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Saint Denny K, Lamore K, Nandrino JL, Rethore S, Prieur C, Mur S, Storme L. Parents' experiences of palliative care decision-making in neonatal intensive care units: An interpretative phenomenological analysis. Acta Paediatr 2024; 113:992-998. [PMID: 38229540 DOI: 10.1111/apa.17109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/18/2023] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
AIM This work explores the experiences and meaning attributed by parents who underwent the decision-making process of withholding and/or withdrawing life-sustaining treatment for their newborn. METHODS Audio-recorded face-to-face interviews were led and analysed using interpretative phenomenological analysis. Eight families (seven mothers and five fathers) whose baby underwent withholding and/or withdrawing of life-sustaining treatment in three neonatal intensive care units from two regions in France were included. RESULTS The findings reveal two paradoxes within the meaning-making process of parents: role ambivalence and choice ambiguity. We contend that these paradoxes, along with the need to mitigate uncertainty, form protective psychological mechanisms that enable parents to cope with the decision, maintain their parental identity and prevent decisional regret. CONCLUSION Role ambivalence and choice ambiguity should be considered when shared decision-making in the neonatal intensive care unit. Recognising and addressing these paradoxical beliefs is essential for informing parent support practices and professional recommendations, as well as add to ethical discussions pertaining to parental autonomy and physicians' rapport to uncertainty.
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Affiliation(s)
- Kelly Saint Denny
- Department of Neonatology, Lille University Hospital, Lille, France
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Kristopher Lamore
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Jean-Louis Nandrino
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Sabine Rethore
- Department of Neonatology, Valenciennes Hospital, Valenciennes, France
| | - Charlotte Prieur
- Regional Resource Team for Pediatric Palliative Care, Lille University Hospital, Lille, France
- Department of Neonatology, Lens Hospital, Lens, France
| | - Sebastien Mur
- Department of Neonatology, Lille University Hospital, Lille, France
| | - Laurent Storme
- Department of Neonatology, Lille University Hospital, Lille, France
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Geurtzen R, Wilkinson DJC. Incorporating parental values in complex paediatric and perinatal decisions. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:225-235. [PMID: 38219752 DOI: 10.1016/s2352-4642(23)00267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 01/16/2024]
Abstract
Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.
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Affiliation(s)
- Rosa Geurtzen
- Amalia Children's Hospital, Radboud Institute of Healthcare Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Dominic J C Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; Oxford Newborn Care Unit, John Radcliffe Hospital, Oxford University, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore
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Uveges MK, Hamilton JB, Pados BF, Thayer WM, Hinds PS, Nolan MT. Being a "Good Parent" to a NICU Infant With a Major Congenital Anomaly. Adv Neonatal Care 2024; 24:14-26. [PMID: 38232327 DOI: 10.1097/anc.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND In the United States, up to one-third of infants with a congenital anomaly require neonatal intensive care unit (NICU) hospitalization. Parents of these infants may have different decision-making priorities, which may be influenced by the timing of the infant's diagnosis. PURPOSE (1) To compare the ranked importance of decision-making beliefs for parents of infants who received a prenatal versus postnatal congenital diagnosis and (2) explore how parents describe their decision-making beliefs. METHODS A cross-sectional, sequential mixed-methods pilot design was applied to collect quantitative data using the Good Parent Ranking Exercise and further explore parents' decision-making beliefs through qualitative interviews. Maximum difference scaling/hierarchical Bayes estimation and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS Forty mothers completed the Good Parent Ranking Exercise and 20 mothers completed qualitative interviews. Four of the top 5 ranked parenting beliefs were shared by mothers in the prenatal and postnatal groups. Mothers in the postnatal group ranked "focusing on my child's quality of life" higher. Qualitative interviews revealed that previously identified decision-making beliefs were consistent in this NICU parent population, with 1 additional belief identified. Mixed-methods analysis revealed high concordance between the prenatal and postnatal groups. IMPLICATIONS FOR PRACTICE NICU nurses need to know that decision-making beliefs for parents who receive a prenatal versus postnatal congenital diagnosis, while largely similar, may have differences. IMPLICATIONS FOR RESEARCH Future research should explore decision-making beliefs in demographically diverse parent groups (ie, fathers, partnered vs nonpartnered couples) and effective strategies for promoting NICU parents' decision-making beliefs.
