Extremely premature birth and the choice of neonatal intensive care versus palliative comfort care: an 18-year single-center experience

Periviability for the Ob-Gyn Hospitalist

Periviable birth refers to births occurring between 20 0/7 and 25 6/7 weeks gestational age. Management of pregnant people and neonates during this fragile time depends on the clinical status, as well as the patient's wishes. Providers should be prepared to counsel patients at the cusp of viability, being mindful of the uncertainty of outcomes for these neonates. While it is important to incorporate the data on projected morbidity and mortality into one's counseling, shared-decision making is most essential to caring for these patients and optimizing outcomes for all.

Perspectives of extremely prematurely born adults on what to consider in prenatal decision-making: a qualitative focus group study

OBJECTIVE

A shared decision-making (SDM) approach is recommended for prenatal decisions at the limit of viability, with a guiding role for parental values. People born extremely premature experience the consequences of the decision made, but information about their perspectives on prenatal decisions is lacking. Therefore, this study aims to describe their perspectives on what is important in decision-making at the limit of viability.

DESIGN

Semi-structured focus group discussions were conducted, recorded and transcribed verbatim. The data were independently analysed by two researchers in Atlas.ti.

RESULTS

Four focus groups were conducted in the Netherlands, with five to six participants each, born between 240/7 and 300/7 weeks gestation in the period between 1965 and 2002. Considering their personal life experiences and how their extremely premature birth affected their families, the participants reflected on decision-making at the limit of viability. Various considerations were discussed and summarised into the following themes: anticipated parental regret, the wish to look at the baby directly after birth, to give the infant a chance at survival, quality of life, long-term outcomes for the infant and the family, and religious or spiritual considerations.

CONCLUSIONS

Insights into the perspectives of adults born extremely premature deepened our understanding of values considered in decision-making at the limit of viability. Results point out the need for a more individualised prediction of the prognosis and more extensive information on the lifelong impact of an extremely premature birth on both the infant and the family. This could help future parents and healthcare professionals in value-laden decision-making.

Relationship Between Palliative Care Consults and Outcomes of Pediatric Surgical Patients During Terminal Admissions

Background: Pediatric patients often undergo surgery during terminal admissions. However, the involvement and timing of palliative care consults in caring for these patients has not been readily described. Objective: To describe the presence and timing of palliative care consults for pediatric patients who undergo surgical procedures during terminal admissions. Design: Retrospective cohort study using data from the electronic health record. Setting and Participants: Pediatric patients who underwent at least one surgical procedure during a terminal admission at an urban, quaternary hospital in the United States from January 1, 2016 to December 31, 2021. Main Outcomes and Measures: Patients' medical, surgical, and admission-level characteristics were abstracted. Associations were evaluated between these characteristics and the occurrence and timing of a palliative care consult relative to surgery and death. Results: Of 134 patients, 84% received a palliative care consult during their terminal admission. Approximately 36% of consults occurred before surgery, and 12% were within one day of death. Children without a palliative care consult were more likely than children with a consult to die during surgery (19.1% vs. 2.7%, p = 0.02), have surgery within 24 hours of death (52.4% vs. 15.9%, p < 0.001), and undergo a full resuscitation attempt (47.6% vs. 12.4%, p = 0.002). Receipt of a palliative care consultation did not differ by patient sex, reported race and ethnicity, language, insurance, or income level. Conclusions and Relevance: Palliative care consults support high-quality end-of-life care for children and impact perioperative outcomes, including intensity of surgical care and resuscitation in the final hours of life.

Extremely premature birth bioethical decision-making supported by dialogics and pragmatism

