neonatologists preferred to meet with parents more frequently, for longer periods of time, and to discuss more intensive care topics, including long-term complications, than Dutch neonatologists. Neonatologists from both countries preferred shared decision-making when deciding whether to initiate intensive care. CONCLUSION Neonatologists in the United States and the Netherlands differed in their approach to prenatal counselling at 24 weeks of gestation. Cross-cultural differences may play a role.
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Affiliation(s)
| | - Rosa Geurtzen
- Radboudumc Amalia Children's Hospital; Nijmegen the Netherlands
| | | | - Louis P. Halamek
- Center for Advanced Pediatric and Perinatal Education; Stanford University; Palo Alto CA USA
| | - Nicole K. Yamada
- Center for Advanced Pediatric and Perinatal Education; Stanford University; Palo Alto CA USA
| | - Marije Hogeveen
- Radboudumc Amalia Children's Hospital; Nijmegen the Netherlands
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Ursin L, Syltern J. In the Best Interest of the. . .Parents: Norwegian Health Personnel on the Proper Role of Parents in Neonatal Decision-making. Pediatrics 2018; 142:S567-S573. [PMID: 30171143 DOI: 10.1542/peds.2018-0478h] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The role of parents in life-and-death decision-making for infants born at the border of viability is challenging. Some argue that parents should have the final say in decisions about life-sustaining treatment. Others disagree. In this article, we report views from health care personnel (HCP) on the appropriate parental role. METHODS Focus group interviews with 5 different groups of HCP (neonatal nurses, midwifes, obstetricians, mother-fetal specialists, and neonatologists) dealing with life-and-death decisions throughout pregnancy and birth were performed at the Norwegian University of Science and Technology and at St Olav's Hospital in Trondheim, Norway in 2014-2017. Interviews were taped and transcribed. Inductive analysis was performed for each group discussion for emergent ethical themes. A summary of the transcribed discussion was sent to the relevant focus group participants for comments. RESULTS Our participants felt strongly that doctors, not parents, should have the final say. They did not think parents should have to live with the burden of the decision. The possible disagreement between parents, lack of necessary knowledge, experience, time, and emotional stability all point toward the neonatologist as the optimal decision-maker, within a model of "Patient Preference-Satisfaction Paternalism." CONCLUSIONS The general attitude of our groups was that parents should have a say and be included in a thorough information and decision-making process. The doctor, or a team of HCP, however, should make the final decision, being in the best position both epistemologically and normatively to promote the best interest of both parents and the child.
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Affiliation(s)
- Lars Ursin
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway; and
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Foe G, Hellmann J, Greenberg RA. Parental Moral Distress and Moral Schism in the Neonatal ICU. JOURNAL OF BIOETHICAL INQUIRY 2018; 15:319-325. [PMID: 29802588 DOI: 10.1007/s11673-018-9858-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 03/28/2018] [Indexed: 05/22/2023]
Abstract
Ethical dilemmas in critical care may cause healthcare practitioners to experience moral distress: incoherence between what one believes to be best and what occurs. Given that paediatric decision-making typically involves parents, we propose that parents can also experience moral distress when faced with making value-laden decisions in the neonatal intensive care unit. We propose a new concept-that parents may experience "moral schism"-a genuine uncertainty regarding a value-based decision that is accompanied by emotional distress. Schism, unlike moral distress, is not caused by barriers to making and executing a decision that is deemed to be best by the decision-makers but rather an encounter of significant internal struggle. We explore factors that appear to contribute to both moral distress and "moral schism" for parents: the degree of available support, a sense of coherence of the situation, and a sense of responsibility. We propose that moral schism is an underappreciated concept that needs to be explicated and may be more prevalent than moral distress when exploring decision-making experiences for parents. We also suggest actions of healthcare providers that may help minimize parental "moral schism" and moral distress.
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Affiliation(s)
- Gabriella Foe
- Bioethics Department, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jonathan Hellmann
- Bioethics Department, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Rebecca A Greenberg
- Bioethics Department, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
- Department of Paediatrics, University of Toronto, Toronto, Canada.
