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Cavolo A, Vears DF, Naulaers G, de Casterlé BD, Gillam L, Gastmans C. Doctor-Parent Disagreement for Preterm Infants Born in the Grey Zone: Do Ethical Frameworks Help? JOURNAL OF BIOETHICAL INQUIRY 2024:10.1007/s11673-024-10354-y. [PMID: 38969916 DOI: 10.1007/s11673-024-10354-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 03/03/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE To examine i) how ethical frameworks can be used in concrete cases of parent-doctors' disagreements for extremely preterm infants born in the grey zone to guide such difficult decision-making; and ii) what challenges stakeholders may encounter in using these frameworks. DESIGN We did a case analysis of a concrete case of parent-doctor disagreement in the grey zone using two ethical frameworks: the best interest standard and the zone of parental discretion. RESULTS Both ethical frameworks entailed similar advantages and challenges. They have the potential 1) to facilitate decision-making because they follow a structured method; 2) to clarify the situation because all relevant ethical issues are explored; and 3) to facilitate reaching an agreement because all parties can explain their views. We identified three main challenges. First, how to objectively evaluate the risk of severe disability. Second, parents' interests should be considered but it is not clear to what extent. Third, this is a value-laden situation and different people have different values, meaning that the frameworks are at least partially subjective. CONCLUSIONS These challenges do not mean that the ethical frameworks are faulty; rather, they reflect the complexity and the sensitivity of cases in the grey zone.
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Affiliation(s)
- Alice Cavolo
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 9, 3000, Leuven, Belgium.
| | - Danya F Vears
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne Parkville, Victoria, Australia
| | - Gunnar Naulaers
- Pregnancy, Fetus and Newborn, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Lynn Gillam
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
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2
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Haward MF, Lorenz JM, Fischhoff B. Antenatal Consultation Research and Practices Through the Lens of Decision Science. J Pediatr 2024; 274:114173. [PMID: 38942356 DOI: 10.1016/j.jpeds.2024.114173] [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: 02/17/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 06/30/2024]
Affiliation(s)
- Marlyse F Haward
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.
| | - John M Lorenz
- Department of Pediatrics, Morgan Stanley Children Hospital of New York, Vagelos College of Physicians & Surgeons Columbia University, New York, NY
| | - Baruch Fischhoff
- Department of Engineering and Public Policy and Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA
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3
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Wilkinson DJ, Bertaud S. End of life care in the setting of extreme prematurity - practical challenges and ethical controversies. Semin Fetal Neonatal Med 2023; 28:101442. [PMID: 37121832 PMCID: PMC10914670 DOI: 10.1016/j.siny.2023.101442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
While the underlying principles are the same, there are differences in practice in end of life decisions and care for extremely preterm infants compared with other newborns and older children. In this paper, we review end of life care for extremely preterm infants in the delivery room and in the neonatal intensive care unit. We identify potential justifications for differences in the end of life care in this population as well as practical and ethical challenges.
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Affiliation(s)
- Dominic Jc Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK; John Radcliffe Hospital, Oxford, UK; Murdoch Children's Research Institute, Melbourne, Australia; Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore.
| | - Sophie Bertaud
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK
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4
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Cavolo A, Gastmans C. Resuscitation thresholds were seen as guidance by Belgian neonatologists and other relevant factors were included in decision-making. Acta Paediatr 2023; 112:1395-1397. [PMID: 37277974 DOI: 10.1111/apa.16803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 06/07/2023]
Affiliation(s)
- Alice Cavolo
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
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5
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Chevallier M, Barrington KJ, Terrien Church P, Luu TM, Janvier A. Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills. Semin Fetal Neonatal Med 2023; 28:101444. [PMID: 37150640 DOI: 10.1016/j.siny.2023.101444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.
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Affiliation(s)
- M Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France; TIMC-IMAG Research Department; Grenoble Alps University; Grenoble, France
| | - K J Barrington
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - P Terrien Church
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - T M Luu
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - A Janvier
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada; Bureau de L'éthique Clinique, Université de Montréal, Canada; Unité D'éthique Clinique, Unité de Soins Palliatifs, Bureau Du Partenariat Patients-Familles-Soignants; CHU Sainte-Justine, Montréal, Canada.
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6
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Mercurio MR, Werner KM. Thinking Inside the Bag: Patient Selection, Framing the Ethical Discourse, and the Importance of Terminology in Artificial Womb Technology. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:79-82. [PMID: 37130397 DOI: 10.1080/15265161.2023.2191056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
| | - Kelly M Werner
- Columbia University Vagelos College of Physicians and Surgeons
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7
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Thivierge E, Luu TM, Bourque CJ, Duquette LA, Pearce R, Jaworski M, Barrington KJ, Synnes A, Janvier A. Guilt and Regret Experienced by Parents of Children Born Extremely Preterm. J Pediatr 2022:S0022-3476(22)01019-8. [PMID: 36463935 DOI: 10.1016/j.jpeds.2022.10.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES To explore decisional regret of parents of babies born extremely preterm and analyze neonatal, pediatric, and parental factors associated with regret. STUDY DESIGN Parents of infants born <29 weeks of gestational age, aged between 18 months and 7 years, attending neonatal follow-up were enrolled. Hospital records were reviewed to examine morbidities and conversations with parents about levels of care. Parents were asked the following question: "Knowing what you know now, is there anything you would have done differently?" Mixed methods were used to analyze responses. RESULTS In total, 248 parents (98% participation) answered, and 54% reported they did not have regret. Of those who reported regret (n = 113), 3 themes were most frequently invoked: 35% experienced guilt, thinking they were responsible for the preterm birth; 28% experienced regret about self-care decisions; and 20% regretted decisions related to their parental role, generally wishing they knew sooner how to get involved. None reported regret about life-and-death decisions made at birth or in the neonatal intensive care unit. Impairment at follow-up, gestational age, and decisions about levels/reorientation of care were not associated with regret. More mothers reported feeling guilt about the preterm birth (compared with fathers); parents of children with severe lesions on ultrasonography of the head were less likely to report regret. CONCLUSIONS Approximately one-half of the parents of infants born extremely preterm had regrets regarding their neonatal intensive care unit stay. Causes of regret and guilt should be addressed and minimized.