Moral values in healthcare range widely between interest groups and are principally subjective. Disagreements diminish dialogue and marginalize alternative viewpoints. Extremely premature births exemplify how discord becomes unproductive when conflicts of interest, cultural misunderstanding, constrained evidence review, and peculiar hierarchy compete without the balance of objective standards of reason. Accepting uncertainty, distributing risk fairly, and humbly acknowledging therapeutic limits are honorable traits, not relativism, and especially crucial in our world of constrained resources. We think dialogics engender a mutual understanding that: i) transitions beliefs beyond bias, ii) moves conflict toward pragmatism (i.e., the truth of any position is verified by subsequent experience), and iii) recognizes value pluralism (i.e., human values are irreducibly diverse, conflicting, and ultimately incommensurable). This article provides a clear and useful Point-Counterpoint of extreme prematurity controversies, an objective neurodevelopmental outcomes table, and a dialogics exemplar to cultivate shared empathetic comprehension, not to create sides from which to choose. It is our goal to bridge the understanding gap within and between physicians and bioethicists. Dialogics accept competing relational interests as human nature, recognizing that ultimate solutions satisfactory to all are illusory, because every choice has downside. Nurturing a collective consciousness via dialogics and pragmatism is congenial to integrating objective evidence review and subjective moral-cultural sentiments, and is that rarest of ethical constructs, a means and an end.

A scoping review of parental values during prenatal decisions about treatment options after extremely premature birth

AIM

To describe what is known in the literature about parental perspectives in making prenatal decisions regarding treatment after birth at the limit of viability, as a better understanding of parental values can help professionals support parents as they decide.

METHODS

PubMed, Cochrane, Embase, CINAHL, PsycINFO and Web of Science were searched to identify relevant literature from 1 January 2010 to 22 April 2022 on parental decision making. Data were extracted from selected studies and organised into themes. The final themes were formed through collaboration with the parents of a premature infant born at 24 weeks.

RESULTS

Of the 15,159 papers examined, 17 were included. Parental perspectives were described in terms of long-term outcomes for the infant, survival, protection against the burden of neonatal treatment, long-term impact on the family, religion and spiritual beliefs, to do everything possible, hope, sense of responsibility, wanting the best, doing what is right, giving a chance and the influence of experience.

CONCLUSION

The extracted parental perspectives show the complexity of these decisions. Some perspectives were clear, but others were multi-interpretable. Increasing the understanding of common parental perspectives can help improve shared prenatal decisions and lead to further improvement and personalisation of the process.

Teaching the Skill of Shared Decision Making Utilizing a Novel Online Module: A Pilot Randomized Controlled Study

OBJECTIVES

In this pilot study, we developed and tested an online educational module for the purpose of teaching optimal shared decision making (SDM) behaviors for physicians in training. We hypothesized that those who received this intervention would show significant improvement in SDM behaviors afterward as compared with those who had not received the intervention.

METHODS

Pediatric subspecialty fellows (pediatric critical care medicine, neonatology, hematology and oncology, and pulmonology) at the Monroe Carell Jr Children's Hospital at Vanderbilt were eligible to participate, if approved by their respective program directors. Design was a randomized crossover trial of an online educational module to promote behaviors essential to SDM. Participants were randomized by subspecialty. Experts in clinical communication blinded to participants' study arms evaluated SDM behaviors in video-taped clinical simulations with standardized parent dyads. The study protocol was approved by the Vanderbilt University Institutional Review Board.

RESULTS

Participants receiving the intervention were approximately 40 times more likely to improve their subsequent total score when compared with simply repeating the simulation alone (95% confidence interval, 1.72-919.29; P = .022).

CONCLUSIONS

This pilot study demonstrates that an online, interactive module can be an effective way of teaching the skill of SDM to pediatric subspecialty trainees. Tools like this one could help overcome the limitations inherent in currently published SDM resources and meet the need for interventions with demonstrated effectiveness, helping to increase the utilization of SDM skills by providing primary or supplemental education at institutions across the resource spectrum.

Assessing shared decision making during antenatal consultations regarding extreme prematurity

OBJECTIVE

To assess whether antenatal decisions regarding the neonatal care at birth for extremely preterm infants are more likely to be made when using shared decision-making (SDM)-style consultations compared to standard consultations.

STUDY DESIGN

In 2015, we implemented a clinical practice guideline promoting SDM use within antenatal consultations in our single-centre university-based perinatal unit. We conducted a prospective cohort study with a retrospective chart review based on data collected from all pregnant women presenting to obstetrical triage between 22 + 0 and 25 + 6 weeks gestation between September 2015 and June 2018.

RESULT

Two-hundred-and-seventeen cases presented; 137 received antenatal consultations with 82 (60%) being SDM-style. Decisions were frequently made (88%; 120/137) after the consultations, with no significant difference between consultation style (RR 1.08, 95% CI [0.95-1.26], p = 0.28).

