The impact of decision quality on mental health following periviable delivery

Periviability for the Ob-Gyn Hospitalist

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

The patient/physician relationship in a post-Roe world: a neonatologist viewpoint

The Supreme Court ruling in Dobbs v. Jackson Women's Health Organization has far-reaching implications that go beyond the practice of obstetrics and gynecology. The ruling and subsequent laws and bills impact many specialties and have implications for healthcare as a whole. The rapidly changing medicolegal landscape has significant bearings on and implications for the fields of neonatology and pediatrics. These rulings have an impact on the patient-physician relationship and a shared decision-making approach to care. Furthermore, there are significant sequelae of forced birth and resuscitation. This review provides a clinically relevant update of the current medicolegal landscape and applications to the practice of neonatology.

Context of a neonatal death affects parental perception of end-of-life care, anxiety and depression in the first year of bereavement

BACKGROUND

Neonatal death is often preceded by end-of-life medical decisions. This study aimed to determine whether the context of death - after a decision of withholding or withdrawing life-sustaining treatment (WWLST) or despite maximum care - was associated with subsequent risk of parental anxiety or depression. The secondary objective was to assess parents' perceptions of end-of-life care according to death context.

METHODS

Prospective single center observational study of all neonatal deaths in a neonatal intensive care unit over a 5-year period. Data were collected during hospitalization and from face-to-face interviews with parents 3 months after the infant's death. Anxiety and depression were assessed using Hospital Anxiety and Depression Scale (HADS) questionnaires, completed by parents 5 and 15 months after death.

RESULTS

Of 179 deaths, 115 (64%) occurred after the WWLST decision and 64 (36%) despite maximum care. Parental satisfaction with newborn care and received support by professionals and relatives was higher in the first condition. Sixty-one percent of parents (109/179) attended the 3-month interview, with the distribution between groups very close to that of hospitalization. The completion rates of the HADS questionnaires by the parents who attended the 3-month interview were 75% (82/109) at 5 months and 65% (71/109) at 15 months. HADS scores at 5 months were consistent with anxiety in at least one parent in 73% (60/82) of cases and with depression in 50% (41/82). At 15 months, these rates were, respectively, 63% (45/71) and 28% (20/71). Risk of depression at 5 months was lower after a WWLST decision (OR 0.35 [0.14, 0.88], p = 0.02). Explicit parental agreement with the WWLST decision had an equivocal impact on the risk of anxiety at 5 months, being higher when expressed during hospitalization, but not at the 3-month interview.

CONCLUSIONS

Context of death has a significant impact on the emotional experience of parents after neonatal loss, which underlines the importance of systematic follow-up conversations with bereaved parents.

Measuring women's empowerment during the perinatal period in high income countries: A scoping review of instruments used

Empowerment is acknowledged as a process facilitating those who are less powerful to be engaged in their problem identification, decision making and actions to gain control over their life. This is an important goal for women during the perinatal period in their transition to motherhood. A concept analysis of women's empowerment during the perinatal period found that psychological and social dimensions play a role in women's perinatal empowerment and identified several defining attributes. The aim of this study was to identify robust validated instruments that measure all the attributes of women's empowerment during the perinatal period. We did a scoping review of scientific literature following the methodology of the JBI Reviewer's Manual. We searched the database MEDLINE, CINAHL, PsycINFO, PsycARTICLES and SocINDEX and selected papers meeting the inclusion criteria. Instruments measuring empowerment or related concepts were identified in the selected papers. Two authors independently cross referenced the items of each instrument against the defining attributes for empowerment. Our search resulted in 9771 unique hits of which 36 papers were finally included. Studies were from various countries with a wide variety of aims, demographics of cohorts and timepoints across the perinatal period. Twenty-one different instruments were used to measure empowerment, of which 11 were validated among women during the perinatal period. However, no identified instrument was developed specifically for women during the perinatal period or included all the dimensions of empowerment and the defining attributes. There is a need for a theoretically sound valid and reliable instrument measuring all the dimensions of empowerment of women during the perinatal period. Once developed this instrument needs testing with a broad range of women. Results from such a study will inform the development of appropriate interventions that have a coherent theoretical basis and are empirically informed to enhance women's empowerment during the perinatal period.