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Affiliation(s)
- Emilie Thivierge
- Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Canada
| | - Thuy Mai Luu
- Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Canada; CHU Sainte-Justine Research Center, Montréal, Canada
| | - Claude Julie Bourque
- CHU Sainte-Justine Research Center, Montréal, Canada; Unité d'éthique clinique, CHU Sainte-Justine, Montréal, Canada; Centre d'excellence en éthique clinique, CHU Sainte-Justine, Montréal, Canada
| | | | - Rebecca Pearce
- Canadian Premature Baby Foundation, Montréal, Quebec, Canada
| | - Magdalena Jaworski
- Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Canada; Unité d'éthique clinique, CHU Sainte-Justine, Montréal, Canada
| | - Keith J Barrington
- Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Canada; CHU Sainte-Justine Research Center, Montréal, Canada
| | - Anne Synnes
- Department of Pediatrics, BC Women's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Annie Janvier
- Department of Pediatrics, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Canada; CHU Sainte-Justine Research Center, Montréal, Canada; Centre d'excellence en éthique clinique, CHU Sainte-Justine, Montréal, Canada; Bureau de l'éthique Clinique, Université de Montréal, Montréal, Canada; Unité de soins palliatifs, CHU Sainte-Justine, Montréal, Canada.
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8
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Janvier A, Barrington KJ. Delayed Withholding: Disguising Withdrawal of Life Sustaining Interventions in Extremely Preterm Infants. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:43-46. [PMID: 36332036 DOI: 10.1080/15265161.2022.2123986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Annie Janvier
- Université de Montréal
- CHU Sainte-Justine Research Center
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9
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Ethical considerations in the management of infants with severe intraventricular hemorrhage. Semin Perinatol 2022; 46:151599. [PMID: 35450739 DOI: 10.1016/j.semperi.2022.151599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.
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10
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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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11
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Prentice TM, Gillam L, Davis PG, Janvier A. Whom are we seeking to protect? Extremely preterm babies and moral distress. Semin Perinatol 2022; 46:151549. [PMID: 34887107 DOI: 10.1016/j.semperi.2021.151549] [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] [Indexed: 01/14/2023]
Abstract
Advances in perinatal care bring with them ethical challenges and difficult questions. When should we provide life-sustaining interventions, and who should decide? Particularly at the edges of viability, some clinicians may feel required to provide a level of care that they believe is not in the patient's interests, resulting in moral distress. This article will discuss the complex nature of moral distress arising during the care of extremely preterm babies. It will describe the challenges and cognitive biases present when contemplating potential harms to the baby and recognize the possible costs to both healthcare provider and baby when moral distress arises. Both clinicians caring for extremely preterm babies and the families themselves can experience moral distress. This article argues that for clinicians, recognizing the range of possible sources of moral distress is vital in order to appropriately address moral distress. Moral distress may arise from a desire to protect the baby, but also from an impulse to protect oneself from the emotional burdens of care. Addressing moral distress requires reflection on the factual beliefs, experiences and personal values which lie behind the distress, both within oneself and in discussion with colleagues. Moral distress indicates that a situation is ethically challenging, but it does not necessarily mean that a wrong decision has been made.
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Affiliation(s)
- Trisha M Prentice
- Neonatal Medicine, Royal Children's Hospital, 50 Flemington Rd, Victoria, Melbourne, Australia; Murdoch Children's Research Institute, Victoria, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia.
| | - Lynn Gillam
- Melbourne School of Population and Global Health, University of Melbourne, Victoria, Melbourne, Australia; Children's Bioethics Centre, Royal Children's Hospital, Victoria, Melbourne, Australia
| | - Peter G Davis
- Women's Newborn Research Centre, Royal Women's Hospital, Victoria, Melbourne, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Melbourne, Australia
| | - Annie Janvier
- Department of Pediatrics, Division of Neonatology, Clinical Ethics Unit, Palliative Care Unit, Unité de Recherche en Éthique Clinique et Partenariat Famille, CHU Ste-Justine, Québec, Montréal, Canada; Department of Pediatrics and Clinical Ethics, Université de Montréal, Québec, Montréal, Canada
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12
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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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13
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Haward MF, Janvier A, Lorenz JM. Using the COVID-19 as an excuse for unjustified devaluation of preterm infants. Acta Paediatr 2021; 110:1097-1099. [PMID: 33426735 PMCID: PMC8014586 DOI: 10.1111/apa.15744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Marlyse F. Haward
- Department of Pediatrics Children’s Hospital at Montefiore Albert Einstein College of Medicine Bronx NY USA
| | - Annie Janvier
- Department of Pediatrics, Bureau de l’Éthique Clinique Université de Montréal Montréal QC 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 QC Canada
| | - John M. Lorenz
- Department of Pediatrics Vagelos College of Physicians and Surgeons Columbia University New York NY USA
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14
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Nayak B, Moon JY, Kim M, Fischhoff B, Haward MF. Optimism bias in understanding neonatal prognoses. J Perinatol 2021; 41:445-452. [PMID: 32778685 DOI: 10.1038/s41372-020-00773-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Discrepancies between physician and parent neonatal prognostic expectations are common. Optimism bias is a possible explanation. STUDY DESIGN Parents interpreted hypothetical neonatal prognoses in an online survey. RESULTS Good prognoses tended to be interpreted accurately, while poor prognoses were interpreted as less than the stated value. One-third of participants consistently overstated survival for the three lowest prognoses, compared to the sample as a whole. Three significant predictors of such optimistic interpretations were single-parent status (OR 0.39; 95% CI 0.2-0.75; p = 0.005), African-American descent (OR 3.78; 95% CI 1.63-8.98; p = 0.002) and the belief that physicians misrepresented prognoses (OR 3.11; 95% CI 1.47-6.65; p = 0.003). Participants' explanations echoed research on optimism bias in clinical and decision science studies. CONCLUSION Participants accepted positive prognoses for critically ill neonates, but reinterpreted negative ones as being unduly pessimistic demonstrating optimism bias.
