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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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de Boer A, De Proost L, de Vries M, Hogeveen M, Verweij EJTJ, Geurtzen R. Perspectives of extremely prematurely born adults on what to consider in prenatal decision-making: a qualitative focus group study. Arch Dis Child Fetal Neonatal Ed 2024; 109:196-201. [PMID: 37726159 DOI: 10.1136/archdischild-2023-325997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
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.
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Affiliation(s)
- Angret de Boer
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lien De Proost
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke de Vries
- Institute for Computing and Information Sciences (iCIS), Radboud University, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E J T Joanne Verweij
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rosa Geurtzen
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
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de Boer A, van Beek PE, Andriessen P, Groenendaal F, Hogeveen M, Meijer JS, Obermann-Borst SA, Onland W, Scheepers L(HCJ, Vermeulen MJ, Verweij EJT(J, De Proost L, Geurtzen R. Opportunities and Challenges of Prognostic Models for Extremely Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1712. [PMID: 37892375 PMCID: PMC10605480 DOI: 10.3390/children10101712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/06/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
Predicting the short- and long-term outcomes of extremely preterm infants remains a challenge. Multivariable prognostic models might be valuable tools for clinicians, parents, and policymakers for providing accurate outcome estimates. In this perspective, we discuss the opportunities and challenges of using prognostic models in extremely preterm infants at population and individual levels. At a population level, these models could support the development of guidelines for decisions about treatment limits and may support policy processes such as benchmarking and resource allocation. At an individual level, these models may enhance prenatal counselling conversations by considering multiple variables and improving transparency about expected outcomes. Furthermore, they may improve consistency in projections shared with parents. For the development of prognostic models, we discuss important considerations such as predictor and outcome measure selection, clinical impact assessment, and generalizability. Lastly, future recommendations for developing and using prognostic models are suggested. Importantly, the purpose of a prognostic model should be clearly defined, and integrating these models into prenatal counselling requires thoughtful consideration.
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Affiliation(s)
- Angret de Boer
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Pauline E. van Beek
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands;
| | - Marije Hogeveen
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
| | - Julia S. Meijer
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Sylvia A. Obermann-Borst
- Care4Neo, Dutch Neonatal Patient and Parent Advocacy Organization, 3068 JN Rotterdam, The Netherlands; (S.A.O.-B.); (M.J.V.)
| | - Wes Onland
- Department of Neonatology, Emma Children’s Hospital, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
- Amsterdam Reproduction & Development, 1105 AZ Amsterdam, The Netherlands
| | | | - Marijn J. Vermeulen
- Care4Neo, Dutch Neonatal Patient and Parent Advocacy Organization, 3068 JN Rotterdam, The Netherlands; (S.A.O.-B.); (M.J.V.)
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Sophia Children’s Hospital, Erasmus Medical Center, 3015 CN Rotterdam, The Netherlands
| | - E. J. T. (Joanne) Verweij
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Lien De Proost
- Department of Ethics and Law, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Rosa Geurtzen
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
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De Proost L, de Boer A, Reiss IKM, Steegers EAP, Verhagen AAE, Hogeveen M, Geurtzen R, Verweij EJJ. Adults born prematurely prefer a periviability guideline that considers multiple prognostic factors beyond gestational age. Acta Paediatr 2023; 112:1926-1935. [PMID: 37272253 DOI: 10.1111/apa.16866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/22/2023] [Accepted: 06/02/2023] [Indexed: 06/06/2023]
Abstract
AIM The aim of the study was to explore the perspectives of adults born prematurely on guidelines for management at extreme premature birth and personalisation at the limit of viability. METHODS We conducted four 2-h online focus group interviews in the Netherlands. RESULTS Twenty-three participants born prematurely were included in this study, ranging in age from 19 to 56 years and representing a variety of health outcomes. Participants shared their perspectives on different types of guidelines for managing extremely premature birth. They agreed that a guideline was necessary to prevent arbitrary treatment decisions and to avoid physician bias. All participants favoured a guideline that is based upon multiple prognostic factors beyond gestational age. They emphasised the importance of discretion, regardless of the type of guideline used. Discussions centred mainly on the heterogeneity of value judgements about outcomes after extreme premature birth. Participants defined personalisation as 'not just looking at numbers and statistics'. They associated personalisation mainly with information provision and decision-making. Participants stressed the importance of involving families in decision-making and taking their care needs seriously. CONCLUSION Adults born prematurely prefer a periviability guideline that considers multiple prognostic factors and allows for discretion.
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Affiliation(s)
- L De Proost
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Neonatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Obstetrics, Leids University Medical Center, Leiden, The Netherlands
| | - A de Boer
- Department of Obstetrics, Leids University Medical Center, Leiden, The Netherlands
- Department of Neonatology, Amalia Children's Hospital, Radboud UMC, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - I K M Reiss
- Department of Neonatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - E A P Steegers
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - A A E Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M Hogeveen
- Department of Neonatology, Amalia Children's Hospital, Radboud UMC, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - R Geurtzen
- Department of Neonatology, Amalia Children's Hospital, Radboud UMC, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - E J Joanne Verweij
- Department of Obstetrics, Leids University Medical Center, Leiden, The Netherlands
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Steurer MA, Ryckman KK, Baer RJ, Costello J, Oltman SP, McCulloch CE, Jelliffe-Pawlowski LL, Rogers EE. Developing a resiliency model for survival without major morbidity in preterm infants. J Perinatol 2023; 43:452-457. [PMID: 36220984 PMCID: PMC10079534 DOI: 10.1038/s41372-022-01521-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Develop and validate a resiliency score to predict survival and survival without neonatal morbidity in preterm neonates <32 weeks of gestation using machine learning. STUDY DESIGN Models using maternal, perinatal, and neonatal variables were developed using LASSO method in a population based Californian administrative dataset. Outcomes were survival and survival without severe neonatal morbidity. Discrimination was assessed in the derivation and an external dataset from a tertiary care center. RESULTS Discrimination in the internal validation dataset was excellent with a c-statistic of 0.895 (95% CI 0.882-0.908) for survival and 0.867 (95% CI 0.857-0.877) for survival without severe neonatal morbidity, respectively. Discrimination remained high in the external validation dataset (c-statistic 0.817, CI 0.741-0.893 and 0.804, CI 0.770-0.837, respectively). CONCLUSION Our successfully predicts survival and survival without major morbidity in preterm babies born at <32 weeks. This score can be used to adjust for multiple variables across administrative datasets.
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Affiliation(s)
- Martina A Steurer
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Kelli K Ryckman
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Rebecca J Baer
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Jean Costello
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Scott P Oltman
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Laura L Jelliffe-Pawlowski
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
| | - Elizabeth E Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
- California Preterm Birth Initiative, University of California San Francisco, San Francisco, CA, USA
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6
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Deligianni M, Voultsos P, Tzitiridou-Chatzopoulou MK, Drosou-Agakidou V, Tarlatzis V. Moral distress among neonatologists working in neonatal intensive care units in Greece: a qualitative study. BMC Pediatr 2023; 23:114. [PMID: 36890500 PMCID: PMC9993694 DOI: 10.1186/s12887-023-03918-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/20/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Working as a neonatologist in a neonatal intensive care unit (NICU) is stressful and involves ethically challenging situations. These situations may cause neonatologists to experience high levels of moral distress, especially in the context of caring for extremely premature infants (EPIs). In Greece, moral distress among neonatologists working in NICUs remains understudied and warrants further exploration. METHODS This prospective qualitative study was conducted from March to August 2022. A combination of purposive and snowball sampling was used and data were collected by semi-structured interviews with twenty neonatologists. Data were classified and analyzed by thematic analysis approach. RESULTS A variety of distinct themes and subthemes emerged from the analysis of the interview data. Neonatologists face moral uncertainty. Furthermore, they prioritize their traditional (Hippocratic) role as healers. Importantly, neonatologists seek third-party support for their decisions to reduce their decision uncertainty. In addition, based on the analysis of the interview data, multiple predisposing factors that foster and facilitate neonatologists' moral distress emerged, as did multiple predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. The predisposing factors that foster and facilitate neonatologists' moral distress thus identified include the lack of previous experience on the part of neonatologists, the lack of clear and adequate clinical practice guidelines/recommendations/protocols, the scarcity of health care resources, the fact that in the context of neonatology, the infant's best interest and quality of life are difficult to identify, and the need to make decisions in a short time frame. NICU directors, neonatologists' colleagues working in the same NICU and parental wishes and attitudes were identified as predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. Ultimately, neonatologists become more resistant to moral distress over time. CONCLUSIONS We concluded that neonatologists' moral distress should be conceptualized in the broad sense of the term and is closely associated with multiple predisposing factors. Such distress is greatly affected by interpersonal relationships. A variety of distinct themes and subthemes were identified, which, for the most part, were consistent with the findings of previous research. However, we identified some nuances that are of practical importance. The results of this study may serve as a starting point for future research.
