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Loth C, Treluyer L, Pierrat V, Ego A, Aubert AM, Debillon T, Zeitlin J, Torchin H, Chevallier M. Variations in neonatal mortality of preterm infants with intraparenchymal haemorrhage in Europe: the EPICE cohort. Arch Dis Child Fetal Neonatal Ed 2024; 109:488-494. [PMID: 38272659 DOI: 10.1136/archdischild-2023-326038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 01/14/2024] [Indexed: 01/27/2024]
Abstract
OBJECTIVE The aim of this study was to investigate variations in mortality before neonatal intensive care unit (NICU) discharge of infants born preterm with intraparenchymal haemorrhage (IPH) in Europe with a special interest for withdrawing life-sustaining therapy (WLST). DESIGN Secondary analysis of the Effective Perinatal Intensive Care in Europe (EPICE) cohort, 2011-2012. SETTING Nineteen regions in 11 European countries. PATIENTS All infants born between 24+0 and 31+6 weeks' gestational age (GA) with a diagnosis of IPH. MAIN OUTCOME MEASURES Mortality rate with multivariable analysis after adjustment for GA, antenatal steroids and gender. WLST policies were described among NICUs and within countries. RESULTS Among 6828 infants born alive between 24+0 and 31+6 weeks' GA and without congenital anomalies admitted to NICUs, IPH was diagnosed in 234 infants (3.4%, 95% CI 3.3% to 3.9%) and 138 of them (59%) died. The median age at death was 6 days (3-13). Mortality rates varied significantly between countries (extremes: 30%-81%; p<0.004) and most infants (69%) died after WLST. After adjustment and with reference to the UK, mortality rates were significantly higher for France, Denmark and the Netherlands, with ORs of 8.8 (95% CI 3.3 to 23.6), 5.9 (95% CI 1.6 to 21.4) and 4.8 (95% CI 1.1 to 8.9). There were variations in WLST between European regions and countries. CONCLUSION In infants with IPH, rates of death before discharge and death after WLST varied between European countries. These variations in mortality impede studying reliable outcomes in infants with IPH across European countries and encourage reflection of clinical practices of WLST across European units.
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Affiliation(s)
- Charline Loth
- University Grenoble Alpes, Neonatology Department, CHU Grenoble-Alpes, Grenoble, France
| | - Ludovic Treluyer
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
| | - Véronique Pierrat
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
| | - Anne Ego
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
- Grenoble Alpes, Inserm CIC1406, CHU Grenoble, Grenoble, France
| | - Adrien M Aubert
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
| | - Thierry Debillon
- University Grenoble Alpes, Neonatology Department, CHU Grenoble-Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, Public Health Department CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, Institute of Engineering, University Grenoble Alpes, Grenoble, France
| | - Jennifer Zeitlin
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
| | - Heloise Torchin
- Université Paris Cité, Inserm, INRAE, Centre for Research in Epidemiology and StatisticS (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, F-75004 Paris, France
- Neonatal Intensive Care Unit, Port-Royal Maternity, Paris, Île-de-France, France
| | - Marie Chevallier
- University Grenoble Alpes, Neonatology Department, CHU Grenoble-Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, Public Health Department CHU Grenoble Alpes, Grenoble INP, TIMC-IMAG, Institute of Engineering, University Grenoble Alpes, Grenoble, France
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Shanks V, Guillen U, Mackley A, Sturtz W. Characterization of Spirituality in Parents of Very Preterm Infants in a Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:1261-1268. [PMID: 35738287 DOI: 10.1055/s-0042-1749189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to characterize the spiritual beliefs, practices, and needs of parents of very preterm infants, those born <32 weeks of gestation, in a level-III NICU and to characterize parental perception of the spiritual support received in the neonatal intensive care unit (NICU). STUDY DESIGN Within 14 days of their infants' birth, parents underwent a recorded semistructured interview. Responses were organized into unique themes using standard qualitative methods. Parents completed the Spiritual Involvement and Beliefs Scale (SIBS) and Spiritual Needs Inventory (SNI). RESULTS Twenty-six parents from 17 families were interviewed and provided SIBS and SNI surveys. Interviews yielded seven major themes describing parents' spirituality and support. Most parents identified themselves as spiritual (n = 14) or sometimes spiritual (n = 2). A high SIBS score was associated with Christian religion (p = 0.007) and non-White race (p = 0.02). The SNI showed ≥80% of parents reported a "frequent" or "always" need for laughter, being with family, thinking happy thoughts, and talking about day-to-day things. The most commonly mentioned sources of spiritual support were parents' connection with a higher power through their faith (n = 12) or religious activities (n = 8). Many parents reported receiving sufficient spiritual support outside of the hospital during their unique experience in the NICU. CONCLUSION Parents of infants born <32 weeks of gestation in our NICU commonly self-identified themselves as spiritual. Many parents have similar spiritual needs which are often met by sources outside of the hospital. KEY POINTS · Parents of infants born <32 weeks of gestation in our NICU commonly self-identify as spiritual.. · Many parents of preterm infants describe their spirituality as a personal experience.. · Many parents of preterm infants have similar spiritual needs.. · Many parents of preterm infants have their spiritual needs met outside of the hospital..