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Affiliation(s)
- Babina Nayak
- Harlem Hospital Medical Center, Columbia University, New York, NY, USA.,Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jee-Young Moon
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mimi Kim
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy and Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Marlyse F Haward
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA.
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15
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Brenner M, Alexander D, Quirke MB, Eustace-Cook J, Leroy P, Berry J, Healy M, Doyle C, Masterson K. A systematic concept analysis of 'technology dependent': challenging the terminology. Eur J Pediatr 2021; 180:1-12. [PMID: 32710305 PMCID: PMC7380164 DOI: 10.1007/s00431-020-03737-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/22/2020] [Accepted: 07/09/2020] [Indexed: 01/08/2023]
Abstract
There are an increasing number of children who are dependent on medical technology to sustain their lives. Although significant research on this issue is taking place, the terminology used is variable and the concept of technology dependence is ill-defined. A systematic concept analysis was conducted examining the attributes, antecedents, and consequences of the concept of technology dependent, as portrayed in the literature. We found that this concept refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide ranging sequelae for the child and family, and health and social care delivery.Conclusion: The term technology dependent is increasingly redundant. It objectifies a heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. What is Known: • There are an increasing number of children who require medical technology to sustain their life, commonly referred to as technology dependent. This concept analysis critically analyses the relevance of the term technology dependent which is in use for over 30 years. What is New: • Technology dependency refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide-ranging sequelae for the child and family, and health and social care delivery. • The paper shows that the term technology dependent is generally portrayed in the literature in a problem-focused manner. • This term is increasingly redundant and does not serve the heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. More appropriate child-centred terminology will be determined within the TechChild project.
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Affiliation(s)
- Maria Brenner
- School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, 24 D'Olier Street, Dublin 2, Ireland.
| | - Denise Alexander
- grid.8217.c0000 0004 1936 9705School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, 24 D’Olier Street, Dublin 2, Ireland
| | - Mary Brigid Quirke
- grid.8217.c0000 0004 1936 9705School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, 24 D’Olier Street, Dublin 2, Ireland
| | - Jessica Eustace-Cook
- grid.8217.c0000 0004 1936 9705Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Piet Leroy
- grid.5012.60000 0001 0481 6099Pediatric Intensive Care Unit & Pediatric Procedural Sedation Unit, Maastricht UMC and Faculty of Health, Life Sciences & Medicine, Maastricht University, Maastricht, Netherlands
| | - Jay Berry
- grid.2515.30000 0004 0378 8438Department of Medicine and Division of General Pediatrics, Boston Children’s Hospital and Harvard Medical School, Boston, MA USA
| | - Martina Healy
- Department of Paediatric Anaesthesia, Paediatric Critical Care Medicine and Paediatric Pain Medicine, Children’s Health Ireland Crumlin, Dublin, Ireland ,grid.8217.c0000 0004 1936 9705School of Medicine, Faculty of Health Sciences, Trinity College Dublin, the University of Dublin, Dublin, Ireland
| | - Carmel Doyle
- grid.8217.c0000 0004 1936 9705School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, 24 D’Olier Street, Dublin 2, Ireland
| | - Kate Masterson
- grid.8217.c0000 0004 1936 9705School of Nursing and Midwifery, Trinity College Dublin, The University of Dublin, 24 D’Olier Street, Dublin 2, Ireland ,grid.416107.50000 0004 0614 0346Paediatric Intensive Care Unit, The Royal Children’s Hospital, Melbourne, Australia
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16
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Critical decision-making in neonatology and pediatrics: the I-P-O framework. J Perinatol 2021; 41:173-178. [PMID: 32999448 DOI: 10.1038/s41372-020-00841-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/25/2020] [Accepted: 09/18/2020] [Indexed: 11/09/2022]
Abstract
Critical decision-making in neonatology and other areas of pediatrics often carries with it a complex and difficult ethical component. For any treatment under consideration, the impermissible-permissible-obligatory (I-P-O) spectrum provides a useful framework for determining how to proceed. Any proposed treatment can be located along this spectrum, and identified as either ethically impermissible, permissible, or obligatory. Treatments determined to be ethically impermissible should not be made available by physicians. Those deemed ethically permissible should be explained to parents, commonly with a specific recommendation. Informed parents should then be free to choose from among permissible options. Potential treatments deemed ethically obligatory should be provided to the patient, even in the face of parental objection. The fundamental ethical work in neonatology and pediatrics is determining where on the I-P-O spectrum a treatment under consideration should be located. This should be determined by the prognosis for the patient with and without the treatment, the feasibility of providing the treatment, and consideration of all relevant rights and obligations. Location on the line is dynamic, and clinicians should be open to movement of a given treatment along the spectrum as new information, particularly regarding effectiveness, toxicity, and/or alternatives, becomes available. This framework provides a structure for ethical conversation and decision-making related to a specific patient, as well as in the formation of institutional and national guidelines.
