The Best Interests of Infants and Families During Palliative Care at the End of Life: A Review of the Literature

Grasping the meaning of perinatal palliative care for the multiprofessional team

OBJECTIVE

To grasp the meaning of perinatal palliative care for the multidisciplinary team.

METHODS

This is a qualitative study guided by content analysis. The study included 56 health professionals working in maternal and child units of a public university hospital. A semi-structured interview was conducted, which was recorded and subsequently fully transcribed. The collection took place from June 2018 to May 2019. Data were entered and exported to Atlas ti: The Qualitative Date Analysis & Research Software, version 23.1.1.0.

RESULTS

Four thematic categories emerged from the data analysis: palliative care and eligible public in the view of professionals; communication between family and team in decision-making; assistance in palliative care; humanized care.

CONCLUSIONS

The professionals think of palliative care in Perinatology in a similar way and perceive the difficulties of communication with the family and decision-making. They agree that it is necessary to provide greater support to the family, and to provide comfort measures, either for the non-viable fetus or for the baby eligible for palliative care.

Perinatal loss in Tanzania: Perspectives of maternal-child healthcare providers

Over 98% of stillbirths and neonatal deaths occur in Low- and Middle-Income Countries, such as Tanzania. Despite the profound burden of perinatal loss in these regions, access to facility or community-based palliative and psychosocial care is poor and understudied. In this study we explore perinatal loss through the lens of front-line healthcare providers, to better understand the knowledge and beliefs that guide their engagement with bereaved families. A Knowledge Attitudes and Practices survey addressing perinatal loss in Tanzania was developed, translated into Swahili, and administered over a 4-month period to healthcare professionals working at the Kilimanjaro Christian Medical Center (KCMC). Results were entered into REDCap and analyzed in R Studio. 74 providers completed the survey. Pediatric providers saw a yearly average of 5 stillbirths and 32.7 neonatal deaths. Obstetric providers saw an average of 11.5 stillbirths and 13.12 neonatal deaths. Most providers would provide resuscitation beginning at 28 weeks gestational age. Respondents estimated that a 50% chance of survival for a newborn occurred at 28 weeks both nationally and at KCMC. Most providers felt that stillbirth and neonatal mortality were not the mother's fault (78.4% and 81.1%). However, nearly half (44.6%) felt that stillbirth reflects negatively on the woman and 62.2% agreed that women are at higher risk of abuse or abandonment after stillbirth. A majority perceived that women wanted hold their child after stillbirth (63.0%) or neonatal death (70.3%). Overall, this study found that providers at KCMC perceived that women are at greater risk of psychosocial or physical harm following perinatal loss. How women can best be supported by both the health system and their community remains unclear. More research on perinatal loss and bereavement in LMICs is needed to inform patient-level and health-systems interventions addressing care gaps unique to resource-limited or non-western settings.

Palliative Care for Infants in the Neonatal Intensive Care Unit: A Scoping Review

This scoping review aimed to explore the characteristics of neonatal palliative care in the neonatal intensive care unit, including the features, contents, and experiences of infants, parents, and nurses during palliative care. Five databases (PubMed, Cochrane, CINAHL, Research Information Sharing Service, and Korean Studies Information Service System) were searched to identify relevant articles published between 2011 and 2020. From the systematic search and review process, 13 studies that met the eligibility criteria were selected for the analysis. From the literature review, 2 key principles were found to facilitate neonatal palliative care: family-centered care and integrative care in the neonatal intensive care unit. In addition, the themes found in this review included (1) providing comfortable care to dying infants with respect to infants and offering parents choices, (2) therapeutic communication, (3) support with respect, and (4) bereavement care for parents of dying infants in the neonatal intensive care unit. Caregivers require effective communication, manpower support, emotional support, educational programs, and well-defined protocols. The evidence mapped and synthesized in this review indicates the need to facilitate the provision of palliative care in the neonatal intensive care unit in line with the unique needs of infants, parents, and nurses.

