Neonatal palliative care: developing consensus among neonatologists using the Delphi technique in Portugal

National Divergences in Perinatal Palliative Care Guidelines and Training in Tertiary NICUs

Objectives: Despite established principles of perinatal palliative care (PnPC), implementation into practice has shown inconsistencies. The aim of this study was to assess PnPC services, examine healthcare professionals (HCPs) awareness and availability of PnPC guidelines, and describe HCPs satisfaction with PC and guidelines. Material and Methods: A nationwide survey was conducted in Swiss tertiary NICUs between April-November 2019. Data were examined by descriptive statistics and linear regression models. Results: Overall response rate was 54% (65% physicians; 49% nurses; 72% psychosocial staff). Half of professionals (50%) received education in PC during their medical/nursing school, whereas 36% indicated they obtained further training in PnPC at their center. PnPC guidelines were available in 4/9 centers, with 68% HCPs being aware of the guideline. Professionals who had access to a PnPC team (P = 0.001) or were part of the nursing (P = 0.003) or psychosocial staff (P = 0.001) were more likely aware of having a guideline. Twenty-eight percent indicated being satisfied with PC in their center. Professionals with guideline awareness (P = 0.025), further training (P = 0.001), and access to a PnPC team (P < 0.001) were more likely to be satisfied, whereas HCPs with a nursing background (P < 0.001) were more likely to be dissatisfied. A majority expressed the need for a PnPC guideline (80%) and further PC training (94%). Conclusion: This study reveals lacking PnPC guidelines and divergences regarding onsite opportunities for continued training across Swiss level III NICUs. Extending PnPC guidelines and training services to all centers can help bridge the barriers created by fragmented practice.

Physicians' attitudes in relation to end-of-life decisions in Neonatal Intensive Care Units: a national multicenter survey

BACKGROUND

End-of-life decisions for neonates with adverse prognosis are controversial and raise ethical and legal issues. In Greece, data on physicians' profiles, motivation, values and attitudes underlying such decisions and the correlation with their background are scarce. The aim was to investigate neonatologists' attitudes in Neonatal Intensive Care Units and correlate them with self-reported practices of end-of-life decisions and with their background data.

METHODS

A structured questionnaire was distributed to all 28 Neonatal Intensive Care Units in Greece. One hundred and sixty two out of 260 eligible physicians answered anonymously the questionnaire (response rate 66%). Demographic and professional characteristics, self-reported practices and opinions were included in the questionnaire, along with a questionnaire of 12 items measuring physicians' attitude and views ranging from value of life to quality of life approach (scale 1-5).

RESULTS

Continuation of treatment in neonates with adverse prognosis without adding further therapeutic interventions was the most commonly reported EoL practice, when compared to withdrawal of mechanical ventilation. Physicians with a high attitude score (indicative of value of quality-of-life) were more likely to limit, while those with a low score (indicative of value of sanctity-of-life) were more likely for continuation of intensive care. Physicians' educational level (p:0.097), involvement in research (p:0.093), religion (p:0.024) and position on the existing legal framework (p < 0.001) were factors that affected the attitude score.

CONCLUSIONS

Physicians presented with varying end-of-life practices. Limiting interventions in neonates with poor prognosis was strongly related to their attitudes. The most important predictors for physicians' attitudes were religiousness and belief for Greek legal system reform.

Linguistic and cultural adaptation to the Portuguese language of antimicrobial dose adjustment software

OBJECTIVE

To adapt an antibiotic dose adjustment software initially developed in English, to Portuguese and to the Brazilian context.

METHODS

This was an observational, descriptive study in which the Delphi method was used to establish consensus among specialists from different health areas, with questions addressing the visual and operational aspects of the software. In a second stage, a pilot experimental study was performed with the random comparison of patients for evaluation and adaptation of the software in the real environment of an intensive care unit, where it was compared between patients who used the standardized dose of piperacillin/tazobactam, and those who used an individualized dose adjusted through the software Individually Designed and Optimized Dosing Strategies.

RESULTS

Twelve professionals participated in the first round, whose suggestions were forwarded to the software developer for adjustments, and subsequently submitted to the second round. Eight specialists participated in the second round. Indexes of 80% and 90% of concordance were obtained between the judges, characterizing uniformity in the suggestions. Thus, there was modification in the layout of the software for linguistic and cultural adequacy, minimizing errors of understanding and contradictions. In the second stage, 21 patients were included, and there were no differences between doses of piperacillin in the standard dose and adjusted dose Groups.