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17
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Wightman A. Caregiver burden in pediatric dialysis. Pediatr Nephrol 2020; 35:1575-1583. [PMID: 31435726 DOI: 10.1007/s00467-019-04332-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/08/2019] [Accepted: 08/06/2019] [Indexed: 12/28/2022]
Abstract
In spite of improvements in expected survival, neurodevelopmental outcome, and quality of life, decision-making in neonatal dialysis remains controversial in high-resource countries. In part, this may be based upon the significant burdens experienced by the child, and also those experienced by the parents as caregivers. Emerging research offers a clearer description of the burdens experienced by dialysis caregivers worldwide. Caregiver burden represents an important area for nephrologists to advocate for patients and their families; however, nephrologists must also recognize the realities caregivers currently experience. Incorporation of caregiver burden into medical decision-making for children with end-stage kidney disease is necessary, but raises several ethical concerns.
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Affiliation(s)
- Aaron Wightman
- Divisions of Nephrology, Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA. .,Division of Nephrology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98115, USA. .,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA, USA.
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18
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Campelia GD, Kett JC, Wightman A. Relational suffering and the moral authority of love and care. THEORETICAL MEDICINE AND BIOETHICS 2020; 41:165-178. [PMID: 33284391 PMCID: PMC7720443 DOI: 10.1007/s11017-020-09530-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Suffering is a ubiquitous yet elusive concept in health care. In a field devoted to the pursuit of objective data, suffering is a phenomenon with deep ties to subjective experience, moral values, and cultural norms. Suffering's tie to subjective experience makes it challenging to discern and respond to the suffering of others. In particular, the question of whether a child with profound neurocognitive disabilities can suffer has generated a robust discourse, rooted in philosophical conceptualizations of personhood as well as the academic and experiential expertise of practiced health-care professionals. The issue remains unresolved because it is difficult, perhaps impossible, to ever truly know an infant's lived experience. But what if this is not the best question? What if instead of asking "can this infant suffer?" the discourse is broadened to ask "is there suffering here?" This latter question demands attention to patients' subjective experiences of suffering, but also to the web of relationships that envelop them. Without losing sight of the importance of patients' experiences, consideration of their relationships may elucidate the presence of suffering when the patients themselves are unable to provide the same clarity. In this essay, care ethics frames an examination of how suffering manifests in the loving and caring relationships that surround an infant with profound neurocognitive disabilities, changing those relationships and affecting the individuals within them. Exploring suffering through these relationships may offer clarity on the presence and content of suffering for infants with profound cognitive disabilities, in turn offering moral guidance for responding to suffering and supporting flourishing in this context.
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Affiliation(s)
- Georgina D. Campelia
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA USA
- Clinical Ethics Consultation Service, University of Washington School of Medicine, Seattle, WA USA
| | - Jennifer C. Kett
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA USA
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
| | - Aaron Wightman
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA USA
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
- Division of Pediatric Nephrology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
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Haward MF, Janvier A, Moore GP, Laventhal N, Fry JT, Lantos J. Should Extremely Premature Babies Get Ventilators During the COVID-19 Crisis? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:37-43. [PMID: 32400291 DOI: 10.1080/15265161.2020.1764134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In a crisis, societal needs take precedence over a patient's best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. But surviving babies will likely live longer, maximizing life-years. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When "triaging" or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies.
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Affiliation(s)
| | | | | | | | - Jessica T Fry
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
| | - John Lantos
- Children's Mercy Bioethics Center
- Children's Mercy Hospital
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20
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Mercurio MR. The Moral Status of Newborns: Before, during, and after the Pandemic. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:122-124. [PMID: 32716776 DOI: 10.1080/15265161.2020.1779869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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21
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Janvier A, Barrington KJ, Payot A. A time for hope: guidelines for the perinatal management of extremely preterm birth. Arch Dis Child Fetal Neonatal Ed 2020; 105:230-231. [PMID: 32156712 DOI: 10.1136/archdischild-2019-318553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Annie Janvier
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada .,Bureau de l'Éthique Clinique, University of Montreal, Montreal, Quebec, Canada.,Division of Neonatology, CHU Sainte-Justine, Montreal, Quebec, Canada.,Clinical Ethics Unit, Bureau du Partenariat Patients-Familles-Soignants, Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Keith J Barrington
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada.,Division of Neonatology, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Antoine Payot
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada.,Bureau de l'Éthique Clinique, University of Montreal, Montreal, Quebec, Canada.,Division of Neonatology, CHU Sainte-Justine, Montreal, Quebec, Canada.,Clinical Ethics Unit, Bureau du Partenariat Patients-Familles-Soignants, Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine, Montreal, Quebec, Canada
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Kett JC, Cunningham ML, Wightman A. The legacy of language: Disfigurement bias in the NICU. Acta Paediatr 2020; 109:880-882. [PMID: 32073682 DOI: 10.1111/apa.15236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/10/2020] [Accepted: 02/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jennifer C. Kett
- Department of Pediatric Palliative Care Mary Bridge Children's Hospital Tacoma WA USA
| | - Michael L. Cunningham
- Department of Pediatrics University of Washington Seattle WA USA