Palliative care for children: methodology for the development of a national clinical practice guideline

BACKGROUND

Provision of paediatric palliative care for children with life-threatening or life-limiting conditions and their families is often complex. Guidelines can support professionals to deliver high quality care. Stakeholders expressed the need to update the first Dutch paediatric palliative care guideline with new scientific literature and new topics. This paper provides an overview of the methodology that is used for the revision of the Dutch paediatric palliative care guideline and a brief presentation of the identified evidence.

METHODS

The revised paediatric palliative care guideline was developed with a multidisciplinary guideline panel of 72 experts in paediatric palliative care and nine (bereaved) parents of children with life-threatening or life-limiting conditions. The guideline covered multiple topics related to (refractory) symptom treatment, advance care planning and shared-decision making, organisation of care, psychosocial care, and loss and bereavement. We established six main working groups that formulated 38 clinical questions for which we identified evidence by updating two existing systematic literature searches. The GRADE (CERQual) methodology was used for appraisal of evidence. Furthermore, we searched for additional literature such as existing guidelines and textbooks to deal with lack of evidence.

RESULTS

The two systematic literature searches yielded a total of 29 RCTs or systematic reviews of RCTs on paediatric palliative care interventions and 22 qualitative studies on barriers and facilitators of advance care planning and shared decision-making. We identified evidence for 14 out of 38 clinical questions. Furthermore, we were able to select additional literature (29 guidelines, two textbooks, and 10 systematic reviews) to deal with lack of evidence.

CONCLUSIONS

The revised Dutch paediatric palliative care guideline addresses many topics. However, there is limited evidence to base recommendations upon. Our methodology will combine the existing evidence in scientific literature, additional literature, expert knowledge, and perspectives of patients and their families to provide recommendations.

Psychometric properties of the Korean version of the Palliative Care Nursing Self-Competence scale for infant use

BACKGROUND

Despite the significant advances in neonatal treatment and care over the past 30 years, palliative care in the neonatal intensive care unit has not been fully provided in South Korea. Neonatal nurses are essential professionals in palliative care as they are directly involved in the care, but there is little information on their palliative care competency because no assessment instrument is available in Korea.

OBJECTIVES

The aim of this study was to develop and test the validity and reliability of the Korean version of the Palliative Care Nursing Self-Competence scale for neonatal palliative care.

METHODS

This scale for infant care was developed through parallel translation techniques and revised based on cognitive interviews. Survey data were then collected from 220 neonatal nurses who worked in 13 neonatal intensive care units in Korea. Internal consistency reliability, construct validity based on exploratory factor analysis, and criterion-related validity were tested.

RESULTS

The final version of the scale included 40 items in five domains that explained 53.4% of the variance. Criterion-related validity was confirmed based on a positive correlation with the Korean version of the attitudes towards neonatal palliative care measurement tool. The Cronbach's alpha for the scale was 0.95.

CONCLUSIONS

The Korean version of the Palliative Care Nursing Self-Competence scale for infant care has satisfactory construct validity and reliability to measure palliative care self-competence of neonatal nurses in Korea and evaluate an education program in future studies.

Perinatal palliative care in sub-Saharan Africa: recommendations for practice, future research, and guideline development

Worldwide, sub-Saharan Africa has the highest burden of global neonatal mortality (43%) and neonatal mortality rate (NMR): 27 deaths per 1,000 live births. The WHO recognizes palliative care (PC) as an integral, yet underutilized, component of perinatal care for pregnancies at risk of stillbirth or early neonatal death, and for neonates with severe prematurity, birth trauma or congenital anomalies. Despite bearing a disproportionate burden of neonatal mortality, many strategies to care for dying newborns and support their families employed in high-income countries (HICs) are not available in low-and-middle-income countries (LMICs). Many institutions and professional societies in LMICs lack guidelines or recommendations to standardize care, and existing guidelines may have limited adherence due to lack of space, equipment, supplies, trained professionals, and high patient load. In this narrative review, we compare perinatal/neonatal PC in HICs and LMICs in sub-Saharan Africa to identify key areas for future, research-informed, interventions that might be tailored to the local sociocultural contexts and propose actionable recommendations for these resource-deprived environments that may support clinical care and inform future professional guideline development.