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Linder E, Burguet A, Nobili F, Vieux R. Neonatal renal replacement therapy: An ethical reflection for a crucial decision. Arch Pediatr 2018; 25:371-377. [PMID: 30143372 DOI: 10.1016/j.arcped.2018.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 06/05/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT Technological advances in fetal and neonatal medicine, recent changes in the French legal framework, and encouraging results of the long-term outcomes in children with neonatal renal failure provide elements for an ethical reflection. METHODS We led a nationwide enquiry among French pediatric nephrologists, intensivists, and neonatologists, exploring the decision-making process when contemplating starting renal replacement therapy (RRT) or delivering palliative care to neonates or infants with pre-end-stage or end-stage renal disease; and the ethical quandaries at hand in such scenarios. RESULTS A total of 134 responses with complete national coverage were obtained. Care to be delivered to an infant in pre-end-stage or end-stage renal disease did not achieve consensus. Pediatric nephrologists were more prone to initiate a dialysis/graft program than pediatric intensivists. When chronic kidney disease was associated with comorbidities, especially neurological impairment, physicians, regardless of their subspecialty, were more reluctant to initiate conservative treatment. Many of the doctors surveyed did not give their opinion in these prenatal and/or postnatal situations, considered to be unique and warranting a multidisciplinary reflection. CONCLUSION Such ethical dilemmas are challenging for parents and physicians. They can only be overcome by taking into account both concrete on the ground realities and general principles and values acknowledged to be a basis for respecting the individual. In this way, it ensures humaneness and humanization of a practice that must meet a variety of challenges, one by one. The answer is not simple; it is always unique to each child and can only be approached by a multidisciplinary, time-consuming, open discussion, which will never totally erase uncertainty.
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Affiliation(s)
- E Linder
- Neonatal Department, Centre Hospitalier Universitaire de Strasbourg, 1, place de l'hôpital BP 426, 67091 Strasbourg cedex, France
| | - A Burguet
- Department of Neonatology, Centre Hospitalier Universitaire de Dijon, 1, rue Paul-Gaffarel, 21079 Dijon, France
| | - F Nobili
- Paediatric Nephrology Unit, Centre Hospitalier Universitaire Regional de Besancon, 3, boulevard Alexander-Fleming, 25030 Besançon cedex, France
| | - R Vieux
- Paediatric Nephrology Unit, Centre Hospitalier Universitaire Regional de Besancon, 3, boulevard Alexander-Fleming, 25030 Besançon cedex, France; Paediatric Department, Centre Hospitalier Universitaire Regional de Besançon, 25030 Besançon cedex, France; SMP, Franche-Comte University, 25030 Besançon, France.
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Motz P, Gray M, Sawyer T, Kett J, Danforth D, Maicher K, Umoren R. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): Pilot Study. JMIR Serious Games 2018; 6:e8. [PMID: 29752249 PMCID: PMC5970284 DOI: 10.2196/games.9611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 11/13/2022] Open
Abstract
Background Prenatal counseling at the limits of newborn viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in times of high stress. Decision aids may help improve provider communication but have not been universally adopted. Virtual standardized patients are increasingly recognized as a modality for education, but prenatal counseling simulations have not been described. To be valuable as a tool, a virtual patient would need to accurately portray emotions and elicit a realistic response from the provider. Objective To determine if neonatal providers can accurately identify a standardized virtual prenatal patient’s emotional states and examine the frequency of empathic responses to statements made by the patient. Methods A panel of Neonatologists, Simulation Specialists, and Ethicists developed a dialogue and identified empathic responses. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA), a screen-based simulation of a woman at 23 weeks gestation, was capable of displaying anger, fear, sadness, and happiness through animations. Twenty-four neonatal providers, including a subgroup with an ethics interest, were asked to identify VANESSA’s emotions 28 times, respond to statements, and answer open-ended questions. The emotions were displayed in different formats: without dialogue, with text dialogue, and with audio dialogue. Participants completed a post-encounter survey describing demographics and experience. Data were reported using descriptive statistics. Qualitative data from open ended questions (eg, “What would you do?”) were examined using thematic analysis. Results Half of our participants had over 10 years of clinical experience. Most participants reported using medical research (18/23, 78%) and mortality calculators (17/23, 74%). Only the ethics-interested subgroup (10/23, 43%) listed counseling literature (7/10, 70%). Of 672 attempts, participants accurately identified VANESSA’s emotions 77.8% (523/672) of the time, and most (14/23, 61%) reported that they were confident in identifying these emotions. The ethics interest group was more likely to choose empathic responses (P=.002). Participants rated VANESSA as easy to use (22/23, 96%) and reported that she had realistic dialogue (15/23, 65%). Conclusions This pilot study shows that a prenatal counseling simulation is feasible and can yield useful data on prenatal counseling communication. Our participants showed a high rate of emotion recognition and empathy in their responses.