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Affiliation(s)
- Melissa K Uveges
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Uveges); Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia (Dr Hamilton); Infant Feeding Care, Wellesley Hills, Massachusetts (Dr Pados); School of Nursing, Johns Hopkins University, Baltimore, Maryland (Mr Thayer); Children's National Health System, Washington, District of Columbia (Dr Hinds); Department of Pediatrics, The George Washington University, Washington, District of Columbia (Dr Hinds); and Conway School of Nursing, The Catholic University of America, Washington, District of Columbia (Dr Nolan)
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Boize P, Garner Y, Neaud E, Borrhomee S. Parents' participation in collegial meetings to discuss withholding or withdrawing treatment for their newborn: Working to improve information-sharing. Arch Pediatr 2024; 31:95-99. [PMID: 38262860 DOI: 10.1016/j.arcped.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/23/2023] [Accepted: 10/21/2023] [Indexed: 01/25/2024]
Abstract
AIM The role of parents in decision-making concerning their child's end-of-life care is not clearly defined. Their participation is encouraged by ethical reflection, in particular by the CCNE (French National Ethics Advisory Committee), but laws are limited to imposing a duty to provide information to doctors. Decisions are taken at the end of a collegial meeting (CM) intended to better inform the child's referring physician (RP) who is in charge of the final decision following the French law. The aim of this study was to describe the support provided to bereaved families after they had been invited to attend a CM concerning their child, if they so wished. Additional aims were to determine the differences resulting from their acceptance or their refusal to participate as regards their perception of their child's history and as regards their grieving process. MATERIAL AND METHOD We conducted a retrospective study of all CMs held between November 2016 and May 2021, drawing a distinction between proposals made or not made to parents and their decision to accept or refuse. RESULTS In total, 49 CMs concerning 46 children were held during the study period. The proposal was not made to the parents in three cases; the parents chose to be present in 28 cases. The psychological follow-up (15/28 parents attending, 10/16 parents absent) illustrated that their presence enabled them to reflect on their child's death after having listened to and understood the reasons why it happened. They did not dispute the team's approach or decisions taken. CONCLUSION It is possible to include parents in CMs if they so wish. It would appear more beneficial than merely providing them with the information required. Studies must be carried out to ensure potential long-term benefit.
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Affiliation(s)
- Philippe Boize
- Neonatal Intensive Care Unit, Hôpital NOVO, 6 avenue Île de France 95300 Pontoise, France.
| | - Yaëlle Garner
- Clinical psychologist, reception and care unit for deaf patients, mother-child unit, CH ANNECY-GENEVOIS, 1 avenue de l'hôpital 74370 Eragny Metz-Tessy, France
| | - Enora Neaud
- Neonatal Intensive Care Unit, Hôpital NOVO, 6 avenue Île de France 95300 Pontoise, France
| | - Suzanne Borrhomee
- Neonatal Intensive Care Unit, Hôpital NOVO, 6 avenue Île de France 95300 Pontoise, France
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Kaempf JW, Moore GP. Extremely premature birth bioethical decision-making supported by dialogics and pragmatism. BMC Med Ethics 2023; 24:9. [PMID: 36774482 PMCID: PMC9922460 DOI: 10.1186/s12910-023-00887-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/26/2023] [Indexed: 02/13/2023] Open
Abstract
Moral values in healthcare range widely between interest groups and are principally subjective. Disagreements diminish dialogue and marginalize alternative viewpoints. Extremely premature births exemplify how discord becomes unproductive when conflicts of interest, cultural misunderstanding, constrained evidence review, and peculiar hierarchy compete without the balance of objective standards of reason. Accepting uncertainty, distributing risk fairly, and humbly acknowledging therapeutic limits are honorable traits, not relativism, and especially crucial in our world of constrained resources. We think dialogics engender a mutual understanding that: i) transitions beliefs beyond bias, ii) moves conflict toward pragmatism (i.e., the truth of any position is verified by subsequent experience), and iii) recognizes value pluralism (i.e., human values are irreducibly diverse, conflicting, and ultimately incommensurable). This article provides a clear and useful Point-Counterpoint of extreme prematurity controversies, an objective neurodevelopmental outcomes table, and a dialogics exemplar to cultivate shared empathetic comprehension, not to create sides from which to choose. It is our goal to bridge the understanding gap within and between physicians and bioethicists. Dialogics accept competing relational interests as human nature, recognizing that ultimate solutions satisfactory to all are illusory, because every choice has downside. Nurturing a collective consciousness via dialogics and pragmatism is congenial to integrating objective evidence review and subjective moral-cultural sentiments, and is that rarest of ethical constructs, a means and an end.
