Swiss neonatal caregivers express diverging views on parental involvement in shared decision-making for extremely premature infants

The ethics and practice of perinatal care at the limit of viability: FIGO recommendations

An arbitrary gestational age limit of viability cannot be set, and in clinical practice the focus should be on a periviability interval-the so-called "gray zone" of prognostic uncertainty. For cases within this interval, the most appropriate decision-making process remains debatable and periviability has emerged as one of the greatest challenges in bioethics. Universally recognized ethical principles may be interpreted differently due to socioeconomic, cultural, and religious aspects. In the case of periviability, there is considerable uncertainty over whether interventions result in a greater balance of clinical good over harm. Furthermore, the fetus or neonate is unable to exercise autonomy and the physicians and parents will act as patient surrogates. When parents and physicians disagree about the infant's best interest, a dialogue without paternalistic attitudes is essential, whereby physicians should only offer, but not recommend, perinatal interventions. Parental choice, based on thorough information, should be respected within the limits of what is medically feasible and appropriate. When disagreements between parents and physicians occur, how is consensus to be achieved? Professional guidelines can be helpful as a framework and starting point for discussion. In reality, however, guidelines only rarely draw categorical lines and in many cases remain vague and ambiguously worded. Local ethics committees can provide counseling and function as moderators during discussions, but ethics committees do not have decision precedence. Counseling assumes the most significant role in periviability discussions, taking into consideration the particular fetal and maternal characteristics, as well as parental values. Several caveats should be observed relative to counseling: message fragmentation or inconsistence should be minimized, prognosis should preferably be presented in a positive framing, and overreliance on statistics should be avoided. It is recommended that decisions regarding neonatal resuscitation in the periviability interval be made before birth and not conditional on the newborn's appearance at birth. Regardless of decision, it is important to assure pre- and postnatal coherence. The present article describes how individual physicians, centers, and countries differ in the approach to the decision to initiate or forgo intensive care in the periviability interval. It is impossible to provide a global consensus view and there can be no unifying ethical, moral, or practical strategy. Nevertheless, ethically justified, quality care comprises early involvement of the obstetric and neonatal team to enable a coherent, comprehensible, nonpaternalistic, and balanced plan of care. Ultimately, physicians will need to adjust the expectations to the local standards, local outcome data, and local neonatal support availability.

The Ethics and Practice of Periviability Care

Since the 1960s, the gestational age at which premature infants typically survive has decreased by approximately one week per decade [...].

[Ethical Attitudes and Handling in Prenatal Conflict Situations - A Survey among Obstetricians and Prenatal Diagnosticians in Germany]

OBJECTIVE

Various studies have shown that belonging to a professional group has an influence on ethical attitudes. The aim of this study was to assess and compare the attitudes and approaches of obstetrical specialists and prenatal diagnosticians in prenatal conflict situations.

METHODS

Explorative cross-sectional online survey among tertiary perinatal care centers and prenatal diagnosticians with DEGUM Level II/III in Germany. The questionnaire included questions on ethical attitudes in the perinatal context and a case presentation of a fetal hypoplastic left heart syndrome.

RESULTS

The response rate was 57.1% (310/543). 55.5% of the respondents practiced both obstetrics and prenatal diagnostics, 24.5% exclusively prenatal diagnostics, and 14.2% purely obstetrics. 27% agreed with the statement "An uncertain prognosis justifies pregnancy termination". For complex fetal malformations joint interdisciplinary counseling was advocated by 98.3%. Addressing the option of postnatal palliative treatment in a case of a hypoplastic left heart syndrome was accepted by 84.3% across all professional groups, while mentioning fetocide was more frequently cited as an option by prenatal diagnosticians than by obstetricians (57.7% vs. 34.1%).

CONCLUSION

Interdisciplinary prenatal parental counseling in complex fetal malformations is uniformly advocated by prenatal diagnosticians and obstetricians in Germany. However, different ethical attitudes appear among specialists groups with regard to the option of termination of pregnancy.

German obstetrician's self-reported attitudes and handling in threatening preterm birth at the limits of viability

OBJECTIVES

Antenatal treatment and information influences the course of pregnancy and parental decision-making in cases of threatened prematurity on the borderline of viability. Numerous studies have shown significant interprofessional differences in assessing ethical boundary decisions; hence, this study aimed to evaluate obstetricians attitudes, practices and antenatal parental counseling regarding threatened preterm birth in Germany.

METHODS

An anonymous online questionnaire was administered to 543 obstetricians at tertiary perinatal centers and prenatal diagnostic centers in Germany. The survey contained questions on basic ethical issues assessed using the Likert scale and a case vignette regarding the practical procedures of an imminent extreme premature birth at 23 1/7 gestational weeks.

RESULTS

In the case of unstoppable preterm birth, 15 % of clinicians said they would carry out a cesarean section; however, specialists from centers with a high number of very low birth weight infants would do so significantly more often. Among respondents, 29.8 % did not take any therapeutic measures without discussing the child's treatment options with their parents, 19.9 % refused to offer actionable advice to the parents, and 57 % said they would advise parents to seek intensive care treatment for the child with the option of changing treatment destination in the event of serious complications. Moreover, 84 % said they would provide information together with neonatologists.

CONCLUSIONS

Joint counseling with neonatologists is widely accepted. The size of the perinatal center significantly influences the practical approach to threatened preterm births. Respect for parents' decision-making autonomy regarding the child's treatment options is central and influences therapy initiation.