Association Between Periviable Delivery and New Onset of or Exacerbation of Existing Mental Health Disorders

OBJECTIVE

To evaluate whether there is an association between periviable delivery and new onset of or exacerbation of existing mental health disorders within 12 months postpartum.

METHODS

We conducted a retrospective cohort study of individuals with liveborn singleton neonates delivered at 22 or more weeks of gestation from 2008 to 2017 in the MarketScan Commercial Research Database. The exposure was periviable delivery , defined as delivery from 22 0/7 through 25 6/7 weeks of gestation. The primary outcome was a mental health morbidity composite of one or more of the following: emergency department encounter associated with depression, anxiety, psychosis, posttraumatic stress disorder, adjustment disorder, self-harm, or suicide; new psychotropic medication prescription; new behavioral therapy visit; and inpatient psychiatry admission in the 12 months postdelivery. Secondary outcomes included components of the primary composite. Those with and without periviable delivery were compared using multivariable logistic regression adjusted for clinically relevant covariates, with results reported as adjusted incident rate ratios (aIRRs). Effect modification by history of mental health diagnoses was assessed. Incidence of the primary outcome by 90-day intervals postdelivery was assessed.

RESULTS

Of 2,300,244 included deliveries, 16,275 (0.7%) were periviable. Individuals with periviable delivery were more likely to have a chronic health condition, to have undergone cesarean delivery, and to have experienced severe maternal morbidity. Periviable delivery was associated with a modestly increased risk of the primary composite outcome, occurring in 13.8% of individuals with periviable delivery and 11.0% of individuals without periviable delivery (aIRR 1.18, 95% CI 1.12-1.24). The highest-risk period for the composite primary outcome was the first 90 days in those with periviable delivery compared with those without periviable delivery (51.6% vs 42.4%; incident rate ratio 1.56, 95% CI 1.47-1.66).

CONCLUSION

Periviable delivery was associated with a modestly increased risk of mental health morbidity in the 12 months postpartum.

Periviable Decision-Making in a New Era of Parentage: Ethical and Legal Considerations and Provider Perspectives on Shared Decision-making in Diverse Family Structures

OBJECTIVE

To explore providers' perspectives about decisional authority, conflict resolution, and diverse family structures within the context of periviable delivery (eg, between 22 and 25 weeks of gestation), with the ultimate goal of helping practitioners support, engage, and navigate conflict with parents facing periviable delivery.

STUDY DESIGN

Qualitative interviews with 30 neonatologists and obstetricians sought opinions about whether and how a pregnant person's partner should be involved in making periviable treatment decisions and how health care teams should proceed when parents do not agree on a treatment plan. Physicians were asked to consider whether their opinions changed under different scenarios involving marriage, biological relationship, adoption, and surrogacy.

RESULTS

Interviews revealed 4 main themes corresponding to providers' perspectives regarding partner involvement and decisional authority: providers care; involvement matters; mom is the priority; and uncertainty and guidance needed. Unique themes arose when discussing diverse family structures.

CONCLUSIONS

Shared decision making is optimal in the setting of periviable delivery, where decisions are both preference sensitive and value laden. Our interviews suggest that incorporating the dynamics and impact of partners' involvement in periviable resuscitation decision-making may facilitate more shared, equitable, and high-quality decision-making tailored to the needs of both pregnant people and their partners.

Top Ten Tips Palliative Care Clinicians Should Know About Spirituality in Serious Illness

Assessment of spiritual suffering and provision of spiritual care are a central component of palliative care (PC). Unfortunately, many PC clinicians, like most medical providers, have received limited or superficial training in spirituality and spiritual distress. This article, written by a group of spiritual care providers, and other PC and hospice clinicians, offers a more in-depth look at religion and spirituality to help to enhance readers' current skills while offering a practical roadmap for screening for spiritual distress and an overview of partnering with colleagues to ensure patients receive values-aligned spiritual care provision.