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Affiliation(s)
- Joseph W. Kaempf
- grid.415337.70000 0004 0456 8744Providence St. Vincent Medical Center, Women and Children’s Services, 9205 SW Barnes Road, Portland, OR 97225 USA
| | - Gregory P. Moore
- grid.412687.e0000 0000 9606 5108Department of Obstetrics, Gynecology, and Newborn Care, The Ottawa Hospital – General Campus, 501 Smyth Road, Box 806, Ottawa, ON K1H 8L6 Canada
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"We Absolutely Had the Impression That It Was Our Decision"-A Qualitative Study with Parents of Critically Ill Infants Who Participated in End-of-Life Decision Making. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010046. [PMID: 36670597 PMCID: PMC9856896 DOI: 10.3390/children10010046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/08/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Guidelines recommend shared decision making (SDM) between neonatologists and parents when a decision has to be made about the continuation of life-sustaining treatment (LST). In a previous study, we found that neonatologists and parents at a German Level-III Neonatal Intensive Care Unit performed SDM to a variable but overall small extent. However, we do not know whether parents in Germany prefer an extent of more or sharing. METHODS We performed a qualitative interview study with parents who participated in our first study. We analyzed the semi-structured interviews with qualitative content analysis according to Kuckartz. RESULTS The participation in medical decision making (MDM) varied across cases. Overall, neonatologists and parents conducted SDM in most cases only to a small extent. All parents appreciated their experience independent of how much they were involved in MDM. The parents who experienced a small extent of sharing were glad that they were protected by neonatologists from having to decide, shielding them from a conflict of interest. The parents who experienced a large extent of sharing especially valued that they were able to fulfil their parental duties even if that meant partaking in a decision to forgo LST. DISCUSSION Other studies have also found a variety of possibilities for parents to partake in end-of-life decision making (EOL-DM). Our results suggest that parents do not have a uniform preference for one specific decision-making approach, but rather different parents appreciate their individual experience regardless of the model for DM. CONCLUSION SDM is apparently not a one-size-fits-all approach. Instead, neonatologists and parents have to adapt the decision-making process to the parents' individual needs and preferences for autonomy and protection. Therefore, SDM should not be prescribed as a uniform standard in medico-ethical guidelines, but rather as a flexible guidance for DM for critically ill patients in neonatology.
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Alexander D, Quirke MB, Berry J, Eustace-Cook J, Leroy P, Masterson K, Healy M, Brenner M. Initiating technology dependence to sustain a child's life: a systematic review of reasons. JOURNAL OF MEDICAL ETHICS 2022; 48:1068-1075. [PMID: 34282042 PMCID: PMC9726963 DOI: 10.1136/medethics-2020-107099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/13/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Decision-making in initiating life-sustaining health technology is complex and often conducted at time-critical junctures in clinical care. Many of these decisions have profound, often irreversible, consequences for the child and family, as well as potential benefits for functioning, health and quality of life. Yet little is known about what influences these decisions. A systematic review of reasoning identified the range of reasons clinicians give in the literature when initiating technology dependence in a child, and as a result helps determine the range of influences on these decisions. METHODS Medline, EMBASE, CINAHL, PsychINFO, Web of Science, ASSIA and Global Health Library databases were searched to identify all reasons given for the initiation of technology dependence in a child. Each reason was coded as a broad and narrow reason type, and whether it supported or rejected technology dependence. RESULTS 53 relevant papers were retained from 1604 publications, containing 116 broad reason types and 383 narrow reason types. These were grouped into broad thematic categories: clinical factors, quality of life factors, moral imperatives and duty and personal values; and whether they supported, rejected or described the initiation of technology dependence. The majority were conceptual or discussion papers, less than a third were empirical studies. Most discussed neonates and focused on end-of-life care. CONCLUSIONS There is a lack of empirical studies on this topic, scant knowledge about the experience of older children and their families in particular; and little written on choices made outside 'end-of-life' care. This review provides a sound basis for empirical research into the important influences on a child's potential technology dependence.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Mary Brigid Quirke
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Jay Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | | | - Piet Leroy
- Pediatric Intensive Care Unit & Pediatric Procedural Sedation Unit, Maastricht UMC+, Maastricht, The Netherlands
| | - Kate Masterson
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Martina Healy
- Paediatric Intensive Care, Our Lady's Hospital Crumlin, Crumlin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Syltern J, Ursin L, Solberg B, Støen R. Postponed Withholding: Balanced Decision-Making at the Margins of Viability. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:15-26. [PMID: 33998962 DOI: 10.1080/15265161.2021.1925777] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental "instinct of saving" and "withdrawal resistance" involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled "postponed withholding." In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.