Provider Perceptions on Bereavement Following Newborn Death: A Qualitative Study from Ethiopia and Ghana

OBJECTIVE

The objective of this study was to explore how clinicians in low- and middle-income countries engage and support parents following newborn death.

STUDY DESIGN

Qualitative interviews of 40 neonatal clinicians with diverse training were conducted in Addis Ababa, Ethiopia, and Kumasi, Ghana. Transcribed interviews were analyzed and coded through the constant comparative method.

RESULTS

Three discrete themes around bereavement communication emerged. (1) Concern for the degree of grief experienced by mothers and apprehension to further contribute to it. This led to modified communication to shield her from emotional trauma. (2) Acknowledgment of cultural factors impacting neonatal loss. Clinicians reported that loss of a newborn is viewed differently than loss of an older child and is associated with a diminished degree of public grief; however, despite cultural expectations dictating private grief, interview subjects noted that mothers do suffer emotional pain when a newborn dies. (3) Barriers impeding communication and psychosocial support for families, often relating to language differences and resource limitations.

CONCLUSIONS

Neonatal mortality remains the leading global cause of mortality under age 5, with the majority of these deaths occurring in low- and middle-income countries, yet scant literature exists on approaches to communication around end-of-life and bereavement care for neonates in these settings. We found that medical providers in Ghana and Ethiopia described structural and cultural challenges that they navigate following the death of a newborn when communicating and supporting bereaved parents.

Ten Years of Neonatal Intensive Care Adaption to the Infants' Needs: Implementation of a Family-Centered Care Model with Single-Family Rooms in Norway

Ten years ago, the Neonatal intensive care unit in Drammen, Norway, implemented Single-Family Rooms (SFR), replacing the traditional open bay (OB) unit. Welcoming parents to stay together with their infant 24 h per day, seven days per week, was both challenging and inspiring. The aim of this paper is to describe the implementation of SFR and how they have contributed to a cultural change among the interprofessional staff. Parents want to participate in infant care, but to do so, they need information and supervision from nurses, as well as emotional support. Although SFR protect infants and provide private accommodation for parents, nurses may feel isolated and lack peer support. Our paper describes how we managed to systematically reorganize the nurse's workflow by using a Plan-Do-Study-Act (PDSA) cycle approach. Significant milestones are identified, and the implementation processes are displayed. The continuous parental presence has changed the way we perceive the family as a care recipient and how we involve the parents in daily care. We provide visions for the future with further developments of care adapted to infants' needs by providing neonatal intensive care with parents as equal partners.

Bereaved parents' perspectives on their child's end-of-life care: connecting a self-report questionnaire and interview data from the nationwide Paediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) study

Background

Paediatric Palliative Care (PPC) focuses on ensuring the best possible quality of life for the child and his/her family by extending beyond the physical domain into psychosocial and spiritual wellbeing. A deep understanding of what is important to parents is crucial in guiding the further evaluation and improvement of PPC and end-of-life (EOL) care services. Much can be learned from specific positive and negative experiences of bereaved parents with the EOL care of their child. This report builds upon a questionnaire survey as part of the national Paediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) study.

Methods

One part of the PELICAN study was set up to assess and explore the parental perspectives on their child’s EOL care. Interview data were used to explain the extremely positive and negative results of a quantitative survey in an explanatory sequential mixed-methods approach. Data integration occurred at different points: during sampling of the interview participants, when designing the interview guide and during analysis. A narrative approach was applied to combine the qualitative results reported here with the already published quantitative survey results.

Results

Eighteen mothers (60%) and twelve fathers (40%) participated in 20 family interviews. All parents reported having both positive and negative experiences during their child’s illness and EOL, which was characterised by many ups and downs. The families transitioned through phases with a prospect of a cure for some children as well as setbacks and changing health status of the child which influenced prognosis, leading to the challenge of making extremely difficult decisions. Severely negative experiences still haunted and bothered the parents at the time when the interview took place.

Conclusions

A deep understanding of the perspectives and needs of parents going through the devastating event of losing a child is important and a prerequisite to providing compassionate care. This complex care needs to recognise and respond to the suffering not only of the child but of the parents and the whole family. Communication and shared decision-making remain pivotal, as do still improvable elements of care that should build on trustful relationships between families and healthcare professionals.