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Affiliation(s)
- Maria Deligianni
- Laboratory of Forensic Medicine & Toxicology (Division: Medical Law and Ethics), School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, GR 54124, Thessaloniki, Greece
| | - Polychronis Voultsos
- Laboratory of Forensic Medicine & Toxicology (Division: Medical Law and Ethics), School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, GR 54124, Thessaloniki, Greece.
| | - Maria K Tzitiridou-Chatzopoulou
- Midwifery Department, School of Healthcare Sciences, University of Western Macedonia (Greece), Ikaron 3, GR 50100, Kozani, Greece
| | - Vasiliki Drosou-Agakidou
- 1st Department of Neonatology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, GR 54124, Thessaloniki, Greece
| | - Vasileios Tarlatzis
- 1st Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, GR 54124, Thessaloniki, Greece
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An e-Delphi study on mode of delivery and extremely preterm breech singletons. J Perinatol 2023; 43:15-22. [PMID: 35864218 DOI: 10.1038/s41372-022-01458-7] [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] [Received: 01/21/2022] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To understand clinicians' consensus on mode of delivery in extremely preterm breech infants; assess knowledge on neonatal outcomes and its impact on consensus. STUDY DESIGN A two-round Delphi of obstetrical or neonatal care providers, recruited from national conferences and investigator networks. Round one assessed decision-making (vignettes), and knowledge; the second round reassessed vignettes after presenting outcome data. RESULTS In round one (102 respondents), consensus (a priori, ≥75% agreement) was achieved in 4/13 vignettes: two when likely/very likely to offer Cesarean (26 and 27 weeks) and two for unlikely/very unlikely (23 weeks growth restriction, ± adverse features). Clinicians generally underestimated neonatal outcomes. In round two (87 respondents), three scenarios achieved consensus (likely/very likely to offer Cesarean at 25-27 weeks); in five other vignettes, not offering Cesarean was reduced in ≥15% of respondents. CONCLUSION Limited consensus exists on extremely preterm breech mode of delivery, partly associated with neonatal outcome underestimation. GESTATIONAL AGE NOTATION The authors follow the World Health Organization's notation on gestational age. Under this notation, the first day of the last menstrual period (LMP) is day 0 of week 0. Therefore, days 0-6 represent completed week 0, days 7-13 represent completed week 1 and so on.
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Assessing shared decision making during antenatal consultations regarding extreme prematurity. J Perinatol 2023; 43:29-33. [PMID: 36284208 DOI: 10.1038/s41372-022-01542-y] [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] [Received: 05/31/2022] [Revised: 10/09/2022] [Accepted: 10/12/2022] [Indexed: 02/07/2023]
Abstract
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.
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Syltern J, Ursin L, Solberg B, Støen R. Postponed Withholding: Balanced Decision-Making at the Margins of Viability. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:15-26. [PMID: 33998962 DOI: 10.1080/15265161.2021.1925777] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental "instinct of saving" and "withdrawal resistance" involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled "postponed withholding." In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.
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Affiliation(s)
- Janicke Syltern
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
| | - Lars Ursin
- The Norwegian University of Science and Technology
| | | | - Ragnhild Støen
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
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10
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Foggin H, Hutcheon JA, Liauw J. Making sense of harms and benefits: Assessing the numeric presentation of risk information in ACOG obstetrical clinical practice guidelines. PATIENT EDUCATION AND COUNSELING 2022; 105:1216-1223. [PMID: 34509341 DOI: 10.1016/j.pec.2021.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 07/31/2021] [Accepted: 08/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To assess the presentation of risk information in American College of Obstetricians and Gynecologists (ACOG) obstetrical Practice Bulletins. METHODS We reviewed B- and C-graded recommendations in Practice Bulletins published from January 2017 to March 2020. We calculated the proportion of recommendations and outcomes that were presented numerically and, of these, the proportion that were presented in accordance with best practices of risk communication - in absolute formats, or as absolute changes in risk from baseline risks. We categorized outcomes as harms or benefits to compare their risk presentation. RESULTS In 21 obstetrical Practice Bulletins, there were 125 recommendations, with 46 (37%) describing risks numerically. Sixteen of these 46 recommendations (35%) presented an absolute change in risk from a baseline risk. For harms, 65% were presented as absolute risks and 25% as relative risks. For benefits, this was 55% and 48% respectively. CONCLUSION Most recommendations do not present numeric risk information. Of those that do, most do not use absolute risk measures. PRACTICE IMPLICATIONS Obstetrical practice guidelines should present numerical risk information wherever possible to support recommendations, increasing the use of absolute risk formats and absolute changes from baseline risks to increase risk comprehension.
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Affiliation(s)
- Hannah Foggin
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Jessica Liauw
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada.
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11
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Zaal‐Schuller IH, Geurtzen R, Willems DL, de Vos MA, Hogeveen M. What hinders and helps in the end-of-life decision-making process for children: Parents' and physicians' views. Acta Paediatr 2022; 111:873-887. [PMID: 35007341 PMCID: PMC9373914 DOI: 10.1111/apa.16250] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/27/2021] [Accepted: 01/07/2022] [Indexed: 11/29/2022]
Abstract
AIM To investigate the main factors which facilitate or hinder end-of-life decision-making (EoLDM) in neonates and children. METHODS A qualitative inductive, thematic analysis was performed of interviews with a total of 73 parents and 71 physicians. The end-of-life decisions mainly concern decisions to withhold or withdraw life-sustaining treatment. RESULTS The importance of taking sufficient time and exchanging clear, neutral and relevant information was main facilitators expressed by both parents and physicians. Lack of time, uncertain information and changing doctors were seen as important barriers by both parties. Most facilitators and barriers could be seen as two sides of the same coin, but not always. For example, some parents and physicians considered the fact that parents hold strong opinions as a barrier while others considered this a facilitator. Furthermore, parents and physicians showed differences. Parents especially underlined the importance of physician-related facilitators, such as a personalised approach, empathy and trust. On the contrary, physicians underlined the importance of the child's visible deterioration and parents' awareness of the seriousness of their child's condition and prognosis as facilitators of EoLDM. CONCLUSIONS This study gained insight into what parents and physicians experience as the main barriers and facilitators in EoLDM for neonates and children.
