Ethical issues for parents of extremely premature infants

Antenatal Consultations at Extreme Prematurity: A Systematic Review of Parent Communication Needs

OBJECTIVE

To synthesize and describe parental expectations on how healthcare professionals should interact with them during a peripartum, antenatal consultation for extremely preterm infants.

STUDY DESIGN

For this systematic literature review with textual narrative synthesis, we included studies that explored parental perspectives regarding the antenatal consultation for an extremely preterm infant. Electronic searches of Medline, CINAHL, PsycInfo, and Embase were conducted, along with a search of the grey literature. Quality appraisal was conducted using the guide by Walsh and Downe. Two independent reviewers reviewed 783 titles, of which 130 abstracts then 40 full-text articles were reviewed. Final data abstraction includes 19 studies. We predetermined 6 topics of interest (setting, timing, preferred healthcare professional, information, resources, and parents-physician interaction) to facilitate thematic analysis.

RESULTS

In consideration of the variability of parents' specific desires, six predetermined topics and additional overarching themes such as perception of support, degree of understanding, hope, spirituality, and decision-making influences emerged. Studies suggest the quality of the antenatal consultation is not purely about information content, but also the manner in which it is provided. Limitations include thematic analysis that can potentially lead to the exclusion of important nuances. Relevant studies may have been missed if published outside the healthcare literature.

CONCLUSIONS

The findings may inform clinical practice guidelines. This paper includes suggested strategies related to parents' perspectives that may facilitate communication during antenatal consultation for an extremely preterm infant. These strategies may also support parental engagement and satisfaction.

Characterization of health care provider attitudes toward parental involvement in neonatal resuscitation-related decision making in Mongolia

The aim of this study was to characterize attitudes and practices among health care providers (HCPs) in Mongolia regarding parental involvement in neonatal resuscitation (NR)-related decisions. A voluntary, anonymous questionnaire was administered to 210 HCPs across 19 of 21 Mongolia provinces. Eligible HCPs included midwives, neonatologists, pediatricians, and obstetricians involved in neonatal-perinatal care in both rural and urban hospitals. A total of 210 pediatric HCPs were surveyed and 100 % completed all questions (response rate 100 %). Despite the absence of nation-wide guidelines, NR is uniformly performed at 32-weeks gestation across HCP professions and across rural/urban settings. Most HCPs (67 %) indicate that parents should be counseled about resuscitation, but only 9 % ask the parents if they want their extremely premature child resuscitated and only 17 % counsel the parents prior to birth of an at-risk infant. Most HCPs (72 %) prefer to unilaterally decide when to withdraw NR, and only 28 % indicated that both parents should be involved in the decision. Following a newborn's death, 75 % of all HCPs reported that they do explain the death to parents, although only 28 % reported receiving any training in parental grief counseling. For HCPs in Mongolia, a discrepancy exists between the perceived value of parental involvement and the actual practice of NR-related counseling. This report is a necessary first step toward understanding the factors that influence NR-related practices in Mongolia, and may serve as model for collecting these types of data in other low and middle income countries.

A transdisciplinary approach to the decision-making process in extreme prematurity

Background

A wide range of dilemmas encountered in the health domain can be addressed more efficiently by a transdisciplinary approach. The complex context of extreme prematurity, which is raising important challenges for caregivers and parents, warrants such an approach.

Methods

In the present work, experts from various disciplinary fields, namely biomedical, epidemiology, psychology, ethics, and law, were enrolled to participate in a reflection. Gathering a group of experts could be very demanding, both in terms of time and resources, so we created a web-based discussion forum to facilitate the exchanges. The participants were mandated to solve two questions: “Which parameters should be considered before delivering survival care to a premature baby born at the threshold of viability?” and “Would it be acceptable to give different information to parents according to the sex of the baby considering that outcome differences exist between sexes?”

Results

The discussion forum was performed over a period of nine months and went through three phases: unidisciplinary, interdisciplinary and transdisciplinary, which required extensive discussions and the preparation of several written reports. Those steps were successfully achieved and the participants finally developed a consensual point of view regarding the initial questions. This discussion board also led to a concrete knowledge product, the publication of the popularized results as an electronic book.

Conclusions

We propose, with our transdisciplinary analysis, a relevant and innovative complement to existing guidelines regarding the decision-making process for premature infants born at the threshold of viability, with an emphasis on the respective responsabilities of the caregivers and the parents.

Moral distress in the resuscitation of extremely premature infants

OBJECTIVE

To increase our understanding of moral distress experienced by neonatal registered nurses when directly or indirectly involved in the decision-making process of resuscitating infants who are born extremely premature.

DESIGN

A secondary qualitative analysis was conducted on a portion of the data collected from an earlier study which explored the ethical decision-making process among health professionals and parents concerning resuscitation of extremely premature infants.

SETTING

A regional, tertiary academic referral hospital in Ontario offering a perinatal program.

PARTICIPANTS

A total of 15 registered nurses were directly or indirectly involved in the resuscitation of extremely premature infants.