Enhancing paediatric palliative care: A rapid review to inform continued development of care for children with life-limiting conditions

AIM

Following the establishment of paediatric palliative care services over recent decades, this study sought to identify information to inform future policy and practice.

METHODS

A rapid review using thematic synthesis was conducted to synthesise existing information about improving paediatric palliative care. Information was extracted in relation to key areas for investment and change: quality, access, advance care planning, skills, research, collaboration and community awareness.

RESULTS

A total of 2228 literature sources were screened, with 369 included. Synthesised information identified clear ways to improve quality of care, access to care, advance care planning, and research and data collection. The synthesis identified knowledge gaps in understanding how to improve skills in paediatric palliative care, collaboration across Australian jurisdictions and community awareness.

CONCLUSIONS

The findings of this review bring together information from a vast range of sources to provide action-oriented information to target investment and change in paediatric palliative care over the coming decades.

Communication of bad news in the context of neonatal palliative care: experience of intensivist nurses

OBJECTIVES

To know the experiences of nurses in neonatal intensive care units in the face of the process of communicating bad news to the family of newborns in palliative care.

METHODS

Study with a descriptive qualitative approach, in which 17 professionals participated. Data were collected through a semi-structured interview script, from December/2018 to February/2019, and submitted to content analysis.

RESULTS

Four theoretical categories emerged, with 11 subcategories inserted: meanings attributed to bad news; nursing as a support for the family; difficulties in dealing with the process of communicating bad news; nursing and involvement with the family's suffering.

FINAL CONSIDERATIONS

The challenges to deal with the situation are related to lack of preparation, impotence, and subjectivities. The results broaden knowledge on the subject and enable the improvement of nursing care in this context.

Nurses' attitudes toward caring for terminally ill neonates and their families in Iran: a cross-sectional study

Providing care for terminally ill neonates is an important issue in NICUs. This research aimed to determine nurses’ attitudes toward providing care for terminally ill neonates and their families. A total of 138 nurses working in neonatal intensive care units (NICUs) affiliated to Tehran University of Medical Sciences participated in this cross-sectional study via convenience sampling in 2019. The Data collection tool was the Frommelt attitudes toward caring for terminally ill persons and their families scale. The nurses in this study had the most positive attitudes toward the items “nursing care should include the family of the terminally ill patient, too” (4.2 ± 0.6) and “the care provider can prepare the patient or his/her family for death” (4.1 ± 0.7). The nurses had the least positive attitude toward the item “the time spent on caring for terminally ill patients creates a sense of frustration in me” (1.06 ± 1). The mean score of the attitudes of NICU nurses toward caring for terminally ill neonates and their families indicates the necessity of improving this attitude.

Parental bereavement - impact of death of neonates and children under 12 years on personhood of parents: a systematic scoping review

BACKGROUND

Losing a child tragically impacts the well-being and functioning of parents. With these effects extending beyond emotional, physical morbidity and compromising self-perceptions, appropriate, longitudinal, timely and personalised support is key to effective care of bereaved parents. However, in the absence of a comprehensive understanding of parental bereavement, effective support of bereaved parents remains suboptimal. To address this gap, we scrutinise prevailing data on the effects of a child's death, aged 0-12 years, through the lens of the Ring Theory of Personhood (RToP).

METHODS

To study prevailing accounts of bereaved parents following the death of a child, we adopt Krishna's Systematic Evidence Based Approach (SEBA) to structure our Systematic Scoping Review (SSR in SEBA).

RESULTS

Three thousand seventy-four abstracts were reviewed, 160 full text articles were evaluated, and 111 articles were included and analysed using thematic and content analysis. Four themes/categories were identified relating to the four rings of the RToP. Findings reveal that static concepts of protective and risk factors for grief are misplaced and that the support of healthcare professionals is key to assisting bereaved parents.