CONCLUSION

The provision of either an SDM-style or a standard antenatal consultation seemed to comparably facilitate the reaching of a care decision.

Active Treatment of Infants Born at 22-25 Weeks of Gestation in California, 2011-2018

OBJECTIVE

To determine the rate and trend of active treatment in a population-based cohort of infants born at 22-25 weeks of gestation and to examine factors associated with active treatment.

STUDY DESIGN

This observational study evaluated 8247 infants born at 22-25 weeks of gestation at hospitals in the California Perinatal Quality Care Collaborative between 2011 and 2018. Multivariable logistic regression was used to relate maternal demographic and prenatal factors, fetal characteristics, and hospital level of care to the primary outcome of active treatment.

RESULTS

Active treatment was provided to 6657 infants. The rate at 22 weeks was 19.4% and increased with each advancing week, and was significantly higher for infants born between days 4 and 6 at 22 or 23 weeks of gestation compared with those born between days 0 and 3 (26.2% and 78.3%, respectively, vs 14.1% and 65.9%, respectively; P < .001). The rate of active treatment at 23 weeks increased from 2011 to 2018 (from 64.9% to 83.4%; P < .0001) but did not change significantly at 22 weeks. Factors associated with increased odds of active treatment included maternal Hispanic ethnicity and Black race, preterm premature rupture of membranes, obstetrical bleeding, antenatal steroids, and cesarean delivery. Factors associated with decreased odds included lower gestational age and small for gestational age birth weight.

CONCLUSIONS

In California, active treatment rates at 23 weeks of gestation increased between 2011 and 2018, but rates at 22 weeks did not. At 22 and 23 weeks, rates increased during the latter part of the week. Several maternal and infant factors were associated with the likelihood of active treatment.

Parental request for non-resuscitation in fetal myelomeningocele repair: an analysis of the novel ethical tensions in fetal intervention

As the field of fetal intervention grows, novel ethical tensions will arise. We present a case of Fetal myelomeningocele repair involving a 25-week fetus where parents requested that if emergent delivery was necessary during the open uterine procedure, that the medical team did not perform resuscitation. This question brings forward an important discussion around the complicated space of maternal autonomy, child rights, and clinician obligations that exists in fetal intervention. In some regions, a mother in this situation may choose to terminate the pregnancy. Parents could also choose not to do the surgery. Parents in some regions could opt for no resuscitation of a child born at 25-weeks' gestation. We offer an analysis of these relevant considerations, the different tensions, and the conflicting duties between the mother, fetus, and medical team. This analysis will provide ethical and clinical guidance for future questions that may arise in this burgeoning field.

Information Order for Periviable Counseling: Does It Make a Difference?

OBJECTIVES

To examine whether the order of presenting survival vs disability information, with or without the description of infant neonatal intensive care unit (NICU) experiences would influence treatment choice during hypothetical periviable birth counseling.

STUDY DESIGN

An internet sample of childbearing-aged women (n = 839) viewed a pictograph displaying the chances of survival and a pictograph on the chances of disability for a baby resuscitated during the periviable period. The sample was randomized to the order of pictographs and level of description of infant NICU experiences. Participants selected between intensive care or comfort care and reported their personal values.

RESULTS

The order of the information influenced treatment choices (P = .02); participants were more likely to choose intensive care if they saw the survival pictograph first (70%) than the disability pictograph first (62%). Level of description of premature infant NICU experiences did not influence treatment choice (P = .92). Participants who valued sanctity of life, autonomy in making decisions, who were more religious, and had adequate health literacy were more likely to choose intensive care. Such participant characteristics had greater explanatory power than the experimental manipulations.

CONCLUSIONS

Subtle differences in how information is presented may influence critical decisions. However, even among women with the same values, diversity in treatment choice remains.

Systematic review of medical literature for medicolegal claims and complaints involving neonates

IMPORTANCE

Complaints and malpractice claims by families on the care of their babies are pertinent issue. Beyond just the financial implications, it involves harm to babies and distress to parents.

OBJECTIVE

The aim was to review published reports of complaints by families on the care of their babies in the neonatal units in order to understand the nature of these complaints and the areas of care that they relate to.