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Affiliation(s)
| | - Rosa Geurtzen
- Amalia Children’s Hospital Radboudumc Nijmegen the Netherlands
| | - Dick L. Willems
- Section of Medical Ethics University of Amsterdam Amsterdam the Netherlands
| | - Mirjam A. de Vos
- Section of Medical Ethics University of Amsterdam Amsterdam the Netherlands
| | - Marije Hogeveen
- Amalia Children’s Hospital Radboudumc Nijmegen the Netherlands
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12
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Verweij EJ, De Proost L, Hogeveen M, Reiss IKM, Verhagen AAE, Geurtzen R. Dutch guidelines on care for extremely premature infants: Navigating between personalisation and standardization. Semin Perinatol 2022; 46:151532. [PMID: 34839939 DOI: 10.1016/j.semperi.2021.151532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE There is no international consensus on what type of guideline is preferred for care at the limit of viability. We aimed to conceptualize what type of guideline is preferred by Dutch healthcare professionals: 1) none; 2) gestational-age-based; 3) gestational-age-based-plus; or 4) prognosis-based via a survey instrument. Additional questions were asked to explore the grey zone and attitudes towards treatment variation. FINDING 769 surveys were received. Most of the respondents (72.8%) preferred a gestational-age-based-plus guideline. Around 50% preferred 24+0/7 weeks gestational age as the lower limit of the grey zone, whereas 26+0/7 weeks was the most preferred upper limit. Professionals considered treatment variation acceptable when it is based upon parental values, but unacceptable when it is based upon the hospital's policy or the physician's opinion. CONCLUSION In contrast to the current Dutch guideline, our results suggest that there is a preference to take into account individual factors besides gestational age.
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Affiliation(s)
- E J Verweij
- Department of Obstetrics, LUMC, Albinusdreef 2, Leiden ZA 2333, the Netherlands; Department of Obstetrics and Gynaecology, Erasmus MC, the Netherlands.
| | - Lien De Proost
- Department of Obstetrics and Gynaecology, Erasmus MC, the Netherlands; Department of Neonatology, Erasmus MC, the Netherlands; Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, the Netherlands
| | - Marije Hogeveen
- Department of Neonatology, Radboud University Medical Centre, Amalia Children's Hospital, the Netherlands
| | - I K M Reiss
- Department of Neonatology, Erasmus MC, the Netherlands
| | - A A E Verhagen
- Department of Paediatrics, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - Rosa Geurtzen
- Department of Neonatology, Radboud University Medical Centre, Amalia Children's Hospital, the Netherlands
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13
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van den Heuvel JFM, Hogeveen M, Lutke Holzik M, van Heijst AFJ, Bekker MN, Geurtzen R. Digital decision aid for prenatal counseling in imminent extreme premature labor: development and pilot testing. BMC Med Inform Decis Mak 2022; 22:7. [PMID: 34991580 PMCID: PMC8734286 DOI: 10.1186/s12911-021-01735-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 12/14/2021] [Indexed: 01/04/2023] Open
Abstract
Background In case of extreme premature delivery at 24 weeks of gestation, both early intensive care and palliative comfort care for the neonate are considered treatment options. Prenatal counseling, preferably using shared decision making, is needed to agree on the treatment option in case labor progresses. This article described the development of a digital decision aid (DA) to support pregnant women, partners and clinicians in prenatal counseling for imminent extreme premature labor.
Methods This DA is developed following the International Patient Decision Aid Standards. The Dutch treatment guideline and the Dutch recommendations for prenatal counseling in extreme prematurity were used as basis. Development of the first prototype was done by expert clinicians and patients, further improvements were done after alpha testing with involved clinicians, patients and other experts (n = 12), and beta testing with non-involved clinicians and patients (n = 15). Results The final version includes information, probabilities and figures depending on users’ preferences. Furthermore, it elicits patient values and provides guidance to aid parents and professionals in making a decision for either early intensive care or palliative comfort care in threatening extreme premature delivery. Conclusion A decision aid was developed to support prenatal counseling regarding the decision on early intensive care versus palliative comfort care in case of extreme premature delivery at 24 weeks gestation. It was well accepted by parents and healthcare professionals. Our multimedia, digital DA is openly available online to support prenatal counseling and personalized, shared decision-making in imminent extreme premature labor. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01735-z.
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Affiliation(s)
- Josephus F M van den Heuvel
- Department of Obstetrics, Wilhelmina's Children Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marije Hogeveen
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Internal Code 804, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Margo Lutke Holzik
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arno F J van Heijst
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Internal Code 804, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics, Wilhelmina's Children Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rosa Geurtzen
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Internal Code 804, PO Box 9101, 6500HB, Nijmegen, The Netherlands.
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14
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Ferretti E, Daboval T, Rouvinez-Bouali N, Lawrence SL, Lemyre B. Extremely low gestational age infants: Developing a multidisciplinary care bundle. Paediatr Child Health 2021; 26:e240-e245. [PMID: 34630783 PMCID: PMC8491076 DOI: 10.1093/pch/pxaa110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical experience in managing extremely low gestational age infants, particularly those born <24 weeks' gestation, is limited in Canada. Our goal was to develop a bedside care bundle for infants born <26 weeks' gestation, with special considerations for infants of <24 weeks, to harmonize and improve quality of care. METHODS We created a multidisciplinary working group with experience in caring for preterm infants, searched the literature from 2000 to 2019 to identify best practices for the care of extremely preterm infants and consulted colleagues across Canada and internationally. Iterative improvements were made following the Plan-Do-Study-Act methodology. RESULTS A care bundle, created in October 2015, was divided into three time periods: initial resuscitation/stabilization, the first 72 hours and days 4 to 7, with each period subdivided in 8 to 12 care themes. Revisions and practice changes were implemented to improve skin integrity, admission temperature, timing of initiation of feeds, reliability of transcutaneous CO2 monitoring and ventilation. Of 127 infants <26 weeks admitted between implementation and end of 2019, 78 survived to discharge (61%). CONCLUSION It will be important to determine, with ongoing auditing and further evaluation, whether our care bundle led to improvements of short- and long-term outcomes in this population. Our experience may be useful to others caring for extremely low gestational age infants.
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Affiliation(s)
- Emanuela Ferretti
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Thierry Daboval
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Nicole Rouvinez-Bouali
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Sarah L Lawrence
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Brigitte Lemyre
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario
- Department of Pediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario
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15
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Geurtzen R, van den Heuvel JFM, Huisman JJ, Lutke Holzik EM, Bekker MN, Hogeveen M. Decision-making in imminent extreme premature births: perceived shared decision-making, parental decisional conflict and decision regret. J Perinatol 2021; 41:2201-2207. [PMID: 34285357 DOI: 10.1038/s41372-021-01159-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 07/09/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To describe levels of perceived shared decision making (SDM), decisional conflict (DC), and decision regret (DR) in prenatal counseling by pregnant women, partners, neonatologists, and obstetricians regarding decision-making around imminent extreme premature birth in which a decision about palliative comfort care versus early intensive care had to be made. STUDY DESIGN Multicenter, cross-sectional study using surveys to determine perceived SDM at imminent extreme premature birth in parents and physicians, and to determine DC and DR in parents. RESULTS In total, 73 participants from 22 prenatal counseling sessions were included (21 pregnant women, 20 partners, 14 obstetricians, 18 neonatologists). High perceived levels of SDM were found (median 82,2), and low levels of DC (median 23,4) and DR at one month (median 12, 5). CONCLUSIONS Reported levels of self-perceived SDM in the setting of prenatal counseling in extreme prematurity were high, by both the parents and the physicians. Levels of DC and DR were low.