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Affiliation(s)
- Janicke Syltern
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
| | - Lars Ursin
- The Norwegian University of Science and Technology
| | | | - Ragnhild Støen
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
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How doctors manage conflicts with families of critically ill patients during conversations about end-of-life decisions in neonatal, pediatric, and adult intensive care. Intensive Care Med 2022; 48:910-922. [PMID: 35773499 PMCID: PMC9273549 DOI: 10.1007/s00134-022-06771-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/31/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Intensive care is a stressful environment in which team-family conflicts commonly occur. If managed poorly, conflicts can have negative effects on all parties involved. Previous studies mainly investigated these conflicts and their management in a retrospective way. This study aimed to prospectively explore team-family conflicts, including its main topics, complicating factors, doctors' conflict management strategies and the effect of these strategies. METHODS Conversations between doctors in the neonatal, pediatric, and adult intensive care unit of a large university-based hospital and families of critically ill patients were audio-recorded from the moment doubts arose whether treatment was still in patients' best interest. Transcripts were coded and analyzed using a qualitative deductive approach. RESULTS Team-family conflicts occurred in 29 out of 101 conversations (29%) concerning 20 out of 36 patients (56%). Conflicts mostly concerned more than one topic. We identified four complicating context- and/or family-related factors: diagnostic and prognostic uncertainty, families' strong negative emotions, limited health literacy, and burden of responsibility. Doctors used four overarching strategies to manage conflicts, namely content-oriented, process-oriented, moral and empathic strategies. Doctors mostly used content-oriented strategies, independent of the intensive care setting. They were able to effectively address conflicts in most conversations. Yet, if they did not acknowledge families' cues indicating the existence of one or more complicating factors, conflicts were likely to linger on during the conversation. CONCLUSION This study underlines the importance of doctors tailoring their communication strategies to the concrete conflict topic(s) and to the context- and family-related factors which complicate a specific conflict.
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Ethical Issues around Death and Withdrawal of Life Support in Neonatal Intensive Care. Indian J Pediatr 2022; 89:274-278. [PMID: 34145563 PMCID: PMC8857086 DOI: 10.1007/s12098-021-03810-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/10/2021] [Indexed: 10/31/2022]
Abstract
Amongst all the traumatic experiences in a human life, death of child is considered the most painful, and has profound and lasting impact on the life of parents. The experience is even more complex when the death occurs within a neonatal intensive care unit, particularly in situations where there have been conflicts associated with decisions regarding the redirection of life-sustaining treatments. In the absence of national guidelines and legal backing, clinicians are faced with a dilemma of whether to prolong life-sustaining therapy even in the most brain-injured infants or allow a discharge against medical advice. Societal customs, vagaries, and lack of bereavement support further complicate the experience for parents belonging to lower socio-economic classes. The present review explores the ethical dilemmas around neonatal death faced by professionals in India, and suggests some ways forward.
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Personalized communication with parents of children born at less than 25 weeks: Moving from doctor-driven to parent-personalized discussions. Semin Perinatol 2022; 46:151551. [PMID: 34893335 DOI: 10.1016/j.semperi.2021.151551] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Communication with parents is an essential component of neonatal care. For extremely preterm infants born at less than 25 weeks, this process is complicated by the substantial risk of mortality or major morbidity. For some babies with specific prognostic factors, the majority die. Although many of these deaths occur after admission to the intensive care unit, position statements have focused on communication during the prenatal consultation. This review takes a more comprehensive approach and covers personalized and parent-centered communication in the clinical setting during three distinct yet inter-related phases: the antenatal consultation, the neonatal intensive care hospitalization, and the dying process (when this happens). We advocate that a 'one-size-fits-all' communication model focused on standardizing information does not lead to partnerships. It is possible to standardize personalized approaches that recognize and adapt to parental heterogeneity. This can help clinicians and parents build effective partnerships of trust and affective support to engage in personalized decision-making. These practices begin with self-reflection on the part of the clinician and continue with practical frameworks and stepwise approaches supporting personalization and parent-centered communication.