- Seattle Children's Hospital Craniofacial Center Seattle WA USA
| | - Aaron Wightman
- Department of Pediatrics University of Washington School of Medicine Seattle WA USA
- Divisions of Nephrology and Bioethics and Palliative Care Treuman Katz Center for Pediatric Bioethics Seattle Children's Hospital and Research Institute Seattle WA USA
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Cavolo A, Dierckx de Casterlé B, Naulaers G, Gastmans C. Ethics of resuscitation for extremely premature infants: a systematic review of argument-based literature. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106102. [PMID: 32341186 DOI: 10.1136/medethics-2020-106102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/18/2020] [Accepted: 04/10/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To present (1) the ethical concepts related to the debate on resuscitation of extremely premature infants (EPIs) as they are described in the ethical literature; and (2) the ethical arguments based on these concepts. DESIGN We conducted a systematic review of the ethical literature. We selected articles based on the following predefined inclusion/exclusion criteria: (1) English language articles (2) presenting fully elaborated ethical arguments (3) on resuscitation (4) of EPIs, that is, infants born before 28 weeks of gestation. ANALYSIS After repeated reading of articles, we developed individual summaries, conceptual schemes and an overall conceptual scheme. Ethical arguments and concepts were identified and analysed. RESULTS Forty articles were included out of 4709 screened. Personhood, best interest, autonomy and justice were concepts grounding the various arguments. Regarding these concepts, included authors agreed that the best interest principle should guide resuscitation decisions, whereas justice seemed the least important concept. The arguments addressed two questions: Should we resuscitate EPIs? Who should decide? Included authors agreed that not all EPIs should be resuscitated but disagreed on what criteria should ground this decision. Overall, included authors agreed that both parents and physicians should contribute to the decision. CONCLUSIONS The included publications suggest that while the best interest is the main concept guiding resuscitation decisions, justice is the least important. The included authors also agree that both parents and physicians should be actively involved in resuscitation decisions for EPIs. However, our results suggest that parents' decision should be over-ridden when in contrast with the EPI's best interest.
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Affiliation(s)
- Alice Cavolo
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Bernadette Dierckx de Casterlé
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Gunnar Naulaers
- Pregnancy, Fetus and Newborn, Department of Development and Regeneration, KU Leuven UZ Leuven, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
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Albersheim S. The Extremely Preterm Infant: Ethical Considerations in Life-and-Death Decision-Making. Front Pediatr 2020; 8:55. [PMID: 32175292 PMCID: PMC7054342 DOI: 10.3389/fped.2020.00055] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 02/05/2020] [Indexed: 01/22/2023] Open
Abstract
Care of the preterm infant has improved tremendously over the last 60 years, with attendant improvement in outcomes. For the extremely preterm infant, <28 weeks' gestation, concerns related to survival as well as neurodevelopmental impairment, have influenced decision-making to a much larger extent than seen in older children. Possible reasons for conferring a different status on extremely preterm infants include: (1) the belief that the brain is a privileged organ, (2) the degree of medical uncertainty in terms of outcomes, (3) the fact that the family will deal with the psychological, emotional, physical, and financial consequences of treatment decisions, (4) that the extremely preterm looks more like a fetus than a term newborn, (5) the initial lack of relational identity, (6) the fact that extremely preterm infants are technology-dependent, and (7) the timing of decision-making around delivery. Treating extremely preterm infants differently does not hold up to scrutiny. They are owed the same respect as other pediatric patients, in terms of personhood, and we have the same duties to care for them. However, the degree of medical uncertainty and the fact that parents will deal with the consequences of decision-making, highlights the importance of providing a wide band of discretion in parental decision-making authority. Ethical principles considered in decision-making include best interest (historically the sine qua non of pediatric decision-making), a reasonable person standard, the "good enough" parent, and the harm principle, the latter two being more pragmatic. To operationalize these principles, potential models for decision-making are the Zone of Parental Discretion, the Not Unreasonable Standard, and a Shared Decision-Making model. In the final analysis shared decision-making with a wide zone of parental discretion, which is based on the harm principle, would provide fair and equitable decision-making for the extremely preterm infant. However, in the rare circumstance where parents do not wish to embark upon intensive care, against medical recommendations, it would be most helpful to develop local guidelines both for support of health care practitioners and to provide consistency of care for extremely preterm infants.
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Affiliation(s)
- Susan Albersheim
- Division of Neonatology, Department of Pediatrics, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
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25
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Variable management strategies for NEC totalis: a national survey. J Perinatol 2019; 39:1521-1527. [PMID: 31371831 DOI: 10.1038/s41372-019-0448-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/17/2019] [Accepted: 05/30/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND/OBJECTIVES Necrotizing enterocolitis (NEC) is a serious disease linked to prematurity. A variant, NEC totalis, is associated with nearly 100% mortality. There is wide variation in counseling practices for NEC totalis. Our objectives are to determine what treatment options, if any, are offered to families, and which factors influence these decisions. METHODS An anonymous survey was distributed to members of the AAP Sections on Neonatal-Perinatal Medicine and Pediatric Surgery. Data were analyzed utilizing chi-square tests and Spearman correlations, where applicable. RESULTS In the setting of NEC totalis, 90% of the 378 respondents viewed offering life-sustaining interventions (LSI) as ethically permissible and 87% felt that transfer to another center willing to provide LSI should be considered; however, only 43% reported offering LSI to families. CONCLUSIONS Management of NEC totalis remains challenging and significant practice variability persists. Most respondents do not offer ongoing medical/surgical management, despite believing it is an ethically permissible option.