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Affiliation(s)
- Patrick Motz
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Megan Gray
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Jennifer Kett
- Division of Neonatology, Department of Pediatrics, Mary Bridge Children's Hospital, Tacoma, WA, United States
| | - Douglas Danforth
- Medical Simulation, Obstetrics and Gynocology, Ohio State University, Columbus, OH, United States
| | - Kellen Maicher
- Medical Simulation, Obstetrics and Gynocology, Ohio State University, Columbus, OH, United States
| | - Rachel Umoren
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
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Antenatal Consultations at Extreme Prematurity: A Systematic Review of Parent Communication Needs. J Pediatr 2018; 196:109-115.e7. [PMID: 29223461 DOI: 10.1016/j.jpeds.2017.10.067] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/28/2017] [Accepted: 10/26/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To synthesize and describe parental expectations on how healthcare professionals should interact with them during a peripartum, antenatal consultation for extremely preterm infants. STUDY DESIGN For this systematic literature review with textual narrative synthesis, we included studies that explored parental perspectives regarding the antenatal consultation for an extremely preterm infant. Electronic searches of Medline, CINAHL, PsycInfo, and Embase were conducted, along with a search of the grey literature. Quality appraisal was conducted using the guide by Walsh and Downe. Two independent reviewers reviewed 783 titles, of which 130 abstracts then 40 full-text articles were reviewed. Final data abstraction includes 19 studies. We predetermined 6 topics of interest (setting, timing, preferred healthcare professional, information, resources, and parents-physician interaction) to facilitate thematic analysis. RESULTS In consideration of the variability of parents' specific desires, six predetermined topics and additional overarching themes such as perception of support, degree of understanding, hope, spirituality, and decision-making influences emerged. Studies suggest the quality of the antenatal consultation is not purely about information content, but also the manner in which it is provided. Limitations include thematic analysis that can potentially lead to the exclusion of important nuances. Relevant studies may have been missed if published outside the healthcare literature. CONCLUSIONS The findings may inform clinical practice guidelines. This paper includes suggested strategies related to parents' perspectives that may facilitate communication during antenatal consultation for an extremely preterm infant. These strategies may also support parental engagement and satisfaction.
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Coughlin KW. La prise de décision médicale en pédiatrie : de la naissance à l’adolescence. Paediatr Child Health 2018; 23:147-155. [PMCID: PMC5905440 DOI: 10.1093/pch/pxx182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
En pédiatrie, la prise de décision médicale est compliquée par les variations importantes du développement physique et psychologique observées entre la naissance et l’adolescence. Les parents et les tuteurs sont les décideurs de facto au nom des nourrissons, mais par la suite, leur rôle et celui des patients deviennent de plus en plus complexe. Tout au long de l’enfance, les dispensateurs de soins (DdS), qui ne sont pas des décideurs en soi, ont un rôle important à jouer dans la prise de décision médicale. Le présent document de principes expose les principes éthiques de la prise de décision médicale pour les DdS qui participent aux soins des patients pédiatriques. Cette mise à jour porte sur la prise de décision individuelle dans le cadre de la relation entre le patient et le DdS et fournit plus de conseils en cas de mésententes.
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Affiliation(s)
- Kevin W Coughlin
- Société canadienne de pédiatrie, comité de bioéthique, Ottawa (Ontario)
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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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Coughlin KW. Medical decision-making in paediatrics: Infancy to adolescence. Paediatr Child Health 2018; 23:138-146. [PMID: 30653623 DOI: 10.1093/pch/pxx127] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Medical decision-making in the paediatric population is complicated by the wide variation in physical and psychological development that occurs as children progress from infancy to adolescence. Parents and legal guardians are the de facto decision-makers in early infancy, but thereafter, the roles of parents/legal guardians and paediatric patients become ever more complex. Health care providers (HCPs), while not decision-makers per se, have a significant role in medical decision-making throughout childhood. This statement outlines the ethical principles of medical decision-making for HCPs involved in caring for paediatric patients. This revision focuses on individual decision-making in the context of the patient-provider relationship and provides increased guidance for dealing with disagreements.