Midwifery scale to support shared decision-making for unplanned pregnancies: A cross-sectional study

Midwives significantly support women with unplanned pregnancies-promoting a shared perspective on the decision-making process. This study aimed to develop a scale to support midwives self-assess their practice of this vital role. Following the derivation of scale items and pilot testing, the final version of the scale was administered to 531 midwives to establish internal consistency and construct criterion-related validity. Through exploratory factor analysis, 35 items with a five-factor structure were retained to form the midwifery practice self-assessment scale to promote shared decision-making in women with unplanned pregnancies. These factors illustrate midwives' general aptitude and competencies in understanding environmental factors, collaborating with significant others and the interprofessional group, forming rapport and problem sharing, focusing on consultation content, and promoting autonomous decision-making. There were high and low scores on the scales after attending the workshops to support the decision-making of women with unplanned pregnancies. The reliability analysis showed acceptable Cronbach's alpha values for the five factors, from .85-.87. The scale was demonstrated to be a reliable and valid measure that would help improve the quality of midwives' practice. This article is protected by copyright. All rights reserved.

'Expert advice' for developing decision support: A qualitative study of women who have experienced periviable birth

OBJECTIVE

To elicit advice from women who have experienced periviable birth to optimize periviable counseling, care, and decision support.

METHODS

We conducted a qualitative study among 21 women who experienced periviable deliveries within three years. Using semi-structured interviews, we asked participants what advice they would offer providers and women/families based on their own experiences. Interviews were independently coded by three trained coders.

RESULTS

For providers: Participants said to be 'patient' and appreciate the novelty of each family's experience. They suggested being 'realistic' and 'factual'; favored joint OB/Neonatology counseling; and encouraged providers to attend to maternal guilt and self-blame. For women/families: They encouraged asking questions, avoiding the internet, and finding joy in whatever time they had with their child. For hospitals: They advocated for changes to facilitate more mother/baby contact.

CONCLUSION

Providers can support parents by presenting facts, showing empathy and patience, and reassuring women that they are not to blame. This study highlights patient perspectives to improve interactions with providers, optimize women/families' experiences, and advance efforts toward developing patient-centered systems of periviable care.

PRACTICE IMPLICATIONS

Women who experience periviable birth desire counseling that is empathetic and 'realistic', encouragement to ask questions, and reassurance that outcomes are not their fault.

Decision-making in imminent extreme premature births: perceived shared decision-making, parental decisional conflict and decision regret

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.

User-testing of a decision-support tool for parents facing threatened periviable delivery: The Periviable GOALS decision aid

BACKGROUND

To report user-centered design methods and stakeholder acceptability ratings of the Periviable GOALS (Getting Optimal Alignment around Life Support) decision aid (DA).

METHODS

'Experienced' and 'expectant' mothers engaged in content and design refining sessions. Five videos (10 families) were embedded in the DA to highlight life after delivery. User-testing sessions were conducted with mothers and providers to assess acceptability. End-user testing was conducted with hospitalized women facing potential periviable delivery to assess acceptability and feasibility in the clinical setting.

RESULTS

108 participants engaged in sessions from July 2017-January 2020. Twenty-seven refining sessions resulted in a DA providing survival estimates, neonatal outcomes descriptions, and values clarification exercises. Five white and five black women participated in the videos; six having surviving children (ages 16 months-4 years). Twelve mothers, 16 providers, and six hospitalized women evaluated acceptability. 95.1 % found the content "just right," 94.9 % rated the videos "good" or "excellent," and 97.2 % believed GOALS would support families in periviable decision-making.

CONCLUSION

Our results highlight the importance of developing a DA that is acceptable for patient use with direct involvement of stakeholders.

PRACTICE IMPLICATIONS

The GOALS DA may prepare families to engage in shared decision-making to facilitate more patient-centered models of periviable care.

Diverse perspectives on death, disability, and quality of life: an exploratory study of racial differences in periviable decision-making

OBJECTIVE

To qualitatively explore perceptions of pain/suffering, disability, and coping by race among pregnant women facing the threat of a periviable delivery (22 0/7-24 6/7 weeks).

STUDY DESIGN

Interviews were conducted in-hospital prior to delivery. Transcripts were coded verbatim and responses were stratified by race (white vs non-white). Conventional content analysis was conducted using NVivo 12.