METHODS

We considered articles in English, which report on complaints made by families to organisations providing neonatal care. We performed our structured search on AMED, CINAHL, EMBASE, EMCARE, SCOPUS and MEDLINE from January 2000 to December 2020. A total of 378 articles were appraised using eligibility criteria.

RESULTS

A total of 12 articles were included. The most common category of complaint was delayed/incorrect diagnosis. Communication issues were highlighted as a significant category of complaints. The majority of such claims were between the physicians and families. Factors implicated for clinician's errors that resulted in complaints were lack of clinical and communication training, inadequate supervision of junior clinicians, work culture and hierarchy, not listening to families' concerns and system failure.

CONCLUSIONS

The most frequent categories of complaint reported in our systematic review were delayed/incorrect diagnosis and delayed/incorrect treatment. Organisations should be encouraged to share complaints data as it can facilitate shared learning. An understanding of human factor principles and its role in patient safety is also emphasised in this report in order to optimise patient outcomes and improve experience for families requiring neonatal care.

Factors Associated With Maternal and Neonatal Interventions at the Threshold of Viability

OBJECTIVE

To quantify the influence of maternal sociodemographic, medical, and pregnancy characteristics on decisions to offer or receive antepartum and neonatal interventions with deliveries occurring at 22-23 weeks of gestation.

METHODS

This is a case-control study of U.S. live births at 22 0/7-23 6/7 weeks of gestation using National Center for Health Statistics vital statistics birth records from 2012 to 2016. We analyzed three outcomes in the treatment of periviable delivery: 1) maternal interventions (cesarean delivery, maternal hospital transfer or antenatal corticosteroid administration), 2) neonatal interventions (neonatal intensive care unit admission, surfactant administration, antibiotic administration, or assisted ventilation), and 3) combined interventions (at least one maternal and at least one neonatal intervention). Logistic regression estimated the influence of characteristics on interventions received.

RESULTS

Of 19,844,580 U.S. live births from 2012 to 2016, 24,379 (0.12%) occurred at 22-23 weeks of gestation. Of these, 37.5% received maternal interventions, 51.7% received neonatal interventions, and 28.0% received combined interventions. Rates of births receiving at least one intervention were 38.9% and 78.3% for 22 and 23 weeks of gestation, respectively. Preeclampsia was the factor most positively associated with interventions. Other factors positively associated with interventions were increasing maternal age, Medicaid, low educational attainment, multiparity, twin gestation, and infertility treatment. Some factors had opposite influences on maternal compared with neonatal interventions. The presence of birth defects was positively associated with maternal interventions but negatively associated with neonatal interventions, whereas being of black race was negatively associated with maternal interventions but positively associated with neonatal interventions.

CONCLUSION

Maternal and neonatal interventions occur frequently at the threshold of viability, especially at 23 weeks of gestation where the occurrence of interventions exceeds 50%. This study identifies sociodemographic and medical factors associated with using interventions with periviable deliveries. These data elucidate observed practice patterns in the management of periviable births and may assist providers in the counseling of women at risk of periviable birth.

An alternative approach to developing guidelines for the management of an anticipated extremely preterm infant

Objectives To identify the probability of survival and severe neurodevelopmental impairment (sNDI) at which perinatal physicians would or would not offer or recommend resuscitation at birth for extremely preterm infants. Methods A Delphi process consisting of five rounds was implemented to seek consensus (>80% agreement) amongst British Columbia perinatal physicians. The first-round consisted of neonatal and maternal-fetal-medicine Focus Groups. Rounds two to five surveyed perinatal physicians, building upon previous rounds. Draft guidelines were developed and agreement sought. Results Based on 401 responses across all rounds, consensus was obtained that resuscitation should not be offered if survival probability <5%, not recommended if survival probability 5 to <10%, resuscitation recommended if survival without sNDI probability >70 to 90% and resuscitation standard care if survival without sNDI >90%. Conclusions This physician consensus-based, objective framework for the management of an anticipated extremely preterm infant is a transparent alternative to existing guidelines, minimizing gestational-ageism and allowing for individualized management utilizing up-to-date data. Further input from other key stakeholders will be required prior to guideline implementation.