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Affiliation(s)
- Kevin W Coughlin
- Canadian Paediatric Society, Bioethics Committee, Ottawa, Ontario
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Abstract
The hospital is a place of encounter between health care providers, patients and family members, the healthy and the suffering, migrants and non-migrants, as well as social and cultural minorities, and majorities of various backgrounds. It is also a space where multiple conceptions of care, life, quality of life, and death are enacted, sometimes inhibiting mutual understanding between caregivers and the cared for, a scenario that in turn may provoke conflict. Through the lens of conflict, we explore in this article the theme of Otherness within the clinic, basing analysis on an ethnographic study conducted in recent years in three cosmopolitan Canadian cities. Daily practices and-on a larger scale-the social space of the clinic become material here for reflecting on recognition (and non-recognition) of the Other as actors in the clinical encounter. The examination of structural and situational conditions that contribute to the emergence of conflict offers an understanding of the diversity of values that pervade the clinic. By way of conclusion, we argue that recognition of diversity, at least on the part of practitioners, is a key condition for the emergence of a pluralist normativity in the social space of the clinic.
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Affiliation(s)
- Sylvie Fortin
- Department of Anthropology, Université de Montréal, C.P.6128 succ. Centre-ville, Montréal, QC, H3C3J7, Canada.
| | - Serge Maynard
- McGill University Health Center, Montréal, QC, Canada
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Abstract
Despite advances in life-saving technology for critically ill neonates, challenges continue to arise for infants delivered with extreme prematurity, congenital anomalies, and genetic conditions that exceed the limits of currently available interventions. In these situations, parents are forced to make cognitively and emotionally difficult decisions, in discussion with a neonatologist, regarding how aggressively to provide supportive measures at the time of delivery and at what point burdens of therapy outweigh benefits. Current guidelines recommend that parents' values should guide these decisions; however, little is known about the values parents hold, and how those values are employed in the context of complexity, uncertainty, and emotionality of these situations. Systematic investigation of how parents derive their values and how clinicians should engage with parents about those values is necessary to guide the development of interventions to enhance shared decision-making processes, ultimately improving satisfaction, coping, and resilience and minimizing the potential for regret.
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Affiliation(s)
- Stephanie K Kukora
- University of Michigan Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Ann Arbor, MI, USA; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Renee D Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA; Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
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Dunn SI, Cragg B, Graham ID, Medves J, Gaboury I. Roles, processes, and outcomes of interprofessional shared decision-making in a neonatal intensive care unit: A qualitative study. J Interprof Care 2018; 32:284-294. [PMID: 29364748 DOI: 10.1080/13561820.2018.1428186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Shared decision-making provides an opportunity for the knowledge and skills of care providers to synergistically influence patient care. Little is known about interprofessional shared decision-making processes in critical care settings. The aim of this study was to explore interprofessional team members' perspectives about the nature of interprofessional shared decision-making in a neonatal intensive care unit (NICU) and to determine if there are any differences in perspectives across professional groups. An exploratory qualitative approach was used consisting of semi-structured interviews with 22 members of an interprofessional team working in a tertiary care NICU in Canada. Participants identified four key roles involved in interprofessional shared decision-making: leader, clinical experts, parents, and synthesizer. Participants perceived that interprofessional shared decision-making happens through collaboration, sharing, and weighing the options, the evidence and the credibility of opinions put forward. The process of interprofessional shared decision-making leads to a well-informed decision and participants feeling valued. Findings from this study identified key concepts of interprofessional shared decision-making, increased awareness of differing professional perspectives about this process of shared decision-making, and clarified understanding of the different roles involved in the decision-making process in an NICU.
