Limits of neonatal treatment: a survey of attitudes in the Danish population

Don't Rush It: Conservative Care in Denmark

One of the first European NICUs was established at Rigshospitalet in Copenhagen in 1965, and mechanical ventilation became the standard of care for preterm infants in 1971. After a failed attempt to extend this to the most immature infants in the early 1980s, a policy with minimally invasive support after birth with nasal continuous positive airway pressure was adopted from the neonatal unit in Odense. The conservative approach was consolidated by a national consensus conference; the lay panel concluded that a lower limit of gestation should be installed and priority should be given to parental counseling and support. This was confirmed some years later by the majority of the members of the Danish Council on Ethics, and questionnaire-based research revealed a significant proportion of the general population that would forego life support in extremely preterm infants. Since the year 2002, the treatment of infants <28 weeks' gestation at birth has been centralized to 4 university-based NICUs, the treatment policies have been rather uniform, and the survival of infants at 23 weeks' gestation or less has been unusual. Most recently, however, a professional initiative has been undertaken to centralize all births >22 weeks' gestation to improve parental counseling and neonatal intervention.

Attitudes towards decisions about extremely premature infants differed between Swiss linguistic regions in population-based study

AIM

Studies have provided insights into the different attitudes and values of healthcare professionals and parents towards extreme prematurity. This study explored societal attitudes and values in Switzerland with regard to this patient group.

METHODS

A nationwide trilingual telephone survey was conducted in the French-, German- and Italian-speaking regions of Switzerland to explore the general population's attitudes and values with regard to extreme prematurity. Swiss residents of 18 years or older were recruited from the official telephone registry using quota sampling and a logistic regression model assessed the influence of socio-demographic factors on end-of-life decision-making.

RESULTS

Of the 5112 people contacted, 1210 (23.7%) participated. Of these 5% were the parents of a premature infant and 26% knew parents with a premature infant. Most participants (77.8%) highlighted their strong preference for shared decision-making, and 64.6% said that if there was dissent then the parents should have the final word. Overall, our logistic regression model showed that regional differences were the most significant factors influencing decision-making.

CONCLUSION

The majority of the Swiss population clearly favoured shared decision-making. The context of sociocultural demographics, especially the linguistic region in which the decision-making took place, strongly influenced attitudes towards extreme prematurity and decision-making.

Categorizing neonatal deaths: a cross-cultural study in the United States, Canada, and The Netherlands

OBJECTIVE

To clarify the process of end-of-life decision-making in culturally different neonatal intensive care units (NICUs).

STUDY DESIGN

Review of medical files of newborns >22 weeks gestation who died in the delivery room (DR) or the NICU during 12 months in 4 NICUs (Chicago, Milwaukee, Montreal, and Groningen). We categorized deaths using a 2-by-2 matrix and determined whether mechanical ventilation was withdrawn/withheld and whether the child was dying despite ventilation or physiologically stable but extubated for neurological prognosis.

RESULTS

Most unstable patients in all units died in their parents' arms after mechanical ventilation was withdrawn. In Milwaukee, Montreal, and Groningen, 4% to 12% of patients died while receiving cardiopulmonary resuscitation. This proportion was higher in Chicago (31%). Elective extubation for quality-of-life reasons never occurred in Chicago and occurred in 19% to 35% of deaths in the other units. The proportion of DR deaths in Milwaukee, Montreal, and Groningen was 16% to 22%. No DR deaths occurred in Chicago.

CONCLUSIONS

Death in the NICU occurred differently within and between countries. Distinctive end-of-life decisions can be categorized separately by using a model with uniform definitions of withholding/withdrawing mechanical ventilation correlated with the patient's physiological condition. Cross-cultural comparison of end-of-life practice is feasible and important when comparing NICU outcomes.

Flaws in the assessment of the best interests of the newborn

We examined the literature on ethical decisions regarding neonates, to assess whether personal beliefs and prejudices influence end-of-life decisions taken by caregivers. Studies show that religion and familiarity with disability influence caregivers' decisions, whereas the influx of already being a parent, age, sex and professional experience is controverse. Caregivers' attitudes towards end-of-life decisions are also affected by personal concerns about litigation, prejudices and their view of disability. The concept of 'poor quality of life' is widely used as a reference in end-of-life decisions, but this can be interpreted differently, leaving room for a wide range of personal viewpoints. In most cases, parents' opinions are considered important and are sometimes the main determinant in decision making. However, it is unclear whether parents' decisions are based on their own wishes or on the best interests of the newborn.

CONCLUSION

In neonatal end-of-life decisions, patients may not receive cures based only on their best interests.

[Clinical bioethics: contributions to decision-making in neonatal intensive care units]

This article presents a reflection about decision-making in Neonatal Intensive Care Units based on the principle of distributive justice and considering the theoretical approaches of the Bioethics of Protection, formulated by Schramm and Kottow, and the Theory of Capabilities developed by Nussbaum and Sen. Within the concept of justice in the health area adopted in this study, we characterize the essential needs of the citizens that must be satisfied by the State. Then we discuss the question of who should be benefited in the neonatal intensive care units--and in which way--given the scarce public resources available, considering three groups of newborn that in general represent the demand for intensive care services in these units. We conclude that, the better the clinical information available, the more it is likely that a better and more qualified ethical choice can be taken. Further studies will be necessary for the construction of reasonable evidence, prognosis included, so that the involved families can be provided with even more adequate information and, most importantly, for allowing the parents of the child to take part in the clinical decisions.

Managing births at the limit of viability: the Danish experience

The issue of how to treat extremely premature infants has been debated several times in Denmark, and the option of withholding intensive care has received considerable support. Accordingly, a conservative, minimally invasive approach is used, with selective use of resuscitation in the delivery room, early nasal continuous positive airway pressure, and elective use of mechanical ventilation. Parents are actively involved, and the clinical process is gradual with the risks and benefits considered at each step. The risks include causing pain, suffering and loss of dignity in the short and long term for both the baby and the family. Few babies delivered before 25 completed weeks' gestation are considered to be alive at birth, and only a minority of those admitted for neonatal care do survive. Now, however, parents seem increasingly prepared to accept the suffering and uncertainty of intensive life support for the most immature babies when it becomes necessary.

Ethical aspects of cardiopulmonary resuscitation in premature neonates: where do we stand?

Advances in diagnosis, techniques, therapeutic interventions, organisation of perinatal care, and socio-economic factors have all contributed to the survival after resuscitation and intensive care of neonates with extremely low birth weight and gestational age. While morbidity during the first years of life in those infants does not increase, at school age multiple dysfunctions may become apparent. What are the limits of intensive care for the newborn? Is it right to use extreme technical and economic measures for neonates with a borderline chance of survival? What is justifiable for the neonate, the family, the society and how does legislation interfere in a decision process which involves starting, stopping or continuing intensive care? A short historical overview for the care of the newborn is given, followed by the outcome after resuscitation and treatment of the very low birth weight infant. Published management strategies and recommendations are discussed.

Ethical issues in neurodevelopmental disabilities

Ethics concerns itself with the search for the good and right option when one faces a choice about a potential action. In persons with significant neurodevelopmental disabilities, clinical ethics has concentrated on such pragmatic issues as justice (the means and measures by which resources are allocated) and informed consent. However, recent papers relevant to this topic have addressed more fundamental issues that underlie our entire approach to the field as a whole. These issues include the moral status of the disabled, the concept of "quality of life," our attitudes toward the disabled, the elements of competence and its evaluation, and models for decision making. This review highlights recent papers on these topics and assesses their impact on ongoing ethical debates.