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Kruithof K, Olsman E, Nieuwenhuijse A, Willems D. Parents' views on medical decisions related to life and death for their ageing child with profound intellectual and multiple disabilities: A qualitative study. RESEARCH IN DEVELOPMENTAL DISABILITIES 2022; 121:104154. [PMID: 34954670 DOI: 10.1016/j.ridd.2021.104154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND The increased life expectancy of persons with profound intellectual and multiple disabilities (PIMD) raises questions regarding the medical decisions related to life and death, made on their behalf during their later lives. However, little is known about how parents make such decisions for their ageing child. AIM Explore parents' views on medical decisions related to life and death for their ageing child with PIMD. METHODS We interviewed 27 parents of persons with PIMD (≥ 15 years) and analyzed the data thematically. RESULTS Parents who were convinced that their ageing child's quality of life (QoL) was good, stated that their child "deserved the same treatment as any other person". Others rejected life-prolonging treatments for their child because they believed such treatment would diminish their child's QoL. Some of the parents who thought their child's QoL was poor, mentioned that withholding treatment is only an option in a crisis situation and contemplated other options to shorten their child's life. CONCLUSIONS Parents feel equipped to take on a central role in medical decisions related to life and death for their ageing child with PIMD, and desire understanding from medical professionals for their views on their child's interests, which sometimes includes physician-assisted death.
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Affiliation(s)
- Kasper Kruithof
- Department of Ethics, Law & Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Erik Olsman
- Department of Mediating Good Life, Section of Spiritual Care & Chaplaincy Studies, Protestant Theological University, Groningen, the Netherlands
| | - Appolonia Nieuwenhuijse
- Department of Ethics, Law & Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Dick Willems
- Department of Ethics, Law & Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Alexander D, Eustace-Cook J, Brenner M. Approaches to the initiation of life-sustaining technology in children: A scoping review of changes over time. J Child Health Care 2021; 25:509-522. [PMID: 32966106 DOI: 10.1177/1367493520961884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is understood about the dynamic circumstances within which the initiation of technology dependence takes place in children. The aim of this scoping review was to identify the influences on the initiation of technology dependence and the issues that require further exploration and consideration. Scientific literature that directly or indirectly discussed the initiation of technology dependence in children was identified. A three-stage screening process of title and abstract scrutiny, full-text scanning and in-depth full-text reading resulted in 63 relevant articles from 1133 initially reviewed. These were then subjected to descriptive and thematic analysis. Articles ranged from the 1970s to the present, reflecting the evolution of ethical debates around the approaches to clinical practice and changes in cultural and societal attitudes. Three themes emerged: how technology alters the meaning of futile care, dissonance in the perspectives of decision makers and increasing support for joint decision-making. Only articles in English and predominantly from the clinician's rather than the patient's perspective were included. Societal and cultural factors as well as the structural, financial and cultural environment influence the initiation of technology dependence in children. However, to what extent these overt and implicit influences guide decision-makers in this field remains largely unknown.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, 8809Trinity College Dublin, Ireland
| | | | - Maria Brenner
- School of Nursing and Midwifery, 8809Trinity College Dublin, Ireland
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14
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Parsons E, Darlington AS. Parents' perspectives on conflict in paediatric healthcare: a scoping review. Arch Dis Child 2021; 106:981-986. [PMID: 33593741 DOI: 10.1136/archdischild-2020-320975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/01/2021] [Accepted: 01/30/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Conflict in paediatric healthcare is becoming increasingly prevalent, in particular relation to paediatric end of life. This is damaging to patients, families, professionals and healthcare resources. Current research has begun to explore perspectives of healthcare professionals (HCPs), but the parental views on conflict are lacking. OBJECTIVES This scoping review explores parental views on conflict during a child's end of life. In addition, parental views are mapped onto HCPs' views. METHODS A search was completed of the databases CINAHL, PubMed, Web of Science, Embase and Medline between 1997 and 2019, focused on parents of children with involvement with palliative or end-of-life care referring to conflict or disagreements. RESULTS The review found 10 papers that included parental views on conflict. Data on conflict were categorised into the following seven themes: communication breakdown, trust, suffering, different understanding of 'best interest', disagreements over treatment, spirituality and types of decision-making. In particular, parental expertise, perspectives on suffering and ways of making decisions were significant themes. A subset of themes mirror those of HCPs. However, parents identified views of conflict unique to their perspective. CONCLUSIONS Parents identified important themes, in particular their perspective of what constitutes suffering and 'best interest'. In addition, parents highlight the importance of being recognised as an expert.
