Ethical decision making in the resuscitation of extremely premature infants: the health care professional's perspective

Obstetricians' Attitudes Toward the Treatment of Extremely Preterm Infants in China

IMPORTANCE

Extremely preterm infants (EPIs) are at high risk of mortality and disability, and whether obstetricians are active in treating EPIs is directly related to whether EPIs can get an opportunity to enter the neonatal intensive care unit (NICU) for treatment. A greater understanding of the attitudes of obstetricians toward the treatment of EPIs is needed to improve treatment of this population and optimize pediatric health policies and services.

OBJECTIVE

To clarify the attitudes of obstetricians toward the treatment of EPIs in China.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, online, questionnaire-based survey was conducted among obstetricians from various provinces and cities in China through the wenjuanxing application (a survey platform) between June and July 2021. The questionnaire included characteristics of the participants, their experiences in delivering EPIs, their attitudes toward EPI resuscitation, and their opinions about the cutoff for providing full care to preterm infants in China. Possible factors associated with their attitudes toward the cutoff for providing full care to preterm infants were analyzed by logistic regression. Data analysis was performed from August 2021 to January 2022.

MAIN OUTCOMES AND MEASURES

The attitudes of obstetricians toward the resuscitation and treatment of EPIs, and the current cutoff for providing full care to premature infants.

RESULTS

A total of 2817 valid questionnaires were recovered from 30 provinces and cities in mainland China. Of the 2817 obstetricians (mean [SD] age, 41.76 [8.50] years) investigated, 156 (5.5%) were male, 2661 (94.5%) were female, 1339 (47.5%) were deputy chief physicians or chief physicians, 1662 (59.0%) were from tertiary hospitals, and 2048 (72.7%) had experience in delivering EPIs. The proportion of obstetricians who supported resuscitation of preterm infants was 19.1% (539 respondents) at a gestational age 24 weeks, 24.1% (679 respondents) at 25 weeks, 54.8% (1543 respondents) at 26 weeks, and 100.0% (2817 respondents) at 27 weeks. A total of 1326 obstetricians (47.1%) reported that it was common or very common for EPIs to be withdrawn from resuscitation and not to be admitted to the NICU for treatment. Regarding the treatment of EPIs with higher possibility of survival, 1621 obstetricians (57.5%) maintained that appropriate information should be communicated but their parents' wishes should be respected. Most obstetricians (2051 respondents [72.8%]) maintained that 28 weeks was the cutoff for providing full care to preterm infants in China; 766 respondents (27.2%) thought of it as inappropriate, suggesting the cutoff should be less than 28 weeks. Logistic regression analysis showed that these differences were significantly associated with the professional titles of the obstetricians, geographical regions, hospital levels and types, whether they had any experience in delivering EPIs, and the total number of EPIs born yearly in their units.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, most Chinese obstetricians maintained a conservative attitude toward the treatment of EPIs. It was very common for EPIs to be withdrawn from treatment without entering the NICU directly after birth. Most obstetricians maintained that 28 weeks' gestational age should be the cutoff for providing full care to premature infants.

Bioethical Decisions in Neonatal Intensive Care: Neonatologists' Self-Reported Practices in Greek NICUs

This study presents, for the first time, empirical data on practices regarding bioethical decision-making in treatment of preterm and ill newborns in Greece. The aim of the study was to: (a) record self-reported practices and involvement of Greek physicians in decisions of withholding and withdrawing neonatal intensive care, and (b) explore the implication of cultural, ethical, and professional parameters in decision-making. Methods: 71 physicians, employed fulltime in all public Neonatal Intensive Care Units (NICUs) (n = 17) in Greece, completed an anonymous questionnaire between May 2009 and May 2011. Results: One-third of the physicians in our sample admitted that they have, at least once in the past, decided the limitation of intensive care of a newborn close to death (37.7%) and/or a newborn with unfavorable neurological prognosis (30.8%). The higher the physicians’ support towards the value of quality of human life, the more probable it was that they had taken a decision to withhold or withdraw neonatal intensive care (p < 0.05). Conclusions: Our research shows that Greek NICU physicians report considerably lower levels of ethical decision-making regarding preterm and ill newborns compared to their counterparts in other European countries. Clinical practices and attitudes towards ethical decision-making appear to be influenced mainly by the Greek physicians’ values.

Physicians' Attitudes on Resuscitation of Extremely Premature Infants: A Systematic Review

CONTEXT

Whether to resuscitate extremely premature infants (EPIs) is a clinically and ethically difficult decision to make. Indications and practices vary greatly across different countries and institutions, which suggests that resuscitation decisions may be influenced more by the attitudes of the individual treating physicians. Hence, gaining in-depth insight into physicians' attitudes improves our understanding of decision-making regarding resuscitation of EPIs.

OBJECTIVE

To better understand physicians' attitudes toward resuscitation of EPIs and factors that influence their attitudes through a systematic review of the empirical literature.

DATA SOURCES

Medline, Embase, Web of Science, and Scopus.

STUDY SELECTION

We selected English-language articles in which researchers report on empirical studies of physicians' attitudes toward resuscitation of EPIs.

DATA EXTRACTION

The articles were repeatedly read, themes were identified, and data were tabulated, compared, and analyzed descriptively.

RESULTS

Thirty-four articles were included. In general, physicians were more willing to resuscitate, to accept parents' resuscitation requests, and to refuse parents' nonresuscitation requests as gestational age (GA) increased. However, attitudes vary greatly for infants at GA 23 to 24 weeks, known as the gray zone. Although GA is the primary factor that influences physicians' attitudes, a complex interplay of patient- and non-patient-related factors also influences their attitudes.