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Affiliation(s)
- Vanessa Shanks
- Division of Neonatology, Christiana Care Health System, Newark, Delaware
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Ursula Guillen
- Division of Neonatology, Christiana Care Health System, Newark, Delaware
| | - Amy Mackley
- Division of Neonatology, Christiana Care Health System, Newark, Delaware
| | - Wendy Sturtz
- Division of Neonatology, Christiana Care Health System, Newark, Delaware
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Friedrich AB. Ethical Consequences of Technological Mediation on Parental Decision-Making Experiences in the Neonatal Intensive Care Unit. QUALITATIVE HEALTH RESEARCH 2023; 33:259-269. [PMID: 36704925 DOI: 10.1177/10497323231151816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The neonatal intensive care unit (NICU) is a morally charged space in which parents may be confronted with difficult decisions about the treatment of their newborns, decisions often complicated and created by the increasing use of technologies. This paper adopts a postphenomenological approach to explore the ethical consequences of technological mediation on parental treatment decision-making in the NICU. Semi-structured interviews were conducted with parents of children who received invasive technological support in the NICU to better understand how they made treatment decisions or decisions about specific interventions during their child's hospitalization. The findings suggest that technological mediation-or the various ways in which humans can interact with their world via technologies-contributes to experiences of ambiguity, ambivalence, and alienation in parental decision-making. The ambiguity of invasive NICU technologies can create uncertainty in a decision, which can then lead to internal ambivalence about which decision to make. Ultimately, this ambiguity and ambivalence may lead to alienation from one's child, as parents are disconnected physically and emotionally from the decision and thus their child. Articulating the effects of technological mediation on parental decision-making is a key step in addressing decisional conflict in neonatal intensive care settings and better supporting parents in their decision-making roles.
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Affiliation(s)
- Annie B Friedrich
- Center for Bioethics and Medical Humanities, Institute for Health & Equity, 5506Medical College of Wisconsin, Milwaukee, WI, USA
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Dworetz AR, Natarajan G, Langer JC, Kinlaw K, James JR, Bidegain M, Das A, Poindexter BB, Bell EF, Cotten CM, Kirpalani H, Shankaran S, Stoll BJ. Withholding or withdrawing life-sustaining treatment in extremely low gestational age neonates. Arch Dis Child Fetal Neonatal Ed 2021; 106:238-243. [PMID: 33082153 PMCID: PMC8055718 DOI: 10.1136/archdischild-2020-318855] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 08/22/2020] [Accepted: 09/09/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To identify sociodemographic and clinical factors associated with withholding or withdrawing life-sustaining treatment (WWLST) for extremely low gestational age neonates. DESIGN Observational study of prospectively collected registry data from 19 National Institute of Child Health and Human Development Neonatal Research Network centres on neonates born at 22-28 weeks gestation who died >12 hours through 120 days of age during 2011-2016. Sociodemographic and clinical factors were compared between infants who died following WWLST and without WWLST. RESULTS Of 1168 deaths, 67.1% occurred following WWLST. Withdrawal of assisted ventilation (97.4%) was the primary modality. WWLST rates were inversely proportional to gestational age. Life-sustaining treatment was withheld or withdrawn more often for non-Hispanic white infants than for non-Hispanic black infants (72.7% vs 60.4%; 95% CI 1.00 to 1.92) or Hispanic infants (72.7% vs 67.2%; 95% CI 1.32 to 3.72). WWLST rates varied across centres (38.6-92.6%; p<0.001). The centre with the highest rate had adjusted odds 4.89 times greater than the average (95% CI 1.18 to 20.18). The adjusted odds of WWLST were higher for infants with necrotiing enterocolitis (OR 1.77, 95% CI 1.21 to 2.59) and severe brain injury (OR 1.98, 95% CI 1.44 to 2.74). CONCLUSIONS Among infants who died, WWLST rates varied widely across centres and were associated with gestational age, race, ethnicity, necrotiing enterocolitis, and severe brain injury. Further exploration is needed into how race, centre, and approaches to care of infants with necrotiing enterocolitis and severe brain injury influence WWLST.