Decision-making at the limit of viability

Babies born at the limit of viability have a high risk of morbidity and mortality. Despite great advances in science, the approach to these newborns remains challenging. Thus, this study reviewed the literature regarding the treatment of newborns at the limit of viability. There are several interventions that can be applied before and after birth to increase the baby's survival with the least sequelae possible, but different countries make different recommendations on the gestational age that each treatment should be given. There is more consensus on the extremities of viability, being that, at the lower extremity, comfort care is preferred and active care in newborns with higher gestational age. The higher the gestational age at birth, the higher the survival and survival without morbidity rates. At all gestational ages, it is important to take into account the suffering of these babies and to provide them the best quality of life possible. Sometimes palliative care is the best therapeutic approach. The parents of these babies should be included in the decision-making process, if they wish, always respecting their needs and wishes. Nevertheless, the process of having such an immature child can be very painful for parents, so it is also important to take into account their suffering and provide them with all the necessary support. This support should be maintained even after the death of the newborn.

The importance of shared decision-making in the neonatal intensive care unit

OBJECTIVE

Neonatal intensive care unit (NICU) admissions are common and rising. Parents with infants in the NICU face difficult decisions about their infants' care. Few studies have investigated parents' engagement in NICU decisions and its effects on decision regret.

STUDY DESIGN

We surveyed parents of children who had a NICU stay in the past 3 years. We explored whether sociodemographic characteristics affected preferred decision involvement, shared decision-making with NICU clinicians, or decision regret. Multivariable linear regression analyses examined the relationship between shared decision-making and decision regret.

RESULTS

Most parents preferred an active (212/405, 52.3%) or shared (139/405, 34.3%) approach to decision-making. No sociodemographic characteristics related to preferred decision involvement or shared decision-making (p's > 0.05). In multivariable analyses, shared decision-making, education and health literacy related to less decision regret (p's < 0.05).

CONCLUSIONS

These data suggest the importance of shared decision-making during NICU stays. Studies should identify ways to support parents through NICU decision-making.

Parents' Descriptions of Neonatal Palliation as a Treatment Option Prior to Periviable Delivery

During periviable deliveries, parents are confronted with overwhelming and challenging decisions. This study aimed to qualitatively explore the language that pregnant women and important others utilize when discussing palliation, or "comfort care," as a treatment option in the context of periviability. We prospectively recruited women admitted for a threatened periviable delivery (22-25 weeks) at 2 hospitals between September 2016 and January 2018. Using a semistructured interview guide, we investigated participants' perceptions of neonatal treatment options, asking items such as "How was the choice of resuscitation presented to you?" and "What were the options presented?" Conventional content analysis was used and matrices were created to facilitate using a within- and across-case approach to identify and describe patterns. Thirty women and 16 important others were recruited in total. Participants' descriptions of treatment options included resuscitating at birth or not resuscitating. Participants further described the option to not resuscitate as "comfort care," "implicit" comfort care, "doing nothing," and "withdrawal of care." This study revealed that many parents facing periviable delivery may lack an understanding of comfort care as a neonatal treatment option, highlighting the need to improve counseling efforts in order to maximize parents' informed decision-making.

The Extremely Preterm Infant: Ethical Considerations in Life-and-Death Decision-Making

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.

Perceptions of Australian and New Zealand clinicians caring for neonates born at the borderline of viability have changed since the 2005 consensus guideline

AIM

To determine whether clinician and consumer considerations have changed regarding the resuscitation and support of neonates born at the borderlines of viability since the 2005 New South Wales (NSW) and Australian Capital Territory (ACT) consensus guidelines were developed.

METHODS

A prospective survey based on the hypotheses and scenarios developed in the original NSW and ACT consensus workshop on perinatal care at the borderlines of viability was sent to neonatologists, fetal medicine specialists, clinical midwife and clinical neonatal consultants and consumer representatives in Australia and New Zealand. Four scenarios and 16 questions were used to explore the respondent's views towards different aspects of the management of neonates born at the borderlines of viability. Australian and New Zealand Neonatal Network data from 2013 or NSW/ACT Neonatal Intensive Care Units (NICUS) data from 1998 to 2004 were used to provide outcome data for each scenario.

RESULTS

A total of 87% or more of respondents advocated for resuscitation of neonates at 24 and 25 weeks' gestation in 2015. Only 29% (49/169) would agree to parental request not to resuscitate at 25 weeks and only 10% (17/170) at 26^0-6 weeks. The number of perinatal clinical care providers considering resuscitation at 23⁵ weeks' gestation increased from 23% in 2005 to more than 50% in 2015.