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Affiliation(s)
- Emily Parsons
- Savannah Neurology, Evelina London Children's Hospital, London, UK .,Health Sciences, University of Southampton, Southampton, UK
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Elternzentrierte ethische Entscheidungsfindung für Frühgeborene im Grenzbereich der Lebensfähigkeit – Reflexion über die Bedeutung probabilistischer Prognosen als Entscheidungsgrundlage. Ethik Med 2021. [DOI: 10.1007/s00481-021-00653-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungFrühgeborene im Grenzbereich der Lebensfähigkeit befinden sich in einer prognostischen Grauzone. Das bedeutet, dass deren Prognose zwar schlecht, aber nicht hoffnungslos ist, woraus folgt, dass nach Geburt lebenserhaltende Behandlungen nicht obligatorisch sind. Die Entscheidung für oder gegen lebenserhaltende Maßnahmen ist wertbeladen und für alle Beteiligten enorm herausfordernd. Sie sollte eine zwischen Eltern und Ärzt*innen geteilte Entscheidung sein, wobei sie unbedingt mit den Präferenzen der Eltern abgestimmt sein sollte. Bei der pränatalen Beratung der Eltern legen die behandelnden Ärzt*innen üblicherweise numerische Schätzungen der Prognose vor und nehmen in der Regel an, dass die Eltern ihre Behandlungspräferenzen davon ableiten. Inwieweit probabilistische Daten die Entscheidungen der Eltern in prognostischen Grauzonen tatsächlich beeinflussen, ist noch unzureichend untersucht. In der hier vorliegenden Arbeit wird eine Studie reflektiert, in welcher die Hypothese geprüft wurde, dass numerisch bessere oder schlechtere kindliche Prognosen die Präferenzen werdender Mütter für lebenserhaltende Maßnahmen nicht beeinflussen. In dieser Studie zeigte sich, dass die elterlichen Behandlungspräferenzen eher von individuellen Einstellungen und Werten als von Überlegungen zu numerischen Ergebnisschätzungen herzurühren scheinen. Unser Verständnis, welche Informationen werdende Eltern, die mit einer extremen Frühgeburt konfrontiert sind, wünschen und brauchen, ist noch immer unvollständig. Bedeutende medizinische Entscheidungen werden keineswegs nur rational und prognoseorientiert gefällt. In der vorliegenden Arbeit wird diskutiert, welchen Einfluss der Prozess der Entscheidungsfindung auf das Beratungsergebnis haben kann und welche Implikationen sich aus den bisher vorliegenden Studienergebnissen ergeben – klinisch-praktisch, ethisch und wissenschaftlich.
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Tornali C, Pratico' A, Vecchio F, Polizzi A, Ruggieri M, Vecchio I. Treatment of lumbar and intrathoracic meningocele: bioethical implications. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021211. [PMID: 34212901 PMCID: PMC8343732 DOI: 10.23750/abm.v92i3.11600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 11/23/2022]
Abstract
Myelomeningocele is a congenital malformation caused by a developmental defect of the spinal cord structures. The exactcause is unknown, but different factors have been involved includingradiation, malnutrition, drugs. Myelomeningocele can develop at any point in the spine, but the lumbosacral region is affected in over 75% of cases. Chest X-raysand computed tomography study are mandatory to reveal tracheal malformations or associatedanomaliesof the ribs. Treatment of myelomeningocele must be multidisciplinary and involve at the same time neurologists, radiologists, neurosurgeons, thoracic surgeons, bioethical experts and take care of the childand also of the family. Some experiences concern the possibility of a in-utero correction of myelomeningocele, in order to avoiding serious and progressive damages to the nervoussystem. Given the improvement of myelomeningocele management, the quality of life is nowadays more acceptable than in the past; however, some severe forms of myelomeningocele cannot still be corrected: in this cases, a "non-interventional" approach may require a form of passive euthanasia that should be discussed and approved with and by parents and Any dissent of the parents must be respected and considered reasonable. The choice of a "non-intervention", which should be guaranteed to all the people capable of self-determination, is not however so immediate and direct in the case of the minor: the dissent expressed on his behalf by the parents or legal representative may be ethically difficult to be accepted.In this case, the best interest of the child must prevail as the goal of any therapeutic choice.