METHODS

Interview transcripts of nurses from the original study were purposefully selected from the original 42 transcripts of health professionals. Inductive content analysis was conducted to identify themes describing factors and situations contributing to moral distress experienced by nurses regarding resuscitation of extremely premature infants.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the research ethics review board for both the initial study and this secondary data analysis.

RESULTS

Five themes, uncertainty, questioning of informed consent, differing perspectives, perceptions of harm and suffering, and being with the family, contribute to the moral distress felt by nurses when exposed to neonatal resuscitation of extremely premature infants. An interesting finding was the nurses' perceived lack of power and influence in the neonatal resuscitation decision-making process.

CONCLUSION

Moral distress continues to be a significant issue for nursing practice, particularly among neonatal nurses. Strategies are needed to help mediate the moral distress experienced by nurses, such as debriefing sessions, effective communication, role clarification, and interprofessional education and collaboration.

A qualitative study of predelivery counselling for extreme prematurity

OBJECTIVE

To ascertain from parents of neonates born before 27 weeks' gestational age how to improve predelivery counselling for delivery room resuscitation.

METHODS

Qualitative ethnographic study using semistructured, face-to-face interviews of 10 families. Data were analyzed using a constant comparative method.

RESULTS

Parents had no previous knowledge about prematurity. They would have preferred prioritized information during predelivery counselling focused on the immediate risks to their child. Resuscitation wishes were inconsistently sought. Opportunities for repeat discussions involving both parents were often missed. Parents agreed that the opportunity to explicitly state resuscitation wishes should be offered. Additional materials, such as pamphlets or videos, would improve counselling.

CONCLUSIONS

Information about prematurity should be offered when the pregnancy is deemed high risk, with repeat counselling opportunities for both parents to discuss options. Once the decision is made to resuscitate, parents want the neonatal team to convey a message of hope and compassion.

Advanced clinical medicine requires advanced clinical ethics

Many advances have occurred in clinical medicine in the last decades. Solid organ transplants, corrective surgery for congenital malformations, improved cytostatic regimes for children with cancer, and respiratory care for premature infants are but a few examples of the changing face of medical practice. Such changes have added years to life. But along the way many patients have paid a price, both in terms of loss of life and of added suffering. Even today, some survivors are faced with a life of impairment and suffering. Follow-up studies of extremely low-birth-weight infants show that the smallest infants have a high rate of severe sequelae. Some argue that such suffering should be sufficient reason to make us desist from further attempts to advance the frontiers of therapy. This paper seeks to reflect on the character of advanced medicine and on how we relate to patients and their kin in our quest for further improvements in therapy. The price for continued advances will inevitably be paid by some patients who will not profit from them. Therefore, patients who are asked to participate in such a quest must receive honest and transparent information, including a discussion about where and how they would draw the limits. Clinical competency is a core concept in advanced medicine, but a caring comportment also demands that our relationship to the patient be characterized by honesty, integrity, and decency. In dialogue with parents, finding the right balance between parental exercise of autonomy and safe-guarding the best interest of the child remains a challenge.

Care at the edge of viability: medical and ethical issues

Decision-making for extremely immature preterm infants at the margins of viability is ethically, professionally, and emotionally complicated. A standard for prenatal consultation should be developed incorporating assessment of parental decision-making preferences and styles, a communication process involving a reciprocal exchange of information, and effective strategies for decisional deliberation, guided by and consistent with parental moral framework. Professional caregivers providing perinatal consultations or end-of-life counseling for extremely preterm infants should be sensitive to these issues and be taught flexibility in counseling techniques adhering to consistent guidelines. Emphasis must shift away from physician beliefs and behaviors about the boundaries of viability.

Providing advice to parents for women at acutely high risk of periviable delivery

OBJECTIVE

To better understand preferred approaches that health care professionals could use when caring for parents who are at risk of giving birth to an extremely premature infant.

METHODS

Women who were at high risk of having a periviable birth were recruited from three tertiary care hospitals with level 3 neonatal intensive care units. These women, as well as their partners, physicians, and nurses underwent structured interviews both before and after delivery. Interviews were analyzed for advice that was provided to health care professionals who could be involved in the future counseling of antenatal patients at high risk of periviable delivery.

RESULTS

Forty women, 14 fathers, and 52 health care providers participated in the interview process. Two main themes were identified--namely, the fundamental importance of information provision and support. Nevertheless, although all participants agreed about the importance of these actions, several areas of discordance among participants were noted. Nearly one third of parents emphasized the importance of "hope"; 60% and 45% recommended the provision of supplementary written and Internet materials, respectively. In contrast, most health care providers expressed the importance of "objectivity," and only 15% and 5% thought written or Internet materials, respectively, were desirable, given the concern that supplementary information sources could be misleading.

CONCLUSION

Both patients and providers agree about the centrality of information provision and emotional support for women at risk of periviable delivery. This study not only elucidates preferred approaches and methods by which this information and support could be optimized, but also shows pitfalls that, if not avoided, may impair the relationship between provider and patient.