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Affiliation(s)
- Brian S. Carter
- University of Missouri-Kansas City School of Medicine; Kansas City MO USA
- Children's Mercy Hospital; Kansas City MO USA
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27
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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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Affiliation(s)
- Brian S Carter
- Children's Mercy Hospital University of Missouri-Kansas City School of Medicine Kansas City, Missouri.
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Provider Perspectives Regarding Resuscitation Decisions for Neonates and Other Vulnerable Patients. J Pediatr 2017; 188:142-147.e3. [PMID: 28502606 DOI: 10.1016/j.jpeds.2017.03.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/06/2017] [Accepted: 03/27/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To use structured surveys to assess the perspectives of pediatric residents and neonatal nurses on resuscitation decisions for vulnerable patients, including neonates. STUDY DESIGN Pediatric providers were surveyed using scenarios for 6 critically ill patients of different ages with outcomes explicitly described. Providers were asked (1) whether resuscitation was in each patient's best interest; (2) whether they would accept families' wishes for comfort care (no resuscitation); and (3) to rank patients in order of priority for resuscitation. In a structured interview, each participant explained how they evaluated patient interests and when applicable, why their answers differed for neonates. Interviews were audiotaped; transcripts were analyzed using thematic analysis and mixed methods. RESULTS Eighty pediatric residents and neonatal nurses participated (response rate 74%). When making life and death decisions, participants considered (1) patient characteristics (96%), (2) personal experience/biases (85%), (3) family's wishes and desires (81%), (4) disease characteristics (74%), and (5) societal perspectives (36%). These factors were not in favor of sick neonates: of the participants, 85% reported having negative biases toward neonates and 60% did not read, misinterpreted, and/or distrusted neonatal outcome statistics. Additional factors used to justify comfort care for neonates included limited personhood and lack of relationships/attachment (73%); prioritization of family's best interest, and social acceptability of death (36%). When these preconceptions were discussed, 70% of respondents reported they would change their answers in favor of neonates. CONCLUSIONS Resuscitation decisions for neonates are based on many factors, such as considerations of personhood and family's interests (that are not traditional indicators of benefit), which may explain why decision making is different for the neonatal population.
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Rieder TN. Saving or Creating: Which Are We Doing When We Resuscitate Extremely Preterm Infants? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:4-12. [PMID: 28768134 DOI: 10.1080/15265161.2017.1340988] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Neonatal intensive care units represent simultaneously one of the great success stories of modern medicine, and one of its most controversial developments. One particularly controversial issue is the resuscitation of extremely preterm infants. Physicians in the United States generally accept that they are required to resuscitate infants born as early as 25 weeks and that it is permissible to resuscitate as early as 22 weeks. In this article, I question the moral pressure to resuscitate by criticizing the idea that resuscitation in this context "saves" a human life. Our radical medical advancements have allowed us to intervene in the life of a human before it makes sense to say that such an intervention "saves" someone; rather, what the physician does in resuscitating and treating an extremely preterm infant is to take over creating it. This matters, I argue, because "rescues" are much more morally urgent than "creations."
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Kukora S, Laventhal N. Rock the Baby, Not the Boat: A Defense of Epidemiology-Based and Values-Based Shared Decision Making at the Margin of Gestational Viability. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:16-18. [PMID: 28768124 DOI: 10.1080/15265161.2017.1341003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Haward M, Mercurio M, Janvier A. Perpetuating Biases and Injustice Toward Preterm Infants. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:27-29. [PMID: 28768125 DOI: 10.1080/15265161.2017.1340994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Marlyse Haward
- a Albert Einstein College of Medicine ; Children's Hospital at Montefiore
| | | | - Annie Janvier
- c Bureau de L'éthique Clinique , Université de Montréal and Unité d'éthique clinique, Unité de soins palliatifs, and Unité de recherche en éthique clinique et partenariat famille, CHU Sainte-Justine
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33
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International variations in application of the best-interest standard across the age spectrum. J Perinatol 2017; 37:208-213. [PMID: 27735929 DOI: 10.1038/jp.2016.168] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 08/30/2016] [Accepted: 09/01/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Ethically and legally, assertions that resuscitation is in a patient's best interest should be inversely correlated with willingness to forego intensive care (and accept comfort care) at the surrogate's request. Previous single country studies have demonstrated a relative devaluation of neonates when compared with other critically ill patients. STUDY DESIGN In this international study, physicians in Argentina, Australia, Canada, Ireland, The Netherlands, Norway and the United States were presented with eight hypothetical vignettes of incompetent critically ill patients of different ages. They were asked to make assessments about best interest, respect for surrogate autonomy and to rank the patients in a triage scenario. RESULTS In total, 2237 physicians responded (average response rate 61%). In all countries and scenarios, participants did not accept to withhold resuscitation if they estimated it was in the patient's best interest, except for scenarios involving neonates. Young children (other than neonates) were given high priority for resuscitation, regardless of existing disability. For neonates, surrogate autonomy outweighed assessment of best interest. In all countries, a 2-month-old-infant with meningitis and a multiply disabled 7-year old were resuscitated first in the triage scenario, with more variable ranking of the two neonates, which were ranked below patients with considerably worse prognosis. CONCLUSIONS The value placed on the life of newborns is less than that expected according to predicted clinical outcomes and current legal and ethical theory relative to best interests. Value assessments on the basis of age, disability and prognosis appear to transcend culture, politics and religion in this domain.