CONCLUSION

The adapted version of the software is safe and reliable for its use in Brazil.

Survey on Neonatal End-of-Life Comfort Care Guidelines Across America

CONTEXT

Infants of age less than one year have the highest mortality rate in pediatrics. The American Academy of Pediatrics published guidelines for palliative care in 2013; however, significant variation persists among local protocols addressing neonatal comfort care at the end-of-life (EOL).

OBJECTIVES

The purpose of this study was to evaluate current neonatal EOL comfort care practices and clinician satisfaction across America.

METHODS

After institutional review board approval (516005), an anonymous, electronic survey was sent to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine. Members of the listserv include neonatologists, neonatal fellow physicians, neonatal nurses, and neonatal nurse practitioners from across America (U.S. and Canada).

RESULTS

There were 346/3000 (11.5%) responses with wide geographic distribution and high levels of intensive care responding (46.1% Level IV, 50.9% Level III, 3.0% Level II). Nearly half (45.2%) reported that their primary institution did not have neonatal comfort care guidelines. Of those reporting institutional neonatal comfort care guidelines, 19.1% do not address pain symptom management. Most guidelines also do not address gastrointestinal distress, anxiety, or secretions. Thirty-nine percent of respondents stated that their institution did not address physician compassion fatigue. Overall, 91.8% of respondents felt that their institution would benefit from further education/training in neonatal EOL care.

CONCLUSION

Across America, respondents confirmed significant variation and verified many institutions do not formally address neonatal EOL comfort care. Institutions with guidelines commonly appear to lack crucial areas of palliative care including patient symptom management and provider compassion fatigue. The overwhelming majority of respondents felt that their institutions would benefit from further neonatal EOL care training.

[Parental roles and needs in neonatal intensive care: a review of Portuguese guidelines]

The scope of this article is to analyze the parental roles and needs included in Neonatal Intensive Care Unit guidelines. Thematic content analysis was conducted of 33 guidelines (28 consensuses and 5 documents directed to parents) freely available on the Portuguese Pediatrics Society website in August 2014. These documents deal mainly with information needs, child care activities performed by the parents and the respective responsibilities in decision making with respect to the health of children. Furthermore, parental and family characteristics were mentioned as risk factors for prematurity and perinatal diseases. The psychosocial consequences of parenthood experienced in Neonatal Intensive Care Units, as well as the adequacy of their environmental characteristics to parental needs, were less frequently touched upon. Issues related to the safety and comfort, confidence of parents in healthcare and social support were rarely touched upon. The results reflect sociocultural norms associated with intensive parenting, which is exclusively child centered, highly emotional and performed under the guidance of health professionals. The important aspect is to issue and disseminate guidelines that foster the integration of family-centered care in the dynamics of Neonatal Intensive Care Units.

Quality predictors of parental satisfaction after birth of infants with life-limiting conditions

AIM

This study examines parental satisfaction with care received in the context of a life-limiting foetal diagnosis and subsequent birth.

METHODS

Survey methods were utilised to embed the Quality Indicators (QI) and Parental Satisfaction of Perinatal Palliative Care Instrument in a survey: 'The Voice of Parents'.

RESULTS

The web-based survey had a final sample of N = 405 parent responders. Overall, parents reported satisfaction with care (80.2%; n = 393). Parents satisfied with care reported higher agreement with quality indicator items for all subscales. In total, 17 items from the 41-item instrument revealed the ability to predict higher parental satisfaction when particular QI are reported.

CONCLUSION

This study has led to credible insights into parental satisfaction with care given after the birth of an infant with a life-limiting condition. The findings contribute to development of a model with a good fit in ascertaining the importance of compassion, unhurried provider-patient communication and bereavement interventions.

Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review

BACKGROUND

The Delphi technique is widely used for the development of guidance in palliative care, having impact on decisions with relevance for patient care.

AIM

To systematically examine the application of the Delphi technique for the development of best practice guidelines in palliative care.

DESIGN

A methodological systematic review was undertaken using the databases PubMed, CINAHL, Web of Science, Academic Search Complete and EMBASE.

DATA SOURCES

Original articles (English language) were included when reporting on empirical studies that had used the Delphi technique to develop guidance for good clinical practice in palliative care. Data extraction included a quality appraisal on the rigour in conduct of the studies and the quality of reporting.

RESULTS

A total of 30 empirical studies (1997-2015) were considered for full-text analysis. Considerable differences were identified regarding the rigour of the design and the reporting of essential process and outcome parameters. Furthermore, discrepancies regarding the use of terms for describing the method were observed, for example, concerning the understanding of a 'round' or a 'modified Delphi study'.