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Affiliation(s)
- R Geurtzen
- Amalia Children's Hospital, department of neonatology, Radboud university medical center, Nijmegen, The Netherlands.
| | - J F M van den Heuvel
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - J J Huisman
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - E M Lutke Holzik
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - M N Bekker
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - M Hogeveen
- Amalia Children's Hospital, department of neonatology, Radboud university medical center, Nijmegen, The Netherlands
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16
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Kim BH, Feltman DM, Schneider S, Herron C, Montes A, Anani UE, Murray PD, Arnolds M, Krick J. What Information Do Clinicians Deem Important for Counseling Parents Facing Extremely Early Deliveries?: Results from an Online Survey. Am J Perinatol 2021; 40:657-665. [PMID: 34100274 DOI: 10.1055/s-0041-1730430] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The study aimed to better understand how neonatology and maternal fetal medicine (MFM) physicians convey information during antenatal counseling that requires facilitating shared decision-making with parents facing options of resuscitation versus comfort care after extremely early delivery STUDY DESIGN: Attending physicians at US centers with both Neo and MFM fellowships were invited to answer an original online survey about antenatal counseling for extremely early newborns. The survey assessed information conveyed, processes for facilitating shared decision-making (reported separately), and clinical experiences. Neonatology and MFM responses were compared. Multivariable logistic regression analyzed topics often and seldom discussed by specialty groups with respect to respondents' clinical experience and resuscitation option preferences at different gestational weeks. RESULTS In total, 74 MFM and 167 neonatologists representing 94% of the 81 centers surveyed responded. Grouped by specialty, respondents were similar in counseling experience and distribution of allowing choices between resuscitation and no resuscitation for delivery at specific weeks of gestational ages. MFM versus neonatology reported similar rates of discussing long-term health and developmental concerns and differed in all other categories of topics. Neonatologists were less likely than MFM to discuss caregiver impacts (odds ratio [OR]: 0.14, 95% confidence interval [CI]: 0.11-0.18, p < 0.001) and comfort care details (OR: 0.19, 95% CI: 0.15-0.25, p < 0.001). Conversely, neonatology versus MFM respondents more frequently reported "usually" discussing topics pertaining to parenting in the NICU (OR: 1.5, 95% CI: 1.2-1.8, p < 0.001) and those regarding stabilizing interventions in the delivery room (OR: 1.8, 95% CI: 1.4-2.2, p < 0.001). Compared with less-experienced respondents, those with 17 years' or more of clinical experience had greater likelihood in both specialties to say they "usually" discussed otherwise infrequently reported topics pertaining to caregiver impacts. CONCLUSION Parents require information to make difficult decisions for their extremely early newborns. Our findings endorse the value of co-consultation by MFM and neonatology clinicians and of trainee education on antenatal consultation education to support these families. KEY POINTS · Neonatology versus MFM counselors provide complementary information.. · More experience was linked to discussing some topics.. · Co-consultation and trainee education is supported.. · What information parents value requires study..
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Affiliation(s)
- Brennan Hodgson Kim
- Department of Pediatrics, University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Dalia M Feltman
- Department of Pediatrics, NorthShore University HealthSystem Evanston Hospital, Evanston, Illinois
| | - Simone Schneider
- Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois.,Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Constance Herron
- Graduate Student Intern, School of Health Studies, Northern Illinois University, DeKalb, Illinois
| | - Andres Montes
- Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Uchenna E Anani
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Peter D Murray
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Marin Arnolds
- Department of Pediatrics, NorthShore University HealthSystem Evanston Hospital, Evanston, Illinois.,Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Jeanne Krick
- Department of Pediatrics, Madigan Army Medical Center, Tacoma, Washington
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17
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Backes CH, Rivera BK, Pavlek L, Beer LJ, Ball MK, Zettler ET, Smith CV, Bridge JA, Bell EF, Frey HA. Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol 2021; 224:158-174. [PMID: 32745459 DOI: 10.1016/j.ajog.2020.07.051] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The objective of this study was to provide a systematic review and meta-analysis to quantify prognosis and identify factors associated with variations in reported mortality estimates among infants who were born at 22 weeks of gestation and provided proactive treatment (resuscitation and intensive care). DATA SOURCES PubMed, Scopus, and Web of Science databases, with no language restrictions, were searched for articles published from January 2000 to February 2020. STUDY ELIGIBILITY CRITERIA Reports on live-born infants who were delivered at 22 weeks of gestation and provided proactive care were included. The primary outcome was survival to hospital discharge; secondary outcomes included survival without major morbidity and survival without neurodevelopmental impairment. Because we expected differences across studies in the definitions for various morbidities, multiple definitions for composite outcomes of major morbidities were prespecified. Neurodevelopmental impairment was based on Bayley Scales of Infant Development II or III. Data extractions were performed independently, and outcomes agreed on a priori. STUDY APPRAISAL AND SYNTHESIS METHODS Methodological quality was assessed using the Quality in Prognostic Studies tool. An adapted version of the Grading of Recommendations Assessment, Development and Evaluation approach for prognostic studies was used to evaluate confidence in overall estimates. Outcomes were assessed as prevalence and 95% confidence intervals. Variabilities across studies attributable to heterogeneity were estimated with the I2 statistic; publication bias was assessed with the Luis Furuya-Kanamori index. Data were pooled using the inverse variance heterogeneity model. RESULTS Literature searches returned 21,952 articles, with 2034 considered in full; 31 studies of 2226 infants who were delivered at 22 weeks of gestation and provided proactive neonatal treatment were included. No articles were excluded for study design or risk of bias. The pooled prevalence of survival was 29.0% (95% confidence interval, 17.2-41.6; 31 studies, 2226 infants; I2=79.4%; Luis Furuya-Kanamori index=0.04). Survival among infants born to mothers receiving antenatal corticosteroids was twice the survival of infants born to mothers not receiving antenatal corticosteroids (39.0% vs 19.5%; P<.01). The overall prevalence of survival without major morbidity, using a definition that includes any bronchopulmonary dysplasia, was 11.0% (95% confidence interval, 8.0-14.3; 10 studies, 374 infants; I2=0%; Luis Furuya-Kanamori index=3.02). The overall rate of survival without moderate or severe impairment was 37.0% (95% confidence interval, 14.6-61.5; 5 studies, 39 infants; I2=45%; Luis Furuya-Kanamori index=-0.15). Based on the year of publication, survival rates increased between 2000 and 2020 (slope of the regression line=0.09; standard error=0.03; P<.01). Studies were highly diverse with regard to interventions and outcomes reported. CONCLUSION The reported survival rates varied greatly among studies and were likely influenced by combining observational data from disparate sources, lack of individual patient-level data, and bias in the component studies from which the data were drawn. Therefore, pooled results should be interpreted with caution. To answer fundamental questions beyond the breadth of available data, multicenter, multidisciplinary collaborations, including alignment of important outcomes by stakeholders, are needed.
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Affiliation(s)
- Carl H Backes
- Centers for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH; Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH; The Heart Center, Nationwide Children's Hospital, Columbus, OH.
| | - Brian K Rivera
- Centers for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Leanne Pavlek
- Centers for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lindsey J Beer
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Molly K Ball
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Eli T Zettler
- Centers for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Charles V Smith
- Center for Integrated Brain Research, Seattle Children's Research Institute, Seattle, WA
| | - Jeffrey A Bridge
- Suicide Prevention and Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Edward F Bell
- Department of Pediatrics, University of Iowa; Iowa City, IA
| | - Heather A Frey
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH
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18
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Williams N, Synnes A, O'Brien C, Albersheim S. An alternative approach to developing guidelines for the management of an anticipated extremely preterm infant. J Perinat Med 2020; 48:751-756. [PMID: 32726290 DOI: 10.1515/jpm-2019-0444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 07/02/2020] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Nicholas Williams
- Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
- Division of Neonatology, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Anne Synnes
- Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
- Division of Neonatology, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Claire O'Brien
- Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Susan Albersheim
- Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
- Division of Neonatology, British Columbia Women's Hospital, Vancouver, BC, Canada
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19
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Mardian E, Bucking S, Dunn S, Lemyre B, Daboval T, Moore GP. Evaluating parental perceptions of written handbooks provided during shared decision making with parents anticipating extremely preterm birth. J Matern Fetal Neonatal Med 2020; 35:2723-2730. [PMID: 32727235 DOI: 10.1080/14767058.2020.1797671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To explore parental perceptions of written handbooks provided to them during antenatal counseling for anticipated extremely preterm birth. STUDY DESIGN This study involved a prospective convenience sample of parents anticipating delivery between 22 weeks + 0 days and 25 weeks + 6 days gestation. The antenatal counseling involved a shared decision-making process. In-person interviews were conducted using a semi-structured interview guide to gather feedback about new parent handbooks developed to support decision making. The questions during the semi-structured interview targeted seven main themes: overall impression, timing, graphs/tables, formatting, imagery, ease of use and understanding, and content. The interviews followed an antenatal consultation and provision of the appropriate handbook(s) by a neonatologist. Interviews were transcribed verbatim and thematic analysis of the data was completed. RESULTS Eleven parents were interviewed. All parents described the provision of the handbook(s) following the consultation with a neonatologist as the ideal time. All parents considered a visual representation of the data to be invaluable. Parents considered the handbooks easy to understand and straightforward. Some parents were satisfied with simple information, which helped them feel less overwhelmed; others felt the depth of information was insufficient. Parents preferred a paper copy to electronic. Reactions to the photo of an infant receiving intensive care varied; some parents felt frightened, others felt comforted. CONCLUSION Overall, parents positively evaluated the handbooks, supporting their utility for parents anticipating extremely preterm birth. Concrete suggestions for improvement were made; the handbooks will be modified accordingly. Parents at other perinatal centers may benefit from receiving such handbooks.