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Affiliation(s)
- Cristina Tornali
- Department of Clinical and Experimental Medicine, University of Catania, Italy.
| | | | - Flavio Vecchio
- Department of Clinical and Experimental Medicine, University of Catania, Italy.
| | - Agata Polizzi
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Italy.
| | - Martino Ruggieri
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Italy.
| | - Ignazio Vecchio
- Department of Clinical and Experimental Medicine, University of Catania, Italy.
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Marlow N, Shaw C, Connabeer K, Aladangady N, Gallagher K, Drew P. End-of-life decisions in neonatal care: a conversation analytical study. Arch Dis Child Fetal Neonatal Ed 2021; 106:184-188. [PMID: 32943530 DOI: 10.1136/archdischild-2020-319544] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/10/2020] [Accepted: 08/16/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To understand the dynamics of conversations between neonatologists and parents concerning limitation of life-sustaining treatments. DESIGN Formal conversations were recorded, transcribed and analysed according to the conventions and methods of conversation analysis. SETTING Two tertiary neonatal intensive care units. PARTICIPANTS Consultant neonatal specialists and families. MAIN OUTCOME MEASURES We used conversation analysis and developed an inductive coding scheme for conversations based on the introduction of limiting life-sustaining treatments and on the parental responses. RESULTS From recordings with 51 families, we identified 27 conversations about limiting life support with 20 families and 14 doctors. Neonatologists adopted three broad strategies: (1) 'recommendations', in which one course of action is presented and explicitly endorsed as the best course of action, (2) a 'single-option choice' format (conditional: referring to a choice that should be made, but without specifying or listing options), and (3) options (where the doctor explicitly refers to or lists options). Our conversation analysis-informed coding scheme was based on the opportunities available for parents to ask questions and assert their preference with minimal interactional constraint or pressure for a certain type of response. Response scores for parents presented with conditional formats (n=15, median 5.0) and options (n=10, median 5.0) were significantly higher than for those parents presented with 'recommendations' (n=16, median 3.75; p=0.002) and parents were more likely to express preferences (p=0.005). CONCLUSION Encouraging different approaches to conversations about limitation of life-supporting treatment may lead to better parent engagement and less misalignment between the conversational partners.
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Affiliation(s)
- Neil Marlow
- Institute for Women's Health, UCL, London, UK
| | - Chloe Shaw
- Institute for Women's Health, UCL, London, UK
| | - Kat Connabeer
- Social Science, Birmingham City University, Birmingham, West Midlands, UK
| | | | | | - Paul Drew
- Department of Language and Linguistic Science, University of York, York, North Yorkshire, UK
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Bertaud S, Lloyd DFA, Sharland G, Razavi R, Bluebond-Langner M. The impact of prenatal counselling on mothers of surviving children with hypoplastic left heart syndrome: A qualitative interview study. Health Expect 2020; 23:1224-1230. [PMID: 32671929 PMCID: PMC7696135 DOI: 10.1111/hex.13103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 06/21/2020] [Accepted: 06/25/2020] [Indexed: 11/26/2022] Open
Abstract
Objective To explore the role of antenatal counselling in how parents make treatment decisions following an antenatal diagnosis of Hypoplastic Left Heart Syndrome (HLHS). Background Antenatal counselling is a critical part of patient management following a diagnosis of fetal congenital heart disease; however, there is a very limited evidence base examining how parents actually experience antenatal counselling and make decisions in this context. Methods Semi‐structured interviews were conducted with women who had received an antenatal diagnosis of HLHS. Interviews were digitally recorded, anonymised and transcribed verbatim. A thematic content analysis was performed using a constant comparative approach. Results Eight mothers of surviving children with HLHS were interviewed. Eight key themes emerged including new perspectives on how women receive antenatal counselling and how it affects their decision making. Three themes in particular are new to the literature: (a) Mothers of children with HLHS reported feelings of intense guilt that arose in the antenatal period around potentially causing the condition in their child. (b) For this group of women, recollections of perceived pessimism during antenatal counselling had a lasting impact. (c) Despite support from partners or extended family, women nevertheless experienced a strong sense that antenatal decision making was largely a ‘maternal’ responsibility. Conclusions When recounting their experiences of antenatal counselling, mothers of surviving children with HLHS offer new perspectives that can guide fetal cardiologists in how best to support their individual patients. Further research is needed to comprehensively understand the experience of prospective parents counselled for severe forms of fetal congenital heart disease.