CONCLUSION

Substantial variation was found concerning the quality of the study conduct and the transparency of reporting of Delphi studies used for the development of best practice guidance in palliative care. Since credibility of the resulting recommendations depends on the rigorous use of the Delphi technique, there is a need for consistency and quality both in the conduct and reporting of studies. To allow a critical appraisal of the methodology and the resulting guidance, a reporting standard for Conducting and REporting of DElphi Studies (CREDES) is proposed.

Characterization of Death in Neonatal Encephalopathy in the Hypothermia Era

This study aimed to characterize the circumstances of death in encephalopathic neonates treated with therapeutic hypothermia. Patients who died after or during treatment with therapeutic hypothermia between 2007-2014 were identified. Patient circumstance of death was characterized using an established paradigm. Thirty-one of 229 patients died (14%) at a median of 3 days of life. Most who died were severely encephalopathic on examination (90%) and had severely abnormal electroencephalographic (EEG) findings (87%). All those who had magnetic resonance images (n = 13) had evidence of moderate-severe brain injury; 6 had near-total brain injury. Cooling was discontinued prematurely in 61% of patients. Most patients (90%) were physiologically stable at the time of death; 81% died following elective extubation for quality of life considerations. Three patients (10%) died following withholding or removal of artificial hydration and nutrition. Characterization of death in additional cohorts is needed to identify differences in decision making practices over time and between centers.

[Palliative care after neonatal intensive care: Contributions of Leonetti Law and remaining challenges]

The 2005 enactment of the "Patients' rights and end-of-life care" act, known as the Leonetti law, has been accompanied by practical changes in the processes of withdrawal and withholding of active life-sustaining treatments. This law has also promoted the implementation of palliative care in perinatal medicine to avoid unreasonable therapeutic interventions and to preserve the dying patient's quality of life and human dignity. Recently, a new law has been voted by the French National Assembly and new reflections on the ethical aspects of the end of life in neonatal medicine should resume again within the French Society of Neonatology in the working group on ethical issues in neonatology. This is why it appears important to discuss the perceived benefits and the persistent difficulties related to the implementation of the Leonetti law in neonatology. Collegiality in the decision-making processes as well as withdrawal and withholding of life-sustaining treatments that were already present in the practices of many centers has been stipulated within a legal framework and promoted in clinical practice. It has brought serenity within perinatal nursing and medical teams. It has helped them face the always-difficult end-of-life situations with parents and deal with decision-making processes in an intense emotional climate. However, new questions inherent to the law have appeared. The most important ones concern the withholding of artificial nutrition and hydration, the time pressure in the management of the decision-making process, and the management of the duration of palliative care. Challenges remain in addressing various persistent ethical dilemmas such as the possible survival of newborns with significant brain lesions detected after the period of life-sustaining treatments that have allowed their survival. The new law carried by Mr. Clayes and Mr. Léonetti should provide answers to some of these ethical issues, but it would probably not solve all of them.

Paternal depression during pregnancy and postpartum: An international Delphi study

BACKGROUND

Fathers are at risk for depression during a mother's gestation and postpartum. Assessment, detection, and treatment are hampered by the lack of consensus on this issue. The purpose of this study was to reach expert consensus through the Delphi method on the defining factors of depression in peripartum fathers.

METHODS

Purposive sampling resulted in the surveying of 14 international expert panelists. The study used a modified Delphi approach in which experts participated in two rounds of open-ended and scale questionnaires, followed by two rounds of opportunities to adjust their responses and/or comment on evolving data until consensus was achieved.

RESULTS

Experts responded to 10 questions on terminology, diagnostics, symptomology, risk/protective factors, biological factors, assessment tools/protocol, cost implications, and key stakeholders. Of these 10 questions presented for discussion, the analysis resulted in 197 coded themes. Consensus was met for 119 of the 197 coded responses (60.41%).

LIMITATIONS

Diversity of opinion within this Delphi Study was excluded for the sake of consensus. Regression to the mean may have occurred after continuous surveying and when evolving results were shared with panelists. Critics of Delphi methodologies have pointed to the issue of small expert samples typically used and the subjectivity of "expert."

CONCLUSION

Consensus identified diagnostic criteria and symptomology that differentiates the paternal experience of peripartum depression. Experts indicated the importance of a father's social context, biological risk factors, limitations of current assessment tools, key stakeholders, and potential financial costs. Stakeholders on this issue would benefit from translating consensus into assessment and treatment.