CONCLUSION

These findings support the development of updated guidelines for the management of neonates in Australia and New Zealand born at the borderlines of viability to reflect the changes in clinical perceptions and management.

Effect of written outcome information on attitude of perinatal healthcare professionals at the limit of viability: a randomized study

Background

Differences in perception and potential disagreements between parents and professionals regarding the attitude for resuscitation at the limit of viability are common. This study evaluated in healthcare professionals whether the decision to resuscitate at the limit of viability (intensive care versus comfort care) are influenced by the way information on incurred risks is given or received.

Methods

This is a prospective randomized controlled study. This study evaluated the attitude of healthcare professionals by testing the effect of information given through graphic fact sheets formulated either optimistically or pessimistically. The written educational fact sheet included three graphical presentations of survival and complication/morbidity by gestational age. The questionnaire was submitted over a period of 4 months to 5 and 6-year medical students from the Geneva University as well as physicians and nurses of the neonatal unit at the University Hospitals of Geneva. Our sample included 102 healthcare professionals.

Results

Forty-nine responders (48%) were students (response rate of 33.1%), 32 (31%) paediatricians (response rate of 91.4%) and 21 (20%) nurses in NICU (response rate of 50%). The received risk tended to be more severe in both groups compared to the graphically presented facts and current guidelines, although optimistic representation favoured the perception of “survival without disability” at 23 to 25 weeks. Therapeutic attitudes did not differ between groups, but healthcare professionals with children were more restrained and students more aggressive at very low gestational ages.

Conclusion

Written information on mortality and morbidity given to healthcare professionals in graphic form encourages them to overestimate the risk. However, perception in healthcare staff may not be directly transferable to parental perception during counselling as the later are usually naïve to the data received. This parental information are always communicated in ways that subtly shape the decisions that follow.

Prenatal parental involvement in decision for delivery room management at 22-26 weeks of gestation in France - The EPIPAGE-2 Cohort Study

OBJECTIVE

Our main objective was to examine if parental prenatal preferences predict delivery-room management of extremely preterm periviable infants. The secondary objectives were to describe parental involvement and the content of prenatal counseling given to parents for this prenatal decision.

DESIGN

Prospective study of neonates liveborn between 22 and 26 weeks of gestation in France in 2011 among the neonates included in the EPIPAGE-2 study.

SETTING

18 centers participating in the "Extreme Prematurity Group" substudy of the EPIPAGE-2 study.

PATIENTS

302 neonates liveborn between 22-26 weeks among which 113 with known parental preferences while parental preferences were unknown or unavailable for 186 and delivery room management was missing for 3.

RESULTS

Data on prenatal counseling and parental preferences were collected by a questionnaire completed by professionals who cared for the baby at birth; delivery room (DR) management, classified as stabilization or initiation of resuscitation (SIR) vs comfort care (CC). The 113 neonates studied had a mean (SD) gestational age of 24 (0.1) weeks. Parents of neonates in the CC group preferred SIR less frequently than those with neonates in the SIR group (16% vs 88%, p < .001). After multivariate analysis, preference for SIR was an independent factor associated with this management. Professionals qualified decisions as shared (81%), exclusively medical (16%) or parental (3%). Information was described as medical with no personal opinion (71%), complete (75%) and generally pessimistic (54%).

CONCLUSION

Parental involvement in prenatal decision-making did not reach satisfying rates in the studied setting. When available, prenatal parental preference was a determining factor for DR management of extremely preterm neonates. Potential biases in the content of prenatal counselling given to parents need to be evaluated.

Development of Nationwide Recommendations to Support Prenatal Counseling in Extreme Prematurity

OBJECTIVES

To develop a nationwide, evidence-based framework to support prenatal counseling in extreme prematurity, focusing on organization, decision-making, content, and style aspects.

METHODS

A nationwide multicenter RAND-modified Delphi method study was performed between November 2016 and December 2017 in the Netherlands. Firstly, recommendations were extracted from literature and previous studies. Secondly, an expert panel (n = 21) with experienced parents, obstetricians, and neonatologists rated the recommendations on importance for inclusion in the framework. Thirdly, ratings were discussed in a consensus meeting. The final set of recommendations was approved and transformed into a framework.