LIMITATIONS

Analysis of English-only articles may limit generalizability of the results. In addition, authors of only 1 study used a qualitative approach, which may have led to a biased reductionist approach to understanding physicians' attitudes.

CONCLUSIONS

Although correlations between GA and attitudes emerged, the results suggested a more complex interplay of factors influencing such attitudes.

Professional ethics: the case of neonatology

Neonatal professionals encounter many ethical challenges especially when it comes to interventions at the limit of viability (weeks 22-25 of gestation). At times, these challenges make the moral dilemmas in neonatology tragic and they require a particular set of intellectual and moral virtues. Intellectual virtues of episteme and phronesis, together with moral virtues of courage, compassion, keeping fidelity to trust, and integrity were highlighted as key virtues of the neonatal professional. Recognition of the role of ethics requires a recognition that answering the obvious question (what shall we do?) does not always suffice. Acknowledging the tragic question (is any of the alternatives open to us free from serious moral wrongdoing) and recognizing the ethical dilemmas, where the lines between right and wrong are blurred, leads to actions taken towards establishing ethics frameworks to support decision-making. In neonatology units, such organizational support can help in allowing the team members to recognize the ethical dilemmas, avoid moral distress, and improve team cohesion and the quality of care provided. Only when the organizational structure allows ethical dilemmas to be recognized, adequate decisions can be made.

Exploring Distress Caused by Blame for a Negative Patient Outcome

OBJECTIVE

The aim of this study was to explore blame-related distress (B-RD).

BACKGROUND

No research exists describing the incidence and characteristics of consequences of blame.

METHODS

Survey research was used to explore the incidence, characteristics, and consequences of the distress caused by blame in the workplace.

RESULTS

B-RD is prevalent among intensive care and oncology staff. Participants reported an organizational impact to B-RD in terms of staff morale, turnover, and employee health. Management, physicians, and peers were the most frequently cited source of blame.

CONCLUSIONS

A proposed model is described to relate blame to other similar constructs.

Initiation of resuscitation in the delivery room for extremely preterm infants: a profile of neonatal resuscitation instructors

OBJECTIVE

The goal of the present study was to examine the decisions of pediatricians who teach neonatal resuscitation in Brazil, particularly those who start resuscitation in the delivery room for newborns born at 23-26 gestational weeks.

METHODS

The present study was a cross-sectional study that used electronic questionnaires (Dec/11-Sep/13) sent to instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics. The primary outcome was the gestational age at which the respondent said that he/she would initiate positive pressure ventilation in the delivery room. Latent class analysis was used to identify the major profiles of these instructors, and logistic regression was used to identify variables associated with belonging to one of the derived classes.

RESULTS

Of 685 instructors, 82% agreed to participate. Two latent classes were identified: 'pro-resuscitation' (instructors with a high probability of performing ventilation on infants born at 23-26 weeks) and 'pro-limitation' (instructors with a high probability of starting ventilation only for infants born at 25-26 weeks). In the multivariate model, compared with the 'pro-limitation' class, 'pro-resuscitation' pediatricians were more likely to be board-certified neonatologists and less likely to base their decision on the probability of the infant's death or on moral/religious considerations.

CONCLUSION

The pediatricians in the most aggressive group were more likely to be specialists in neonatology and to use less subjective criteria to make delivery room decisions.

Workplace Blame and Related Concepts: An Analysis of Three Case Studies

Blame has been thought to affect quality by decreasing error reporting. Very little is known about the incidence, characteristics, or consequences of the distress caused by being blamed. Blame-related distress (B-RD) may be related to moral distress, but may also be a factor in burnout, compassion fatigue, lateral violence, and second-victim syndrome. The purpose of this article is to explore these related concepts through a literature review applied to three index critical care clinician cases.

Moral distress in the resuscitation of extremely premature infants

OBJECTIVE

To increase our understanding of moral distress experienced by neonatal registered nurses when directly or indirectly involved in the decision-making process of resuscitating infants who are born extremely premature.

DESIGN

A secondary qualitative analysis was conducted on a portion of the data collected from an earlier study which explored the ethical decision-making process among health professionals and parents concerning resuscitation of extremely premature infants.

SETTING

A regional, tertiary academic referral hospital in Ontario offering a perinatal program.

PARTICIPANTS

A total of 15 registered nurses were directly or indirectly involved in the resuscitation of extremely premature infants.

METHODS

Interview transcripts of nurses from the original study were purposefully selected from the original 42 transcripts of health professionals. Inductive content analysis was conducted to identify themes describing factors and situations contributing to moral distress experienced by nurses regarding resuscitation of extremely premature infants.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the research ethics review board for both the initial study and this secondary data analysis.

RESULTS

Five themes, uncertainty, questioning of informed consent, differing perspectives, perceptions of harm and suffering, and being with the family, contribute to the moral distress felt by nurses when exposed to neonatal resuscitation of extremely premature infants. An interesting finding was the nurses' perceived lack of power and influence in the neonatal resuscitation decision-making process.

CONCLUSION

Moral distress continues to be a significant issue for nursing practice, particularly among neonatal nurses. Strategies are needed to help mediate the moral distress experienced by nurses, such as debriefing sessions, effective communication, role clarification, and interprofessional education and collaboration.