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Affiliation(s)
- April R Dworetz
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - John C Langer
- Biostatistics and Epidemiology Division, RTI International, Rockville, MD
| | - Kathy Kinlaw
- Department of Pediatrics and the Center for Ethics, Emory University, Atlanta, GA
| | - Jennifer R James
- Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA
| | | | - Abhik Das
- Biostatistics and Epidemiology Division, RTI International, Rockville, MD
| | - Brenda B Poindexter
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Haresh Kirpalani
- Department of Pediatrics, The Children’s Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA
| | | | - Barbara J Stoll
- McGovern Medical School, University of Texas Health Sciences Center, Houston, TX
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Coughlin K, Mackley A, Kwadu R, Shanks V, Sturtz W, Munson D, Guillen U. Characterization of Spirituality in Maternal-Child Caregivers. J Palliat Med 2017; 20:994-997. [PMID: 28060549 DOI: 10.1089/jpm.2016.0361] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To characterize spiritual beliefs and support provided by maternal-child staff at three academic hospitals. BACKGROUND Parents in neonatal intensive care units (NICUs) believe that addressing spirituality is important. The spiritual beliefs and the support provided by NICU staff are currently unknown. METHODS This prospective study surveyed all maternal-child staff (NICU and Obstetrics): physicians, neonatal nurse practitioners, physician assistants, nurses, respiratory therapists, and social workers. Two validated tools were used: Spiritual Involvement and Beliefs Scale (SIBS) and Spiritual Care Inventory (SCI); SIBS assesses spiritual beliefs and practices, SCI assesses the perception of spiritual care that one provides. Demographic information, including self-identified religious affiliation, was collected. RESULTS Respondents of 406 completed surveys were mostly nurses, female, white, and Christian. SIBS scores ranged between 21 and 136. Higher SIBS score was associated with Christian religion (p = 0.001) and African American (p = 0.003) and Asian (p = 0.017) race, when controlling for site, age, gender, education, role in the NICU, and years in practice. A high SCI score was also associated with Christian religion (p = 0.01). There was a trend toward an association between SCI and older age (p = 0.051). There was an association between a high SIBS score and higher ratings on both SCI subscales used. DISCUSSION There is a wide range in spirituality and perceived spiritual support among maternal-child staff. This may coincide with the spiritual needs of families in the NICU.
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Affiliation(s)
| | - Amy Mackley
- 2 Christiana Care Health System , Newark, Delaware
| | - Rachel Kwadu
- 2 Christiana Care Health System , Newark, Delaware
| | | | - Wendy Sturtz
- 2 Christiana Care Health System , Newark, Delaware
| | - David Munson
- 1 Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
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Boss RD, Hutton N, Donohue PK, Arnold RM. Neonatologist training to guide family decision making for critically ill infants. ACTA ACUST UNITED AC 2009; 163:783-8. [PMID: 19736330 DOI: 10.1001/archpediatrics.2009.155] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To assess neonatology fellow training in guiding family decision making for high-risk newborns and in several critical communication skills for physicians in these scenarios. DESIGN A Web-based national survey. SETTING Neonatal-perinatal training programs in the United States. PARTICIPANTS Graduating fellows in their final month of fellowship. MAIN OUTCOME MEASURES Fellows' perceived training and preparedness to communicate with families about decision making. RESULTS The response rate was 72%, representing 83% of accredited training programs. Fellows had a great deal of training in the medical management of extremely premature and dying infants. However, they reported much less training to communicate and make collaborative decisions with the families of these infants. More than 40% of fellows reported no communication training in the form of didactic sessions, role play, or simulated patient scenarios and no clinical communication skills training in the form of supervision and feedback of fellow-led family meetings. Fellows felt least trained to discuss palliative care, families' religious and spiritual needs, and managing conflicts of opinion between families and staff or among staff. Fellows perceived communication skills training to be of a higher priority to them than to faculty, and 93% of fellows feel that training in this area should be improved. CONCLUSIONS Graduating neonatology fellows are highly trained in the technical skills necessary to care for critically ill and dying neonates but are inadequately trained in the communication skills that families identify as critically important when facing end-of-life decisions.
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Affiliation(s)
- Renee D Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD 21287, USA.
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Abstract
UNLABELLED We examined the literature on ethical decisions regarding neonates, to assess whether personal beliefs and prejudices influence end-of-life decisions taken by caregivers. Studies show that religion and familiarity with disability influence caregivers' decisions, whereas the influx of already being a parent, age, sex and professional experience is controverse. Caregivers' attitudes towards end-of-life decisions are also affected by personal concerns about litigation, prejudices and their view of disability. The concept of 'poor quality of life' is widely used as a reference in end-of-life decisions, but this can be interpreted differently, leaving room for a wide range of personal viewpoints. In most cases, parents' opinions are considered important and are sometimes the main determinant in decision making. However, it is unclear whether parents' decisions are based on their own wishes or on the best interests of the newborn. CONCLUSION In neonatal end-of-life decisions, patients may not receive cures based only on their best interests.
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Affiliation(s)
- Carlo V Bellieni
- Department of Pediatrics, Obstetrics and Reproduction Medicine, University of Siena, Italy.
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