Morbidity and mortality of preterm infants less than 26 weeks of gestational age

BACKGROUND

Extreme preterm infants have a high risk of morbidity and mortality. Newborns delivered between 23+0 and 25+6 weeks, are considered to be in the "gray zone" and have uncertain prognosis. For these children medical decision-making becomes complex and controversial. The present study intends to evaluate the neonatal morbidity and mortality of preterm infants born between 23 weeks and 25+6 weeks of gestational age.

METHODS

A retrospective study was conducted including all inborn preterm infants, with a gestational age between 23+0 and 25+6 weeks, admitted to a level IIIC NICU, between January 1st, 1996 and December 31st, 2014.

RESULTS

A total of 72 preterm neonates were included, 18.1% had a full cycle of antenatal steroids. The most frequent major morbidities were RDS (95.4%), patent ductus arteriosus (81.3%), sepsis (55.7%, being 19.7% early sepsis, and 36.1% late sepsis), intraventricular hemorrhage (34.4%), retinopathy of prematurity (21.9%) and necrotizing enterocolitis (10.9%). Fifty-four (75%) children died. The only factor adjusted to age associated with high mortality founded was hypotension (OR=4.99, P<0.019). Morbidity at discharge was: severe bronchopulmonary dysplasia (77.8%), retinopathy of prematurity (72.2%), intraventricular hemorrhage (16.7%), cystic periventricular leukomalacia (11.1%), and sequalae of necrotizing enterocolitis (5.6%).

CONCLUSIONS

The survival rate was 25% and a high morbidity at discharge was observed, which leave us with the huge responsibility to improve this result in a near future. Extreme prematurity is still a very controversial and complex issue and particular challenge for neonatologists. The use of antenatal steroid in the more immature preterm infants should be encouraged.

Neonatal end of life care in a tertiary care centre in Canada: a brief report

OBJECTIVE

To describe the processes followed by a neonatal team engaging parents with respect to end of life care of babies in whom long term survival was negligible or impossible; and to describe feedback from these parents after death of their child.

METHODS

A retrospective review was conducted of health records of neonates who had died receiving palliative care over a period of 5 years at a tertiary neonatal centre. Specific inclusion criteria were determined in advance that identified care given by a dedicated group of caregivers.

RESULTS

Thirty infants met eligibility criteria. After excluding one outlier an average of 4 discussions occurred with families before an end of life decision was arrived at. Switching from aggressive care to comfort care was a more common decision-making route than having palliative care from the outset. Ninety per cent of families indicated satisfaction with the decision making process at follow-up and more than half of them returned later to meet with the NICU team. Some concerns were expressed about the availability of neonatologists at weekends.

CONCLUSIONS

A compassionate and humane approach to the family with honesty and empathy creates a positive environment for decision-making. An available, experienced team willing to engage families repeatedly is beneficial. Initiating intensive care with subsequent palliative care is acceptable to families and caregivers.

Paediatric trainees and end-of-life care: a needs assessment for a formal educational intervention

BACKGROUND

Literature suggests a paucity of formal training in end-of-life care in contemporary American medical education. Similar to trainees in adult medicine, paediatric trainees are frequently involved in end-of-life cases.

OBJECTIVE

To determine current experience and comfort levels among paediatric trainees when caring for dying patients with the hypothesis that more clinical experience alone would not improve comfort.

METHODS

Paediatric residents, subspeciality fellows and programme directors at the University of Chicago completed a voluntary electronic needs assessment in June and July 2013. Ten question pairs determined frequency of experiencing various aspects of end-of-life care in clinical practice and comfort levels during these encounters.

RESULTS

118 respondents participated (63.8 % response rate): 66.4 % were female; 53 % had previous education in end-of-life care. The proportion of those with experience in end-of-life care increased through the third year of training, and remained at 1.0 thereafter. Conversely, positive comfort scores increased gradually throughout all six years of training to a maximum proportion of 0.45. Comfort in many specific aspects of care lagged behind experience. Previous education had a significant positive effect on comfort levels of most, but not all, aspects of care. 58 % or more of trainees desired further education on specific end-of-life topics.

CONCLUSIONS

Paediatric trainees are often involved in end-of-life care but may not be comfortable in this role. More experience alone does not improve comfort levels; however, there is a positive correlation with comfort and previous education. Trainees had a strong interest in further education on a variety of end-of-life care topics.