RESULTS

A total of 101 recommendations on organization, decision-making, content, and style were included in the framework, including tools to support personalization. The most important recommendations regarding organization were to have both parents involved in the counseling with both the neonatologist and obstetrician. The shared decision-making model was recommended for deciding between active support and comfort care. Main recommendations regarding content of conversation were explanation of treatment options, information on survival, risk of permanent consequences, impossibility to predict an individual course, possibility for multiple future decision moments, and a discussion on parental values and standards. It was considered important to avoid jargon, check understanding, and provide a summary. The expert panel, patient organization, and national professional associations (gynecology and pediatrics) approved the framework.

CONCLUSIONS

A nationwide, evidence-based framework for prenatal counseling in extreme prematurity was developed. It contains recommendations and tools for personalization in the domains of organization, decision-making, content, and style of prenatal counseling.

Extremely premature birth, informed written consent, and the Greek ideal of sophrosyne

Most extremely premature infants die in the intensive care unit or suffer significant neurologic impairment. Many therapies result in unhealthy consequences, and the emotional and financial turmoil for families warrant reappraisal of our motives. Shared decision-making and informed consent in preference-sensitive conditions imply the family: (a) understands the medical problem, (b) grasps the risks and benefits of each therapy, (c) has the opportunity to ask questions and reflect upon options, (d) knows their values and preferences are understood, and (e) accepts or declines therapies without judgment or penalty. Mandatory resuscitation of premature infants or inflexible palliative comfort care policies are inconsistent with the principles of informed consent and shared decision-making. Physicians should emulate the Greek ideal of sophrosyne-virtue inherent to balance, reasoned limits, freedom but restraint, and humility. Informed choice is fundamental to liberty; evidence-based periviability guidelines and decision aids bolstered by structured informed consent ensure process integrity.

A different perspective: anesthesia for extreme premature infants: is there an age limitation or how low should we go?

PURPOSE OF REVIEW

To put in perspective, the various challenges that faces pediatric anesthesiologists because of the recently lowered limits with regards to the viability of a fetus. Both medical and ethical considerations will be highlighted.

RECENT FINDINGS

Issues related to: who should anesthetize these tiny babies; can we provide adequate and legal monitoring during the anesthetic; does these immature babies need hypnosis and amnesia and the moral/ethical implications associated with being involved with care of doubtful long-term outcome are reviewed.

SUMMARY

There does currently not exist sufficient research data to provide any evidence-based guidelines for the anesthetic handling of extreme premature infants. Current practice relies on extrapolations from other patient groups and from attempting to preserve normal physiology. Thus, focused research initiatives within this specific field of anesthesia should be a priority. Furthermore, in-depth multiprofessional ethical discussions regarding long-term outcome of aggressive care of extremely premature babies are urgently needed, including the new concepts of disability-free survival and number-need-to-suffer.

Prenatal (non)treatment decisions in extreme prematurity: evaluation of Decisional Conflict and Regret among parents

OBJECTIVE

To evaluate Decisional Conflict and Regret among parents regarding the decision on initiating comfort or active care in extreme prematurity and to relate these to decision-making characteristics.

STUDY DESIGN

A nationwide, multicenter, cross-sectional study using an online survey in the Netherlands. Data were collected from March 2015 to March 2016 among all parents with infants born at 24^+0/7-24^+6/7 weeks gestational age in 2010-2013. The survey contained a Decisional Conflict and Decision Regret Scale (potential scores range from 0 to 100) and decision-making characteristics.

RESULTS

Sixty-one surveys were returned (response rate 27%). The median Decisional Conflict score was 28. From the subscores within Decisional Conflict, 'values clarity' revealed the highest median score of 42-revealing that parents felt unclear about personal values for benefits and risks of the decision on either comfort care or active care. The median Decision Regret score was 0. Regret scores were influenced by the actual decision made and by outcome: Decision Regret was lower in the active care group and in the survivor group.

CONCLUSION

We found little Decisional Conflict and no Decision Regret among parents regarding decision-making at 24 weeks gestation.