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Affiliation(s)
- Sandra I Dunn
- a School of Nursing , University of Ottawa , Ottawa , Ontario , Canada
| | - Betty Cragg
- a School of Nursing , University of Ottawa , Ottawa , Ontario , Canada
| | - Ian D Graham
- a School of Nursing , University of Ottawa , Ottawa , Ontario , Canada
| | - Jennifer Medves
- b School of Nursing , Queen's University , Kingston , Ontario , Canada
| | - Isabelle Gaboury
- c Department of Family Medicine and Emergency Medicine , Université de Sherbrooke , Québec , Canada
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Haward MF, Janvier A, Lorenz JM, Fischhoff B. Counseling parents at risk of delivery of an extremely premature infant: Differing strategies. AJOB Empir Bioeth 2017; 8:243-252. [PMID: 29048264 DOI: 10.1080/23294515.2017.1394399] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND It is not known how neonatologists address the affective and cognitive loads on parents deciding whether to resuscitate infants born extremely preterm. This study explores expert neonatologists' views on these decision-making processes and their own roles in counseling parents. METHODS Semistructured interviews asked internationally recognized experts to share their perspectives on perinatal consultations. Their responses were subjected to thematic analysis. RESULTS Eighteen of 22 invited experts participated. Approximately equal numbers reported employing a physician-driven approach, a parent-driven approach, and a combined approach during these consultations. Those who followed a physician-driven approach typically focused on conveying standard information about adverse outcomes. Those who followed a parent-driven approach typically focused on addressing parents' information requests, guiding their decision making, and providing affective support. Nearly all experts, in each group, endorsed addressing the child's quality of life, in terms of functionality, when discussing long-term outcomes. Although many believed that families adjusted to life with a disabled child, few discussed the topic during prenatal consultations. Most, in each group, reported trying to alleviate future "decisional regret" for parents whose premature infants subsequently became disabled. None spoke to parents about possible decisional regret after deciding to forgo resuscitation. CONCLUSIONS Expert neonatologists are deeply concerned that parents understand the decision facing them. However, they differ on what information they offer and how they balance parents' need for cognitive and affective support. They expressed more concern about parents' decisional regret should their child survive resuscitation, but have severe disability, than about decisional regret after foregoing resuscitation.
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Affiliation(s)
- Marlyse F Haward
- a Children's Hospital at Montefiore, Albert Einstein College of Medicine
| | - Annie Janvier
- b Department of Pediatrics and Clinical Ethics , Université de Montréal, Division of Neonatology, Hôpital Sainte-Justine, Bureau de L'éthique Clinique, Université de Montréal, and Centre de Recherche, Hôpital Sainte-Justine
| | - John M Lorenz
- c Department of Pediatrics , Columbia University College of Physicians and Surgeons, and Morgan Stanley Children's Hospital of New York
| | - Baruch Fischhoff
- d Department of Engineering and Public Policy and Institute for Politics and Strategy , Carnegie Mellon University
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Lemyre B, Moore G. Les conseils et la prise en charge en prévision d’une naissance extrêmement prématurée. Paediatr Child Health 2017. [DOI: 10.1093/pch/pxx059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lemyre B, Moore G. Counselling and management for anticipated extremely preterm birth. Paediatr Child Health 2017; 22:334-341. [PMID: 29485138 DOI: 10.1093/pch/pxx058] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Counselling couples facing the birth of an extremely preterm infant is a complex and delicate task, entailing both challenges and opportunities. This revised position statement proposes using a prognosis-based approach that takes the best estimate of gestational age into account, along with additional factors, including estimated fetal weight, receipt of antenatal corticosteroids, singleton versus multiple pregnancy, fetal status and anomalies on ultrasound and place of birth. This statement updates data on survival in Canada, long-term neurodevelopmental disability at school age and quality of life, with focus on strategies to communicate effectively with parents. It also proposes a framework for determining the prognosis-based management option(s) to present to parents when initiating the decision-making process. This statement replaces the 2012 position statement.
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Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Gregory Moore
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Moore GP, Daboval T, Moore-Hepburn C, Lemyre B. ‘Counselling and management for anticipated extremely preterm birth’: Informing CPS statements through national consultation. Paediatr Child Health 2017. [DOI: 10.1093/pch/pxx030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Counselling about the Risk of Preterm Delivery: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7320583. [PMID: 28848765 PMCID: PMC5564059 DOI: 10.1155/2017/7320583] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/17/2017] [Accepted: 07/10/2017] [Indexed: 11/24/2022]
Abstract
We aimed to describe the outcomes of counselling for preterm delivery. PubMed, Embase, and PsycInfo were systematically searched (from 2000 to 2016) using the following terms: counselling, pregnancy complications, high-risk pregnancy, fetal diseases, and prenatal care. A total of nine quantitative studies were identified, five randomized and four nonrandomized. All studies were conducted in the USA, and half of them were based on a simulated counselling session. Two main clinical implications can be drawn from the available studies: firstly, providing written information before or during the consultation seems to have a positive effect, while no effect was detected when written material was provided after the consultation. Secondly, parents' choices about treatment seemed to be influenced by spiritual-related aspects and/or preexisting preferences, rather than by the level of detail or by the order with which information was provided. Therefore, the exploration of parents' beliefs is crucial to reduce the risks of misconception and to guarantee choice in line with personal values. More research is necessary to validate these findings in cross-cultural contexts and in real world settings of care. Moreover, the centeredness of conversations and the characteristics of the clinician involved in counselling should be addressed in future studies.