Uncertainty and probability in neonatal end-of-life decision-making: analysing real-time conversations between healthcare professionals and families of critically ill newborns

BACKGROUND

A significant number of critically ill neonates face potentially adverse prognoses and outcomes, with some of them fulfilling the criteria for perinatal palliative care. When counselling parents about the critical health condition of their child, neonatal healthcare professionals require extensive skills and competencies in palliative care and communication. Thus, this study aimed to investigate the communication patterns and contents between neonatal healthcare professionals and parents of neonates with life-limiting or life-threatening conditions regarding options such as life-sustaining treatment and palliative care in the decision-making process.

METHODS

A qualitative approach to analysing audio-recorded conversations between neonatal team and parents. Eight critically ill neonates and a total of 16 conversations from two Swiss level III neonatal intensive care units were included.

RESULTS

Three main themes were identified: the weight of uncertainty in diagnosis and prognosis, the decision-making process, and palliative care. Uncertainty was observed to impede the discussion about all options of care, including palliative care. Regarding decision-making, neonatologists oftentimes conveyed to parents that this was a shared endeavour. However, parental preferences were not ascertained in the conversations analysed. In most cases, healthcare professionals were leading the discussion and parents expressed their opinion reactively to the information or options received. Only few couples proactively participated in decision-making. The continuation of therapy was often the preferred course of action of the healthcare team and the option of palliative care was not mentioned. However, once the option for palliative care was raised, the parents' wishes and needs regarding the end-of-life care of their child were obtained, respected, and implemented by the team.

CONCLUSION

Although shared decision-making was a familiar concept in Swiss neonatal intensive care units, parental involvement in the decision-making process illustrated a somewhat different and complex picture. Strict adherence to the concept of certainty might impede the process of decision-making, thereby not discussing palliation and missing opportunities to include parental values and preferences.

Decision-Making for Extremely Preterm Infants: A Qualitative Systematic Review

OBJECTIVE

To synthesize and describe important elements of decision-making during antenatal consultation for threatened preterm delivery at the margin of gestational viability.

STUDY DESIGN

Data sources including PubMed, EMBASE, Web of Science, and CINAHL Plus were searched. We included all qualitative literature published on decision-making from 1990 to July 2021. Two authors independently screened and evaluated each study using the Critical Appraisal Skills Programme checklist; studies reaching moderate and high quality were included. We developed an extraction tool to collect and categorize data from each qualitative article, then used thematic analysis to analyze and describe the findings.

RESULTS

Twenty-five articles incorporating the views of 504 providers and 352 parents were included for final review. Thematic analysis revealed 4 main themes describing the experience of health care providers and parents participating in decision-making: factors that influence decision-making, information sharing, building a partnership, and making the decision. Parents and providers were not always in agreement upon which elements were most essential to the process of decision-making. Articles published in languages other than English were excluded.

CONCLUSIONS

Qualitative literature highlighting key factors which are important during antenatal counseling can inform and guide providers through the process of shared decision-making. Communicating clear, honest, and balanced information; avoiding artificially dichotomized options; and focusing on partnership building with families will help providers use the antenatal consultation to reach personalized decisions for each infant.

Effect of Continuous Nutrition Management Intervention on Nutritional Status and Development of Premature Infants Based on Mobile Medical APP

Objective

To explore the effect of continuous nutrition management intervention based on mobile medical APP on the nutritional status and development of premature infants.

Methods

Eighty premature infants treated in our hospital from May 2019 to April 2021 were enrolled. The patients were randomly divided into the control group and research group. The control group received routine nursing, and the research group received continuous nutrition management intervention based on mobile medical APP. The Neonatal Behavioral Neurological Assessment (NBNA) score, pain score, height, weight, head circumference, intellectual development score, serum Prealbumin (PA), retinol-binding protein (RBP), and disease occurrence were elucidated.

Results

First of all, the NBNA scores of the two groups were compared. The behavioral ability, passive muscle tension, active muscle tension, original reflex, and general evaluation scores of the research group were significantly higher when compared to the control. Secondly, we compared the pain scores of the two groups, there was no significant difference between the two groups before nursing (P > 0.05), but the pain scores of the research group were lower compared to the control group during the period of blood collection, recovery, discharge, and 6 months after discharge (P < 0.05). Compared with the growth and development indexes of the two groups, there was no significant difference between the two groups before nursing (P > 0.05). After nursing, the GDS score of the two groups increased, and the GDS score of the research group was higher than that of the control group. The difference of data was statistically significant (P < 0.05). Compared with the motor scores of the two groups, there was no significant difference between the two groups before nursing (P > 0.05). After nursing, the motor scores of the two groups increased, and the scores of PDMS-2 and TIMP in the research group were higher than those in the control group, and the difference was statistically significant (P < 0.05). There was no significant difference in serum PA and RBP before nursing, but the serum PA and RBP in the two groups increased after nursing, and the PA and RBP in the research group were higher than those in the control group, and the difference was statistically significant (P < 0.05). Finally, we compared the incidence of diseases between the two groups. Before nursing, the incidence of infection, retinopathy, chronic lung injury and anemia in the research group was lower, when compared to the control, and the difference was statistically significant (P < 0.05).

Conclusion

The intervention strategy of continuous nutrition management based on mobile medical APP for premature infants can significantly strengthen their nutritional status after discharge, promote their growth and development, improve their nutritional status, reduce the incidence of diseases in premature infants, and then enhance their quality of life.

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.