CONCLUSION

In the absence of consistent support of bereaved parents, this study highlights the need for effective training of healthcare professionals, beginning with an appreciation that every aspect of an individual parent's personhood is impacted by the loss of their child. Acknowledging grief as a complex, evolving and personalised process subjected to parental characteristics, settings, context and available support, this SSR in SEBA calls attention to effective nurturing of the relationship between parents and healthcare professionals, and suggests use of the RToP to assess and direct personalised, timely, specific support of parents in evolving conditions. We believe the findings of this review also call for further studies to support healthcare professionals as they journey with bereaved parents.

Parent Perceptions of Infant Symptoms and Suffering and Associations With Distress Among Bereaved Parents in the NICU

CONTEXT

Healthcare providers and parents face many challenges caring for infants at the end of life (EOL). Symptom assessment and management in critically ill infants can be especially difficult. However, the impact of the infant's EOL experience on bereaved parents is largely unknown.

OBJECTIVE

Explore associations between parental perceptions of infant symptoms and suffering at EOL in the neonatal intensive care unit (NICU) and parent adjustment following the death.

METHODS

Retrospective, cross-sectional pilot study involving parents of infants who died within the previous five years in a large, Midwestern, level IV NICU. Parents were recruited through mailed invitations, and 40 mothers and 27 fathers participated from 40 families. Parents retrospectively reported on infant symptom burden and suffering during the last week of life and the Impact of Events Scale-Revised (IES-R), and Prolonged Grief-13 (PG-13). Hierarchical regressions examined demographic/medical factors and parent perceptions at EOL in relation to post-traumatic stress symptoms (PTSS) and prolonged grief (PG).

RESULTS

Clinical levels of PTSS (Mothers = 18%; Fathers = 11%) and PG (Mothers and Fathers = 3%) were low. Maternal perception of higher symptom burden was associated with greater PTSS, R² = 0.46, P= 0.001, and PG, R² = 0.47, P < 0.01. Paternal perception of greater infant suffering was associated with greater PTSS, R² = 0.48, P= 0.001, and PG, R² = .38, P < 0.01.

CONCLUSION

Perceptions of symptoms and suffering were associated differently with mother and father adjustment after bereavement. While not necessarily causal, better symptom management at EOL could minimize distress for both infants and their parents.

Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care

Specialty care for preterm and critically ill infants has evolved over many years. Neonatal intensive care nurseries were developed, and physicians and nurses learned how to provide intensive care for these infants. Neonatal and maternal (in utero) transport to tertiary centers became common in regionalized systems of care to facilitate the specialized care of high-risk neonates when childbirth occurred in settings without specialized personnel or equipment. Annually, nearly 70,000 neonatal transports occur in the United States. Although specialty care helps reduce rates of neonatal mortality, racial disparities and disparities between urban and rural areas exist. The purpose of this article is to review the progress achieved in neonatal and maternal transport over the past 50 years. The knowledge developed can be used to improve the care provided to women, their fetuses, and infants.

A Concept Analysis of Neonatal Palliative Care in Nursing: Introducing a Dimensional Analysis

Despite the increasing need for neonatal palliative care, it is not adequately implemented in practice. This analysis aimed to clarify the dimension of the neonatal palliative care concept to increase understanding of the concept to give more insight into clinical practice. Using dimensional analysis methodology, 46 English language papers from 2001-2018 were analyzed. The coding of the literature for the perspective, context, conditions, process, and consequences of the concept was completed. Five dimensions informed the conceptualization of this concept and interrelationships among their themes/sub-themes were presented in the matrix named, "improving quality of life and death". Within the family-centered care perspective and under different conditions/contexts through the processes of neonate's comfort and providing holistic care, the consequences of this care were improving quality of life/a good death. Family-centered care was the fundamental dimension and essential to achieving the consequences. The other dimensions of context, conditions, and processes were also affected by the family's needs, preferences, culture, and expectations. This analysis reinforces that neonatal palliative care is a multidimensional concept. To provide the standard of neonatal palliative care an integrated plan to get together many stakeholders including community, parents, clinical staff, policymakers, insurance authorities, health care systems, and education system is required. All NICUs should have neonatal palliative care-trained nurses and protocols with a family-centered care approach to focus on the quality of life of neonates with life-threatening conditions from diagnosis of disease to death. Regular training and educational courses on neonatal palliative care and family-centered care principles can make nurses more sensitive to their advocacy role.

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.