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Affiliation(s)
- Emily Mardian
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon Bucking
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Sandra Dunn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Brigitte Lemyre
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.,Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Thierry Daboval
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.,Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Gregory P Moore
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.,Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
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20
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Garten L, Globisch M, von der Hude K, Jäkel K, Knochel K, Krones T, Nicin T, Offermann F, Schindler M, Schneider U, Schubert B, Strahleck T. Palliative Care and Grief Counseling in Peri- and Neonatology: Recommendations From the German PaluTiN Group. Front Pediatr 2020; 8:67. [PMID: 32181234 PMCID: PMC7058113 DOI: 10.3389/fped.2020.00067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 02/11/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Lars Garten
- Department of Neonatology, Palliative Neonatology Team, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcel Globisch
- Department for Content and Development, German Children's Hospice Association, Olpe, Germany
| | - Kerstin von der Hude
- Department of Neonatology, Palliative Neonatology Team, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Karin Jäkel
- Association of Premature and At-Risk Born Children, Regional group of Rhineland-Palatinate, Mainz, Germany
| | - Kathrin Knochel
- Center for Pediatric Palliative Care, University Children's Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Tanja Krones
- University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine, University of Zürich, Zurich, Switzerland
| | - Tatjana Nicin
- Department of Obstetrics, Klinikum Hanau, Hanau, Germany
| | - Franziska Offermann
- Federal Association of Orphaned Parents and Mourning Siblings in Germany, Leipzig, Germany
| | - Monika Schindler
- Department of Neonatology and Paediatric Intensive Care, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Uwe Schneider
- Department of Obstetrics, Universitätsklinikum Jena, Jena, Germany
| | - Beatrix Schubert
- Roman-Catholic Diocese of Rottenburg-Stuttgart, Department Pastoral Care in Health Care, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Thomas Strahleck
- Department of Neonatology and Neonatal Intensive Care, Klinikum Stuttgart, Olgahospital, Stuttgart, Germany
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Abstract
OBJECTIVE To quantify the rate of maternal complications associated with a periviable birth in a contemporary population of live births in the state of Ohio. METHODS We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Maternal, obstetric, and neonatal characteristics were compared between women who delivered in the periviable period (20-25 weeks of gestation) with those who delivered preterm (26-36 weeks of gestation) and at term (greater than 36 weeks of gestation). Women were also stratified by 3-week gestational age epochs (ie, 20-22, 23-25 weeks of gestation). The primary study outcome was a composite of individual adverse maternal outcomes (chorioamnionitis, blood product transfusion, hysterectomy, unplanned operation, and intensive care unit [ICU] admission). Multivariate logistic regression estimated the relative association of periviable birth with maternal complications. RESULTS Of 1,457,706 live births in Ohio during the 10-year study period, 6,085 live births (0.4%) occurred during the periviable period (20-25 weeks of gestation). The overall rate of the composite adverse outcome was 17.2%. In multivariate analysis, periviable birth was associated with an increased risk of the composite adverse maternal outcome (adjusted relative risk [RR] 5.8, CI 5.4-6.2) and individual complications including transfusion (adjusted RR 4.4, CI 3.4-5.7), unplanned operative procedure (adjusted RR 2.0, CI 1.7-2.4), unplanned hysterectomy (adjusted RR 7.8, CI 4.6-13.0), uterine rupture (adjusted RR 7.1, CI 3.8-13.4), and ICU admission (adjusted RR 9.6, CI 7.2-12.7) compared with the term cohort. Delivery between 20-22 weeks and 23-25 weeks of gestation was associated with the highest risk of composite adverse outcome. The risk of composite adverse outcome decreased with advancing gestational age stratum. CONCLUSION Periviable birth is associated with significant maternal morbidity. Nearly one in five women in this cohort had a serious morbidity associated with their periviable delivery.
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22
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O'Neill J. 'Whatever decision you make it will be the right one': A parent's reflection on difficult decision-making in premature birth. J Paediatr Child Health 2019; 55:885-889. [PMID: 31168872 DOI: 10.1111/jpc.14529] [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] [Received: 05/12/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 11/27/2022]
Abstract
In 2007, our daughter Lily was born prematurely. My husband and I were faced with a very difficult decision about the level of intervention for her, a decision that had to be made in an emergency situation under the pressure of time. As a paediatric nurse I had more knowledge about prematurity than most parents, and it was certainly enough to appreciate the fragility of babies born early, and their uncertain and often complicated path through neonatal intensive care. What I didn't fully appreciate was the key role of health professionals, not only in providing care, but in supporting difficult decision-making. In the years since Lily's birth I've also reflected on the power of health professionals to shape, or reshape, the narrative of premature birth which is pivotal in the long-term psychological trajectory of parents.
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Affiliation(s)
- Jenny O'Neill
- Department of Neurodevelopment and Disability, Royal Children's Hospital, Melbourne, Victoria, Australia
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Ladhani NNN, Chari RS, Dunn MS, Jones G, Shah P, Barrett JFR. No. 347-Obstetric Management at Borderline Viability. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 39:781-791. [PMID: 28859764 DOI: 10.1016/j.jogc.2017.03.108] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The primary objective of this guideline was to develop consensus statements to guide clinical practice and recommendations for obstetric management of a pregnancy at borderline viability, currently defined as prior to 25+6 weeks. INTENDED USERS Clinicians involved in the obstetric management of women whose fetus is at the borderline of viability. TARGET POPULATION Women presenting for possible birth at borderline viability. EVIDENCE This document presents a summary of the literature and a general consensus on the management of pregnancies at borderline viability, including maternal transfer and consultation, administration of antenatal corticosteroids and magnesium sulfate, fetal heart rate monitoring, and considerations in mode of delivery. Medline, EMBASE, and Cochrane databases were searched using the following keywords: extreme prematurity, borderline viability, preterm, pregnancy, antenatal corticosteroids, mode of delivery. The results were then studied, and relevant articles were reviewed. The references of the reviewed studies were also searched, as were documents citing pertinent studies. The evidence was then presented at a consensus meeting, and statements were developed. VALIDATION METHODS The content and recommendations were developed by the consensus group from the fields of Maternal-Fetal Medicine, Neonatology, Perinatal Nursing, Patient Advocacy, and Ethics. The quality of evidence was rated using criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework (reference 1). The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. METHODS The quality of evidence was rated using the criteria described in the Grading of Recommendations, Assessment, Development, and Evaluation methodology framework. The interpretation of strong and weak recommendations is described later. The Summary of Findings is available upon request. BENEFITS, HARMS, AND COSTS A multidisciplinary approach should be used in counselling women and families at borderline viability. The impact of obstetric interventions in the improvement of neonatal outcomes is suggested in the literature, and if active resuscitation is intended, then active obstetric interventions should be considered. GUIDELINE UPDATE Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. SPONSORS This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada and the Women and Babies Program at Sunnybrook Health Sciences Centre. RECOMMENDATIONS