Field testing of decision coaching with a decision aid for parents facing extreme prematurity

OBJECTIVE

The objective of this study is to assess and modify an existing decision aid and field-test decision coaching with the modified aid during consultations with parents facing potential delivery at 23 to 24 weeks gestation.

STUDY DESIGN

International Patient Decision Aid Standards instrument (IPDASi) scoring deficits, multi-stakeholder group feedback and α-testing guided modifications. Feasibility/acceptability were assessed. The Decisional Conflict Scale was used to measure participants' decisional conflict before (T1) and immediately after (T2) the consultation.

RESULTS

IPDASi assessment of the existing aid (score 11/35) indicated it required updated data, more information and a palliative care description. Following modification, IPDASi score increased to 26/35. Twenty subjects (12 pregnancies) participated in field-testing; 15 completed all questionnaires. Most participants (89%) would definitely recommend this form of consultation. Decisional conflict scores decreased (P<0.001) between T1 (52±25) and T2 (10±16).

CONCLUSION

Field testing demonstrated that consultations using the aid with decision coaching were feasible, reduced decisional conflict and may facilitate shared decision-making.

The quest for sustained multiple morbidity reduction in very low-birth-weight infants: the Antifragility project

OBJECTIVE

Can a comprehensive, explicitly directive evidence-based guideline for all therapies that might affect the major morbidities of very low-birth-weight (VLBW) infants help a neonatal intensive care unit (NICU) further improve generally favorable morbidity rates? Can Antifragility principles of provider adaptive growth from stressors, enhanced infant risk assessment and adherence to effective therapies minimize unproven treatments and reduce all morbidities?

STUDY DESIGN

Prospectively planned observational trial in VLBW infants: control group born October 2011 to September 2013 and study group October 2013 to September 2015. Multi-disciplinary evidence-based review assigned all NICU treatments into one of four distinct categories: (1) always employ this therapy for VLBW infants, (2) never use this therapy, (3) employ this questionable therapy thoughtfully, only in certain circumstances and (4) this therapy has insufficient evidence of efficacy and safety. Extensive staff education emphasized evidence-based potentially better practice (PBP) selection with compliance checks, appreciation of intertwined co-morbidities and prioritizing infant risk reduction strategies.

RESULTS

Control included 221 infants, mean (s.d.) age 29 (2.6) weeks, birth weight 1129 (257) g and Study included 197 infants, 29 (2.7) weeks, 1093 (292) g. One hundred and four distinct therapies were placed into categories 1 to 4, with 32 specific compliance checks. Overall mean compliance with the process checks during the second era was 70%, high: 100% (exclusive breast milk use), low: 24% (correct pulse oximetry alarm settings). Morbidity and mortality rates did not significantly change during the second era.

CONCLUSIONS

In our NICU with favorable morbidity rates, an expanded effort using a comprehensive therapy guideline for VLBW infants did not further improve outcomes. We need deeper understanding of continuous quality improvement (CQI) fundamentals, therapy compliance, co-morbidity relationships and enhanced sensitivity of risk assessment. Our innovative Antifragility PBP guideline could be useful to other NICUs seeking improvement in VLBW infant morbidities, as we offer a reasoned and concise template of a broad array of therapies categorized efficiently for transparency and review, designed to enhance responsible CQI decision-making.

Prognostic neurodevelopmental testing of preterm infants: do we need to change the paradigm?

Longitudinal follow-up with assessment of developmental status at about 2 years of age is routine for high-risk newborns. The results of these assessments can be used for many purposes, including helping physicians, parents, and teachers plan educational or developmental interventions. These assessments also provide outcome measures for clinical research studies. Outcome results may also serve as a source of information for clinicians when counseling parents regarding provision of care for extreme preterm infants. Consideration should be given to use of different outcome metrics based on the purpose for testing. Categorization of composite cognitive, motor and neurosensory findings to define levels of impairment should be limited to research. Planning for individual interventions is better guided by descriptive findings. Current tools for assessing neurodevelopmental status at 2 years of age have important limitations. First, outcomes at early ages do not always predict function later in life. They are, at best, an estimate of longer-term outcomes, with important individual variation. For infants without severe neurologic injury, postnatal environmental factors play a predominant role in determining long-term cognitive and academic outcomes. Further investigations should assess quality of life and other considerations that are important for parents when making decisions about neonatal intensive care unit care for their infant.