RESULTS

We recruited 30 women (50% white, 50% non-white). Most women expressed love and acceptance of their babies and described pain as a "means to an end." Non-white women focused almost exclusively on immediate survival and perseverance, while white women expressed concerns about quality of life beyond the NICU. The majority of non-white women were unable to recall any discussions with their doctors about their baby's comfort, pain, or suffering.

CONCLUSIONS

These findings may suggest that culturally tailored approaches to counseling and decision-support may be beneficial for patients from marginalized or minoritized groups.

Values clarification: Eliciting the values that inform and influence parents' treatment decisions for periviable birth

BACKGROUND

Values clarification can assist families facing the threat of periviable delivery in navigating the complexity of competing values related to death, disability, and quality of life (QOL).

OBJECTIVE

We piloted values clarification exercises to inform resuscitation decision making and qualitatively assess perceptions of QOL.

METHODS

We conducted a mixed-method study of women with threatened periviable delivery (22 0/7-24 6/7 weeks) and their important others (IOs). Participants engaged in three values clarification activities as part of a semi-structured interview-(a) Card sorting nine conditions as an acceptable/unacceptable QOL for a child; (b) Rating/ranking seven common concerns in periviable decision making (scale 0-10, not at all to extremely important); and (c) "Agreed/disagreed" with six statements regarding end-of-life treatment, disability, and QOL. Participants were also asked to define "QOL" and describe their perceptions of a good and poor QOL for their child. Analysis was conducted using SAS version 9.4 and NVivo 12.

RESULTS

All mild disabilities were an acceptable QOL, while two-thirds of participants considered long-term mechanical ventilation unacceptable. Although pregnant women rated "Impact on Your Physical/Mental Health" (average 5.6) and IOs rated "Financial Concerns" the highest (average 6.6), both groups ranked "Financial Concerns" as the most important concern (median 5.0 and 6.0, respectively). Most participants agreed that "Any amount of life is better than no life at all" (pregnant women 62.1%; IOs 75.0%) and disagreed that resuscitation would cause "Too much suffering" for their child (pregnant women 71.4%; IOs 80.0%). Half were familiar with the phrase "QOL". Although the majority described a good QOL in terms of emotional well-being (eg "loved", "happy", "supported"), a poor QOL was described in terms of functionality (eg "dependent" and "confined"). Additionally, financial stability emerged as a distinctive theme when IOs discussed poor QOL.

CONCLUSION

The study offers important insights on parental perspectives in periviable decision making and potential values clarification tools for decision support.

Post-traumatic stress disorder in critical illness survivors and its relation to memories of ICU

BACKGROUND

Stressors in intensive care units (ICUs) are sometimes so severe that they result in Post-traumatic Stress Disorder (PTSD) in ICU survivors. The memories that survivors have from the ICU may play a role in developing PTSD.

AIM

This study aimed to determine the prevalence of PTSD-related symptoms in ICU survivors in Southeast Iran and its relationship with their memories of the ICU.

METHODS

In this descriptive correlational study, 100 people discharged from ICUs in southeastern Iran completed the Impact of Event Scale-Revised (IES-R) and ICU memory tool (ICU-MT).

RESULTS

Findings indicated that, from 100 participants who, on average, were assessed 3.19 ± 5.37 months after discharge, 13% were suffering from PTSD. The total mean IES-R score and the scores of "Intrusion," "Avoidance," and "Hyperarousal" subscales in patients with delusional memories were higher compared with the patients who did not have such memories. In the patients who were mechanically ventilated at the time of their stay in the ICU, the total mean IES-R score was 6.86 times higher (P = .03).

CONCLUSION

This research provided further evidence of the relationship between delusional memories and PTSD in patients who had been discharged from the ICU.

RELEVANCE TO CLINICAL PRACTICE

In the care of patients admitted to the ICU, preventive strategies should be used to minimize delusional memories and PTSD. It is necessary to detect post-ICU psychiatric morbidities and provide early psychological intervention in post-discharge follow-up programmes to improve psychological outcomes after critical illness.

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

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