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Geurtzen R, van Heijst AFJ, Draaisma JMT, Kuijpers LJMK, Woiski M, Scheepers HCJ, van Kaam AH, Oudijk MA, Lafeber HN, Bax CJ, Koper JF, Duin LK, van der Hoeven MA, Kornelisse RF, Duvekot JJ, Andriessen P, van Runnard Heimel PJ, van der Heide-Jalving M, Bekker MN, Mulder-de Tollenaer SM, van Eyck J, Eshuis-Peters E, Graatsma M, Hermens RPMG, Hogeveen M. Development of Nationwide Recommendations to Support Prenatal Counseling in Extreme Prematurity. Pediatrics 2019; 143:peds.2018-3253. [PMID: 31160512 DOI: 10.1542/peds.2018-3253] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2019] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Mallory Woiski
- Obstetrics and Gynecology, Amalia Children's Hospital and
| | | | | | - Martijn A Oudijk
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center and University of Amsterdam, Amsterdam, Netherlands
| | | | - Caroline J Bax
- Obstetrics and Gynecology, Vrije Universteit Medical Center and Vrije Universteit Amsterdam, Amsterdam, Netherlands
| | | | - Leonie K Duin
- Obstetrics, Gynecology, and Prenatal Diagnosis, University Medical Center Groningen and University of Groningen, Groningen, Netherlands
| | | | | | - Johannes J Duvekot
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | | | | | - Mireille N Bekker
- Obstetrics and Gynecology, Wilhelmina Children's Hospital, University Medical Centre, Utrecht, Netherlands
| | | | - Jim van Eyck
- Obstetrics and Gynecology, Isala Woman and Children's Hospital Zwolle, Zwolle, Netherlands; and
| | - Ellis Eshuis-Peters
- Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Rosella P M G Hermens
- Scientific Institute for Quality of Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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25
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Myrhaug HT, Brurberg KG, Hov L, Markestad T. Survival and Impairment of Extremely Premature Infants: A Meta-analysis. Pediatrics 2019; 143:peds.2018-0933. [PMID: 30705140 DOI: 10.1542/peds.2018-0933] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2018] [Indexed: 02/04/2023] Open
Abstract
CONTEXT Survival of infants born at the limit of viability varies between high-income countries. OBJECTIVE To summarize the prognosis of survival and risk of impairment for infants born at 22 + 0/7 weeks' to 27 + 6/7 weeks' gestational age (GA) in high-income countries. DATA SOURCES We searched 9 databases for cohort studies published between 2000 and 2017 in which researchers reported on survival or neurodevelopmental outcomes. STUDY SELECTION GA was based on ultrasound results, the last menstrual period, or a combination of both, and neurodevelopmental outcomes were measured by using the Bayley Scales of Infant Development II or III at 18 to 36 months of age. DATA EXTRACTION Two reviewers independently extracted data and assessed the risk of bias and quality of evidence. RESULTS Sixty-five studies were included. Mean survival rates increased from near 0% of all births, 7.3% of live births, and 24.1% of infants admitted to intensive care at 22 weeks' GA to 82.1%, 90.1%, and 90.2% at 27 weeks' GA, respectively. For the survivors, the rates of severe impairment decreased from 36.3% to 19.1% for 22 to 24 weeks' GA and from 14.0% to 4.2% for 25 to 27 weeks' GA. The mean chance of survival without impairment for infants born alive increased from 1.2% to 9.3% for 22 to 24 weeks' GA and from 40.6% to 64.2% for 25 to 27 weeks' GA. LIMITATIONS The confidence in these estimates ranged from high to very low. CONCLUSIONS Survival without impairment was substantially lower for children born at <25 weeks' GA than for those born later.
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Affiliation(s)
| | | | - Laila Hov
- VID Specialized University, Oslo, Norway; and
| | - Trond Markestad
- Department of Clinical Science, University of Bergen and Innlandet Hospital Trust, Bergen, Norway
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Barker C, Dunn S, Moore GP, Reszel J, Lemyre B, Daboval T. Shared decision making during antenatal counselling for anticipated extremely preterm birth. Paediatr Child Health 2018; 24:240-249. [PMID: 31239813 DOI: 10.1093/pch/pxy158] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 07/24/2018] [Indexed: 01/08/2023] Open
Abstract
Objectives To explore health care providers' (HCPs) perceptions of using shared decision making (SDM) and to identify facilitators of and barriers to its use with families facing the anticipated birth of an extremely preterm infant at 22+0 to 25+6 weeks gestational age. Study Design Qualitative descriptive study design: we conducted interviews with 25 HCPs involved in five cases at a tertiary care centre and completed qualitative content analysis of their responses. Results Nine facilitators and 16 barriers were identified. Facilitators included: a correct understanding of this process and how to apply it, a belief that parents should be the decision makers in these situations, and a positive outlook toward using SDM during antenatal counselling. Barriers included: HCPs' misunderstandings of how and when to apply SDM during antenatal counselling, challenges using the process for cases at the lower end of the gestational age range, fear of the negative emotions and stress parents face when making decisions, and HCPs' uncertainty about their ability to properly apply SDM. Conclusions This study identified facilitators and barriers to use of SDM during antenatal counselling for anticipated birth of extremely preterm infants that can be used to inform development of tailored strategies to facilitate future implementation of shared decision making in this area.
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Affiliation(s)
- Conor Barker
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario
| | - Sandra Dunn
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario.,Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute (CHEORI)
| | - Gregory P Moore
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario.,Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute (CHEORI).,Department of Obstetrics Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario.,The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario
| | - Jessica Reszel
- Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario
| | - Brigitte Lemyre
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario.,Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute (CHEORI).,Department of Obstetrics Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario.,The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario
| | - Thierry Daboval
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario.,Department of Paediatrics, The Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute (CHEORI).,Department of Obstetrics Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario.,The Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario
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27
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Geurtzen R, Draaisma J, Hermens R, Scheepers H, Woiski M, van Heijst A, Hogeveen M. Various experiences and preferences of Dutch parents in prenatal counseling in extreme prematurity. PATIENT EDUCATION AND COUNSELING 2018; 101:2179-2185. [PMID: 30029812 DOI: 10.1016/j.pec.2018.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/28/2018] [Accepted: 07/03/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate experienced and preferred prenatal counseling among parents of extremely premature babies. METHODS A Dutch nationwide, multicenter, cross-sectional study using an online survey. Surveys were sent to all parents of extremely premature babies born between 2010 and 2013 at 24+0/7-24+6/7 weeks of gestation. RESULTS Sixty-one out of 229 surveys were returned. A minority (14%) had no counseling conversation. Conversations were done more often by neonatologists (90%) than by obstetricians (39%) and in 37% by both these experts. Supportive material was rarely used (19%). Mortality (92%) and short-term morbidity (88%) were discussed the most, and more frequently than long-term morbidity (65%), practical items (63%) and delivery mode (52%). Most decisions on active care or palliative comfort care were perceived as decisions by doctor and parents together (61%). 80% felt they were involved in decision-making. The preferred way of involvement in decision-making varied among parents. CONCLUSION The vast majority of parents were counseled: mostly by neonatologists, and mainly about mortality and short-term morbidity. Parents wanted to be involved in the decision-making process but differed on the preferred extent of involvement. Practice implications Understanding of shared decision-making may contribute to meet the various preferences of parents.