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Studer EM, Marc-Aurele KL. Lost in explanation: Lessons learned from audio-recordings and surveys of the antenatal consultation. J Neonatal Perinatal Med 2017; 9:393-400. [PMID: 27834784 DOI: 10.3233/npm-16168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Determine content of antenatal prematurity consultations and identify factors associated with satisfaction. DESIGN This is an observational study of consultations for possible preterm delivery. Consultations were audio-recorded and analyzed. Parents and physicians were surveyed post-consultation. RESULTS We analyzed 17 audio-recordings. Mean gestation was 28 weeks. Frequency of topics discussed were: antenatal steroids 82%, intubation 82%, breast milk 76%, time in NICU 65%, development 59%, and survival 53%. Parents frequently asked about length of hospitalization stay, feeding, and separation concerns. Parents' greatest fears were developmental problems, survival, separation from baby, infant health, and length of hospitalization. The parent satisfaction score was 8.9, and physician satisfaction score was 4.8 on a ten-point scale. No factors were found to be associated with satisfaction. Physicians felt 82% of consultations could be improved. CONCLUSIONS In consultations for possible preterm delivery, physicians discussed resuscitation details and initial neonatal care. Parental greatest fears involved more global issues. Despite content variability, parents were highly satisfied. No specific factors (such as topics discussed or length of consultation) were found to be statistically associated with parent satisfaction. Physicians were less satisfied. Providing too much/too little information was a repeated physician concern.
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Affiliation(s)
- E M Studer
- Kaiser Permanente San Diego Medical Center, San Diego, CA, USA
| | - K L Marc-Aurele
- University of California San Diego/Rady Children's Hospitals, San Diego, CA, USA
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Field testing of decision coaching with a decision aid for parents facing extreme prematurity. J Perinatol 2017; 37:728-734. [PMID: 28358384 DOI: 10.1038/jp.2017.29] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/21/2016] [Accepted: 02/14/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The objective of this study is to assess and modify an existing decision aid and field-test decision coaching with the modified aid during consultations with parents facing potential delivery at 23 to 24 weeks gestation. STUDY DESIGN International Patient Decision Aid Standards instrument (IPDASi) scoring deficits, multi-stakeholder group feedback and α-testing guided modifications. Feasibility/acceptability were assessed. The Decisional Conflict Scale was used to measure participants' decisional conflict before (T1) and immediately after (T2) the consultation. RESULTS IPDASi assessment of the existing aid (score 11/35) indicated it required updated data, more information and a palliative care description. Following modification, IPDASi score increased to 26/35. Twenty subjects (12 pregnancies) participated in field-testing; 15 completed all questionnaires. Most participants (89%) would definitely recommend this form of consultation. Decisional conflict scores decreased (P<0.001) between T1 (52±25) and T2 (10±16). CONCLUSION Field testing demonstrated that consultations using the aid with decision coaching were feasible, reduced decisional conflict and may facilitate shared decision-making.
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Stokes TA, Kukora SK, Boss RD. Caring for Families at the Limits of Viability: The Education of Dr Green. Clin Perinatol 2017; 44:447-459. [PMID: 28477671 DOI: 10.1016/j.clp.2017.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Resuscitation decisions for infants born at the edges of viability are complicated moral dilemmas, and the process of making these decisions is emotionally exhausting and morally distressful for families and physicians alike. An ethical approach to making these decisions requires input from physicians and parents; individuals tasked with facilitating such decisions must possess the communication and counseling skills needed to assist families with these painful and life-altering decisions. It is incumbent on all of us to continue our investigation into how we can better assist families in this process while providing care that is in their best interest.
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Affiliation(s)
- Theophil A Stokes
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
| | - Stephanie K Kukora
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics and Communicable Diseases, Floor 8, 1540 E Hospital Dr SPC 4254, Ann Arbor, MI 48109, USA
| | - Renee D Boss
- Division of Neonatology, Johns Hopkins School of Medicine, Berman Institute of Bioethics, 600 North Wolfe Street, Baltimore, MD 21287, USA
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