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Perlbarg J, Ancel PY, Khoshnood B, Durox M, Boileau P, Garel M, Kaminski M, Goffinet F, Foix-L'Hélias L. Delivery room management of extremely preterm infants: the EPIPAGE-2 study. Arch Dis Child Fetal Neonatal Ed 2016; 101:F384-90. [PMID: 26837310 DOI: 10.1136/archdischild-2015-308728] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 01/06/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To analyse the delivery room management of babies born between 22 and 26 weeks of completed gestational age and to identify the factors associated with the withholding or withdrawal of intensive care. STUDY DESIGN Population-based cohort study. PATIENTS AND METHODS Our study population comprised 2145 births between 22 and 26 completed weeks enrolled in the EPIPAGE-2 study, a French cohort of very preterm infants born in 2011. The primary outcome measure was withholding or withdrawal of intensive care in the delivery room. RESULTS Among infants born alive at 22-23 weeks, intensive care was withheld or withdrawn for >90%. At 24 weeks, resuscitative measures were withheld or withdrawn for 38%, at 25 weeks for 8% and at 26 weeks for 3%. Other factors besides gestational age at birth associated with this withholding or withdrawal for infants born at 24-26 weeks were birth weight <600 g, emergency delivery (within 24 h of the mother's admission) and singleton pregnancy. Although rates of withholding or withdrawal of intensive care varied substantially between maternity units (from 0% to 100%), the variability was primarily explained by differences in distributions of gestational age at birth. CONCLUSIONS Although gestational age is only one factor predicting survival of preterm infants, practices in France appear to be based primarily on this factor, which thus has direct effects on the survival of extremely preterm infants. The ethical implications of basing life and death decisions only on gestational age before 25 weeks require further examination.
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Affiliation(s)
- J Perlbarg
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - P Y Ancel
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France URC-CIC P1419, DHU Risk in Pregnancy, Cochin Hôtel-Dieu Hospital, APHP, Paris, France
| | - B Khoshnood
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - M Durox
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - P Boileau
- Neonatal Intensive Care Unit, CHI Poissy Saint-Germain-en-Laye, Poissy, France EA 7285, Versailles Saint-Quentin-en-Yvelines University, Versailles, France
| | - M Garel
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - M Kaminski
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - F Goffinet
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France Maternité Port-Royal, Paris-Descartes University, Cochin Broca Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris, DHU Risk in Pregnancy, Paris, France
| | - L Foix-L'Hélias
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France
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Murray PD, Esserman D, Mercurio MR. In what circumstances will a neonatologist decide a patient is not a resuscitation candidate? JOURNAL OF MEDICAL ETHICS 2016; 42:429-434. [PMID: 26988548 DOI: 10.1136/medethics-2015-102941] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 02/22/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the opinions of practising neonatologists regarding the ethical permissibility of unilateral Do Not Attempt Resuscitation (DNAR) decisions in the neonatal intensive care unit. STUDY DESIGN An anonymous survey regarding the permissibility of unilateral DNAR orders for three clinical vignettes was sent to members of the American Academy of Pediatrics Section of Perinatal Medicine. RESULTS There were 490 out of a possible 3000 respondents (16%). A majority (76%) responded that a unilateral DNAR decision would be permissible in cases for which survival was felt to be impossible. A minority (25%) responded 'yes' when asked if a unilateral DNAR order would be permissible based solely on neurological prognosis. CONCLUSIONS A majority of neonatologists believed unilateral DNAR decisions are ethically permissible if survival is felt to be impossible, but not permissible based solely on poor neurological prognosis. This has significant implications for clinical care.
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Affiliation(s)
- Peter Daniel Murray
- Division of Newborn Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Mark Randolph Mercurio
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA Program for Biomedical Ethics, Yale University School of Medicine, New Haven, Connecticut, USA
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Extremely premature birth and the choice of neonatal intensive care versus palliative comfort care: an 18-year single-center experience. J Perinatol 2016; 36:190-5. [PMID: 26583942 DOI: 10.1038/jp.2015.171] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/06/2015] [Accepted: 10/13/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Review all live births 22 0/7 through 26 6/7 weeks gestation born 1996 through 2013 at our institution to describe the decision process and immediate outcomes of palliative comfort care (PCC) versus neonatal intensive care (NICU) and whether any significant family complaints or quality assurance concerns arose. STUDY DESIGN Retrospective chart review, physician and ethicist interview process and database review focused upon our established periviability counseling guidelines that are directive of PCC at 22 weeks gestation and NICU at 26 weeks but supportive of informed family choice of either option at 23, 24 and 25 weeks. RESULT At 22 weeks--all 54 infants had PCC; at 23 weeks--29/78 (37%) chose NICU care, 6/29 (21%) infants survived; at 24 weeks--79/108 (73%) chose NICU care, 47/79 (59%) survived; at 25 weeks--147/153 (96%) chose NICU care, 115/147 (78%) survived; and at 26 weeks--all infants had NICU care, 176/203 (87%) survived. Over 18 years and 606 births, we identified only three significant concerns from families and/or physicians that required formal review. CONCLUSION Most pregnant women and families choose NICU care for their extremely premature infant, but if given the option via shared decision making, a significant proportion will choose PCC at gestational ages that some NICUs mandate resuscitation. We support a reasoned dialogue and bioethical framework that recognizes human values to be irreducibly diverse, sometimes conflicting, and ultimately incommensurable--value pluralism. Respectful shared decision making requires thoughtful and compassionate flexibility, nuanced and individualized suggestions for PCC or NICU and the reduction of hierarchical directives from physicians to families. We continue to advocate and rely upon informed family preference between 23 and 25 weeks gestation in our updated 2015 periviability guidelines.