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Affiliation(s)
- Rosa Geurtzen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands.
| | - Jos Draaisma
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| | - Rosella Hermens
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of IQ Healthcare, Nijmegen, The Netherlands
| | | | - Mallory Woiski
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Gynecology, Nijmegen, The Netherlands
| | - Arno van Heijst
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
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Moore G, Reszel J, Daboval T, Lemyre B, Barker C, Dunn S. Qualitative evaluation of a guideline supporting shared decision making for extreme preterm birth. J Matern Fetal Neonatal Med 2018; 33:973-981. [PMID: 30107754 DOI: 10.1080/14767058.2018.1512575] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background and objectives: The decision to attempt resuscitation or provide palliative care at birth for extremely preterm infants between 22 and 25 weeks remains complex. The purpose of this study was to identify facilitators and barriers to implementation of a clinical practice guideline developed to support shared decision-making for these cases.Methods: A purposeful sample of healthcare providers, involved in the care of one of five cases of anticipated extremely preterm birth, was recruited for interviews. Participants shared their views on the guideline content, implementation process, and facilitators and barriers encountered. Interviews were audio-recorded and transcribed verbatim. Qualitative content analysis was used to code, categorize, and thematically describe the data. The Knowledge-Attitudes-Behaviours framework was used to organize the findings.Results: Twenty-five key informants (16 physicians, nine nurses) were interviewed. Participants described varying levels of knowledge of the guideline. Facilitators to implementation included: (1) an awareness of, familiarity with and belief in the content; (2) hard copy and electronic guideline accessibility; and, (3) institutional expertise to provide necessary care. Barriers included: (1) minimal awareness or familiarity with the content; (2) lack of agreement with the recommendations; (3) inadequate evidence and applicability to support changes in practice; and, (4) lack of resources to care for the most immature infants.Conclusions: Identified facilitators and barriers will inform the development of tailored strategies for improved local and future broader implementation. Other institutions can use the results to facilitate implementation of their guidelines on this ethically charged area.
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Affiliation(s)
- Gregory Moore
- Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Obstetrics and Gynecology, Division of Newborn Care, Ottawa Hospital, Ottawa, Canada
| | - Jessica Reszel
- Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Canada
| | - Thierry Daboval
- Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Obstetrics and Gynecology, Division of Newborn Care, Ottawa Hospital, Ottawa, Canada
| | - Brigitte Lemyre
- Department of Paediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Department of Obstetrics and Gynecology, Division of Newborn Care, Ottawa Hospital, Ottawa, Canada
| | - Conor Barker
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Sandra Dunn
- Faculty of Medicine, University of Ottawa, Ottawa, Canada.,Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Canada
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Bucher HU, Klein SD, Hendriks MJ, Baumann-Hölzle R, Berger TM, Streuli JC, Fauchère JC. Decision-making at the limit of viability: differing perceptions and opinions between neonatal physicians and nurses. BMC Pediatr 2018; 18:81. [PMID: 29471821 PMCID: PMC5822553 DOI: 10.1186/s12887-018-1040-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 01/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background In the last 20 years, the chances for intact survival for extremely preterm infants have increased in high income countries. Decisions about withholding or withdrawing intensive care remain a major challenge in infants born at the limits of viability. Shared decision-making regarding these fragile infants between health care professionals and parents has become the preferred model today. However, there is an ongoing ethical debate on how decisions regarding life-sustaining treatment should be reached and who should have the final word when health care professionals and parents do not agree. We designed a survey among neonatologists and neonatal nurses to analyze practices, difficulties and parental involvement in end-of-life decisions for extremely preterm infants. Methods All 552 physicians and nurses with at least 12 months work experience in level III neonatal intensive care units (NICU) in Switzerland were invited to participate in an online survey with 50 questions. Differences between neonatologists and NICU nurses and between language regions were explored. Results Ninety six of 121 (79%) physicians and 302 of 431(70%) nurses completed the online questionnaire. The following difficulties with end-of-life decision-making were reported more frequently by nurses than physicians: insufficient time for decision-making, legal constraints and lack of consistent unit policies. Nurses also mentioned a lack of solidarity in our society and shortage of services for disabled more often than physicians. In the context of limiting intensive care in selected circumstances, nurses considered withholding tube feedings and respiratory support less acceptable than physicians. Nurses were more reluctant to give parents full authority to decide on the course of action for their infant. In contrast to professional category (nurse or physician), language region, professional experience and religion had little influence if any on the answers given. Conclusions Physicians and nurses differ in many aspects of how and by whom end-of-life decisions should be made in extremely preterm infants. The divergencies between nurses and physicians may be due to differences in ethics education, varying focus in patient care and direct exposure to the patients. Acknowledging these differences is important to avoid potential conflicts within the neonatal team but also with parents in the process of end-of-life decision-making in preterm infants born at the limits of viability. Electronic supplementary material The online version of this article (10.1186/s12887-018-1040-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hans Ulrich Bucher
- Department of Neonatology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zürich, Switzerland.
| | - Sabine D Klein
- Department of Neonatology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zürich, Switzerland
| | - Manya J Hendriks
- Department of Neonatology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zürich, Switzerland.,Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Ruth Baumann-Hölzle
- Dialogue Ethics Foundation, Interdisciplinary Institute for Ethics in Health Care, Zurich, Switzerland
| | - Thomas M Berger
- Neonatal and Paediatric Intensive Care Unit, Children's Hospital of Lucerne, Lucerne, Switzerland
| | - Jürg C Streuli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Jean-Claude Fauchère
- Department of Neonatology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zürich, Switzerland
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Ladhani NNN, Chari RS, Dunn MS, Jones G, Shah P, Barrett JF. No 347-Prise en charge obstétricale près de la limite de viabilité du fœtus. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:792-804. [DOI: 10.1016/j.jogc.2017.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lemyre B, Moore G. Les conseils et la prise en charge en prévision d’une naissance extrêmement prématurée. Paediatr Child Health 2017. [DOI: 10.1093/pch/pxx059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Geurtzen R, Draaisma J, Hermens R, Scheepers H, Woiski M, van Heijst A, Hogeveen M. Prenatal (non)treatment decisions in extreme prematurity: evaluation of Decisional Conflict and Regret among parents. J Perinatol 2017; 37:999-1002. [PMID: 28617426 DOI: 10.1038/jp.2017.90] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 05/01/2017] [Accepted: 05/15/2017] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- R Geurtzen
- Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - J Draaisma
- Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - R Hermens
- Scientific Institute for Quality of Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - H Scheepers
- Department of Gynecology, Maastricht UMC+, Maastricht, The Netherlands
| | - M Woiski
- Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A van Heijst
- Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
| | - M Hogeveen
- Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, Nijmegen, The Netherlands
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Lemyre B, Moore G. Counselling and management for anticipated extremely preterm birth. Paediatr Child Health 2017; 22:334-341. [PMID: 29485138 DOI: 10.1093/pch/pxx058] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Counselling couples facing the birth of an extremely preterm infant is a complex and delicate task, entailing both challenges and opportunities. This revised position statement proposes using a prognosis-based approach that takes the best estimate of gestational age into account, along with additional factors, including estimated fetal weight, receipt of antenatal corticosteroids, singleton versus multiple pregnancy, fetal status and anomalies on ultrasound and place of birth. This statement updates data on survival in Canada, long-term neurodevelopmental disability at school age and quality of life, with focus on strategies to communicate effectively with parents. It also proposes a framework for determining the prognosis-based management option(s) to present to parents when initiating the decision-making process. This statement replaces the 2012 position statement.
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Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Gregory Moore
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Moore GP, Daboval T, Moore-Hepburn C, Lemyre B. ‘Counselling and management for anticipated extremely preterm birth’: Informing CPS statements through national consultation. Paediatr Child Health 2017. [DOI: 10.1093/pch/pxx030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Field testing of decision coaching with a decision aid for parents facing extreme prematurity. J Perinatol 2017; 37:728-734. [PMID: 28358384 DOI: 10.1038/jp.2017.29] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/21/2016] [Accepted: 02/14/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The objective of this study is to assess and modify an existing decision aid and field-test decision coaching with the modified aid during consultations with parents facing potential delivery at 23 to 24 weeks gestation. STUDY DESIGN International Patient Decision Aid Standards instrument (IPDASi) scoring deficits, multi-stakeholder group feedback and α-testing guided modifications. Feasibility/acceptability were assessed. The Decisional Conflict Scale was used to measure participants' decisional conflict before (T1) and immediately after (T2) the consultation. RESULTS IPDASi assessment of the existing aid (score 11/35) indicated it required updated data, more information and a palliative care description. Following modification, IPDASi score increased to 26/35. Twenty subjects (12 pregnancies) participated in field-testing; 15 completed all questionnaires. Most participants (89%) would definitely recommend this form of consultation. Decisional conflict scores decreased (P<0.001) between T1 (52±25) and T2 (10±16). CONCLUSION Field testing demonstrated that consultations using the aid with decision coaching were feasible, reduced decisional conflict and may facilitate shared decision-making.