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Hansen TWR, Førde R. Premature og behandlingsgrenser. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:45-7. [DOI: 10.4045/tidsskr.15.0336] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Hayman WR, Leuthner SR, Laventhal NT, Brousseau DC, Lagatta JM. Cost comparison of mechanically ventilated patients across the age span. J Perinatol 2015; 35:1020-6. [PMID: 26468935 PMCID: PMC4821466 DOI: 10.1038/jp.2015.131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 09/01/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the use of mechanical ventilation and hospital costs across ventilated patients of all ages, preterm through adults, in a nationally representative sample. STUDY DESIGN Secondary analysis of the 2009 Agency for Healthcare Research and Quality National Inpatient Sample. RESULTS A total of 1 107 563 (2.8%) patients received mechanical ventilation. For surviving ventilated patients, median costs for infants ⩽32 weeks' gestation were $51000 to $209 000, whereas median costs for older patients were lower from $17 000 to $25 000. For non-surviving ventilated patients, median costs were $27 000 to $39 000 except at the extremes of age; the median cost was $10 000 for <24 week newborns and $14 000 for 91+ year adults. Newborns of all gestational ages had a disproportionate share of hospital costs relative to their total volume. CONCLUSION Most intensive care unit resources at the extremes of age are not directed toward non-surviving patients. From a perinatal perspective, attention should be directed toward improving outcomes and reducing costs for all infants, not just at the earliest gestational ages.
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Affiliation(s)
- W R Hayman
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, USA
| | - S R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - N T Laventhal
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - D C Brousseau
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J M Lagatta
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Mills BA, Janvier A, Argus BM, Davis PG, Frøisland DH. Attitudes of Australian neonatologists to resuscitation of extremely preterm infants. J Paediatr Child Health 2015; 51:870-4. [PMID: 25752752 DOI: 10.1111/jpc.12862] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2015] [Indexed: 11/30/2022]
Abstract
AIM We aimed to investigate how Australian neonatologists made decisions when incompetent patients of different ages needed resuscitation. METHODS A survey including vignettes of eight incompetent patients requiring resuscitation was sent to 140 neonatologists. Patients ranged from a very preterm infant to 80 years old. While some had existing impairments, all faced risk of death or neurological sequelae. Respondents indicated whether they would resuscitate, whether they believed resuscitation was in the patients' best interests, whether they would want intervention for a family member and whether they would comply with families' wishes to withhold resuscitation. They were also asked how they would rank the eight patients in a triage situation. RESULTS Seventy-eight per cent of specialists completed the survey. The majority of respondents gave priority to the resuscitation of children over adults. Less than 40% would agree to withhold resuscitation at families' request for all children except for the preterm infant, where 96% would comply with families' wishes to withhold intensive care despite 77% believing resuscitation to be in the infant's best interest. CONCLUSION This study found inconsistencies between physicians' perceptions of the patient's best interest regarding resuscitation and their willingness to comply with families' wishes to withhold resuscitation and give comfort care. Accepting a family's refusal of resuscitation was more marked for the premature infant, even among respondents who thought that resuscitation was in the patient's best interest. These findings are consistent with other international studies.
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Affiliation(s)
- Bernice A Mills
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Annie Janvier
- Department of Pediatrics and Clinical Ethics, Sainte-Justine Hospital, Université de Montréal, Montréal, Quebec, Canada
| | - Brenda M Argus
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Peter G Davis
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Dag Helge Frøisland
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Pediatrics, Innlandet Hospital Trust Lillehammer, Lillehammer, Norway
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Dupont-Thibodeau A, Barrington KJ, Farlow B, Janvier A. End-of-life decisions for extremely low-gestational-age infants: why simple rules for complicated decisions should be avoided. Semin Perinatol 2014; 38:31-7. [PMID: 24468567 DOI: 10.1053/j.semperi.2013.07.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Interventions for extremely preterm infants bring up many ethical questions. Guidelines for intervention in the "periviable" period generally divide infants using predefined categories, such as "futile," "beneficial," and "gray zone" based on completed 7-day periods of gestation; however, such definitions often differ among countries. The ethical justification for using gestational age as the determination of the category boundaries is rarely discussed. Rational criteria used to make decisions regarding life-sustaining interventions must incorporate other important prognostic information. Precise guidelines based on imprecise data are not rational. Gestational age-based guidelines include an implicit judgment of what is deemed to be an unacceptably poor chance of "intact" survival but fail to explore the determination of acceptability. Furthermore, unclear definitions of severe disability, the difficulty, or impossibility, of accurately predicting outcome in the prenatal or immediate postnatal period make such simplistic formulae inappropriate. Similarly, if guidelines for intervention for the newborn are based on the "qualitative futility" of survival, it should be explicitly stated and justified according to established ethical guidelines. They should discuss whether newborn infants are morally different to older individuals or explain why thresholds recommended for intervention are different to recommendations for those in older persons. The aim should be to establish individualized goals of care with families while recognizing uncertainty, rather than acting on labels derived from gestational age categories alone.
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Affiliation(s)
- Amélie Dupont-Thibodeau
- Department of Pediatrics and Clinical Ethics, University of Montreal; Neonatology and Clinical Ethics, Sainte-Justine Hospital, Montreal, Quebec, Canada H3T 1C5.
| | - Keith J Barrington
- Department of Pediatrics, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Barbara Farlow
- The deVeber center for Bioethics and Social Research, Toronto, Ontario, Canada; Patients for Patient Safety Canada, Edmonton, Alberta, Canada
| | - Annie Janvier
- Department of Pediatrics and Clinical Ethics, University of Montreal; Neonatology and Clinical Ethics, Sainte-Justine Hospital, Montreal, Quebec, Canada H3T 1C5
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