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Haward MF, Gaucher N, Payot A, Robson K, Janvier A. Personalized Decision Making: Practical Recommendations for Antenatal Counseling for Fragile Neonates. Clin Perinatol 2017; 44:429-445. [PMID: 28477670 DOI: 10.1016/j.clp.2017.01.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Emphasis has been placed on engaging parents in processes of shared decision making for delivery room management decisions of critically ill neonates whose outcomes are uncertain and unpredictable. The goal of antenatal consultation should rather be to adapt to parental needs and empower them through a personalized decision-making process. This can be done by acknowledging individuality and diversity while respecting the best interests of neonates. The goal is for parents to feel like they have agency and ability and are good parents, before birth, at birth, and after, either in the NICU or until the death of their child.
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Affiliation(s)
- Marlyse F Haward
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, New York, NY 10467, USA
| | - Nathalie Gaucher
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada
| | - Antoine Payot
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada; Palliative Care Unit, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Unité d'Éthique Clinique et de Partenariat Famille, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada
| | - Kate Robson
- Canadian Premature Babies Foundation, Toronto, Ontario M4N 3M5, Canada
| | - Annie Janvier
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada; Palliative Care Unit, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Unité d'Éthique Clinique et de Partenariat Famille, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Department of Pediatrics and Clinical Ethics, Sainte-Justine Hospital, University of Montreal, 3175 Chemin Côte-Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada.
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Mackin R, Ben Fadel N, Feberova J, Murray L, Nair A, Kuehn S, Barrowman N, Daboval T. ASQ3 and/or the Bayley-III to support clinicians' decision making. PLoS One 2017; 12:e0170171. [PMID: 28151969 PMCID: PMC5289417 DOI: 10.1371/journal.pone.0170171] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 12/30/2016] [Indexed: 11/18/2022] Open
Abstract
Background Appropriate tools are essential to support a clinician’s decision to refer very preterm infants to developmental resources. Streamlining the use of developmental assessment or screening tools to make clinical decisions offers an alternative methodology to help to choose the most effective way to assess this very high-risk population. Objective To examine the influence of the Ages and Stages Questionnaire-3rd edition (ASQ3) and the Bayley Scales of Infant Development-3rd edition (Bayley-III) scores within a clinically-based decision-making process. Methods This retrospective cohort study includes children born at less than 29 weeks gestation who had completed both psychologist-administered Bayley-III and physician-observed ASQ3 assessments at 18 months corrected age. Theoretical referral decisions (TRDs) based on each assessment results were formulated, using cut-off scores between the lower first and second standard deviation values and below the lower second standard deviation values. TRDs to refer to developmental resources were evaluated in light of the multidisciplinary team’s actual final integrated decisions (FID). Results Complete data was available for 67 children. The ASQ3 and the Bayley-III had similar predictive value for the FID, with comparable kappa values. Comparisons of the physicians’ and psychologists’ TRDs with the FIDs demonstrated that the ASQ3 in conjunction with the medical and socio-familial findings predicted 93% of referral decisions. Conclusion Taking into consideration potential methodological biases, the results suggest that either ASQ3 or Bayley-III, along with socio-environmental, medical and neurological assessment, are sufficient to guide the majority of clinicians’ decisions regarding referral for specialty services. This retrospective study suggests that the physician-supervised ASQ3 may be sufficient to assess children who had been extremely preterm infants for referral purposes. The findings need to be confirmed in a larger, well-designed prospective study to minimize and account for potential sources of bias.
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Affiliation(s)
| | - Nadya Ben Fadel
- University of Ottawa, Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario, Department Pediatrics, The Ottawa Hospital, Department of Obstetrics and Gynecology, Ottawa, Ontario, Canada
| | - Jana Feberova
- University of Ottawa, Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario, Department Pediatrics, The Ottawa Hospital, Department of Obstetrics and Gynecology, Ottawa, Ontario, Canada
| | - Louise Murray
- University of Ottawa, Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario, Department Pediatrics, The Ottawa Hospital, Department of Obstetrics and Gynecology, Ottawa, Ontario, Canada
| | - Asha Nair
- University of Ottawa, Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario, Department Pediatrics, The Ottawa Hospital, Department of Obstetrics and Gynecology, Ottawa, Ontario, Canada
| | - Sally Kuehn
- Children’s Hospital of Eastern Ontario, Department Pediatrics, The Ottawa Hospital, Department of Obstetrics and Gynecology, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Clinical Research Unit, Ottawa, Ontario, Canada
| | - Thierry Daboval
- University of Ottawa, Ottawa, Ontario, Canada
- Children’s Hospital of Eastern Ontario, Department Pediatrics, The Ottawa Hospital, Department of Obstetrics and Gynecology, Ottawa, Ontario, Canada
- * E-mail:
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Geurtzen R, van Heijst A, Draaisma J, Ouwerkerk L, Scheepers H, Woiski M, Hermens R, Hogeveen M. Professionals' preferences in prenatal counseling at the limits of viability: a nationwide qualitative Dutch study. Eur J Pediatr 2017; 176:1107-1119. [PMID: 28687856 PMCID: PMC5511326 DOI: 10.1007/s00431-017-2952-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/12/2017] [Accepted: 06/13/2017] [Indexed: 11/27/2022]
Abstract
UNLABELLED Prenatal counseling practices at the limits of viability do vary, and constructing a counseling framework based on guidelines, professional and parental preferences, might achieve more homogeneity. We aimed to gain insight into professionals' preferences on three domains of counseling, particularly content, organization, and decision making and their influencing factors. A qualitative, nationwide in-depth exploration among Dutch perinatal professionals by semi-structured interviews in focus groups was performed. Regarding content of prenatal counseling, preparing parents on the short-term situation (delivery room care) and revealing their perspectives on "quality of life" were considered important. Parents should be informed on the kind of decision, on the difficulty of individual outcome predictions, on survival and mortality figures, short- and long-term morbidity, and the burden of hospitalization. For organization, the making of and compliance with agreements between professionals may promote joint counseling by neonatologists and obstetricians. Supportive materials were considered useful but only when up-to-date, in addition to the discussion and with opportunity for personalization. Regarding decision making, it is not always clear to parents that a prenatal decision needs to be made and they can participate, influencing factors could be, e.g., unclear language, directive counseling, overload of information, and an immediate delivery. There is limited familiarity with shared decision making although it is the preferred model. CONCLUSION This study gained insight into preferred content, organization, and decision making of prenatal counseling at the limits of viability and their influencing factors from a professionals' perspective. What is Known: • Heterogeneity in prenatal counseling at the limits of viability exists • Differences between preferred counseling and actual practice also exists What is New: • Insight into preferred content, organization, and decision making of prenatal periviability counseling and its influencing factors from a professionals' perspective. Results should be taken into account when performing counseling. • Particularly the understanding of true shared decision making needs to be improved. Furthermore, implementation of shared decision making in daily practice needs more attention.
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Affiliation(s)
- Rosa Geurtzen
- Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, PO Box 9101, 6500HB, Nijmegen, Internal Code 804, The Netherlands.
| | - Arno van Heijst
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | - Jos Draaisma
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | - Laura Ouwerkerk
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | | | - Mallory Woiski
- Department of Gynecology, Radboud university medical center, Nijmegen, The Netherlands
| | - Rosella Hermens
- Scientific Institute for Quality of Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
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Schibli K, D'Angiulli A. Frameworks are pretty on paper but often do not fit reality: Reply to Lemyre et al. J Perinatol 2016; 36:1138-1139. [PMID: 27899811 DOI: 10.1038/jp.2016.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- K Schibli
- Department of Neuroscience, Carleton University, Ottawa, ON, Canada
| | - A D'Angiulli
- Department of Neuroscience and Institute of Interdisciplinary Studies, Carleton University, Ottawa, ON, Canada
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