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Affiliation(s)
- Sophie Bertaud
- Department of Imaging Sciences and Biomedical Engineering, King's College London, Guy's and St Thomas' Hospital, London, UK.,Louis Dundas Centre for Children's Palliative Care, UCL Great Ormond Street Institute of Child Health, London, UK
| | - David F A Lloyd
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gurleen Sharland
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Reza Razavi
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Myra Bluebond-Langner
- Louis Dundas Centre for Children's Palliative Care, UCL Great Ormond Street Institute of Child Health, London, UK
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Abstract
The ethical dilemmas and predominant frameworks surrounding decision making for critically ill newborns have evolved substantially over the last 40 years. A shared decision-making approach is now favored, involving an exchange of information between parents and clinicians that emphasizes parental values and preferences, resulting in a personalized approach to decision making. In this review, we summarize the history of clinical decision making with a focus on the NICU, highlight different models of decision making, describe the advantages and current limitations of shared decision making, and discuss the ongoing and future challenges of decision making in the NICU amidst medical innovations and emerging technologies.
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Affiliation(s)
- Anne Sullivan
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Christy Cummings
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
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Brick C, Kahane G, Wilkinson D, Caviola L, Savulescu J. Worth living or worth dying? The views of the general public about allowing disabled children to die. JOURNAL OF MEDICAL ETHICS 2020; 46:7-15. [PMID: 31615879 PMCID: PMC6984061 DOI: 10.1136/medethics-2019-105639] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/15/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Decisions about withdrawal of life support for infants have given rise to legal battles between physicians and parents creating intense media attention. It is unclear how we should evaluate when life is no longer worth living for an infant. Public attitudes towards treatment withdrawal and the role of parents in situations of disagreement have not previously been assessed. METHODS An online survey was conducted with a sample of the UK public to assess public views about the benefit of life in hypothetical cases similar to real cases heard by the UK courts (eg, Charlie Gard, Alfie Evans). We then evaluated these public views in comparison with existing ethical frameworks for decision-making. RESULTS One hundred and thirty participants completed the survey. The majority (94%) agreed that an infant's life may have no benefit when well-being falls below a critical level. Decisions to withdraw treatment were positively associated with the importance of use of medical resources, the infant's ability to have emotional relationships, and mental abilities. Up to 50% of participants in each case believed it was permissible to either continue or withdraw treatment. CONCLUSION Despite the controversy, our findings indicate that in the most severe cases, most people agree that life is not worth living for a profoundly disabled infant. Our survey found wide acceptance of at least the permissibility of withdrawal of treatment across a range of cases, though also a reluctance to overrule parents' decisions. These findings may be useful when constructing guidelines for clinical practice.
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Affiliation(s)
- Claudia Brick
- Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Guy Kahane
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
- John Radcliffe Hospital, Oxford, UK
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Lucius Caviola
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
- Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
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Abstract
BACKGROUND Neonatologists, legal experts and ethicists extensively discuss the ethical challenges of decision-making when a child is born at the limit of viability. The voices of parents are less heard in this discussion. In Norway, parents are actively shielded from the burden of decision-making responsibility. In an era of increasing patient autonomy, is this position still defendable? RESEARCH QUESTION In this article, we discuss the role of parents in neonatal decision-making, based on the following research question: Should parents decide whether to provide lifesaving treatment when their child is born at the limit of viability? RESEARCH DESIGN We conducted eight interviews with 12 parents, 4 individuals and 4 couples, all having experienced prenatal counselling at the limit of viability. The interviews took place at different university locations in Norway in the years 2014-2018. ETHICAL CONSIDERATIONS All study participants gave their written informed consent. The Regional Committee for Medical Research Ethics approved the study. FINDINGS We identified six main themes in parents' responses to the research question. Parents (1) experienced an emotional turmoil confronted with birth at the border of viability, (2) emphasized the importance of being involved in decision-making, (3) described and reflected on the need to balance the parental instinct of saving, (4) were concerned about the dilemmas involved in protecting the family, (5) were worried about the burden of overwhelming responsibility and (6) called for guideline relief. CONCLUSION The perceived parental instinct of saving the life of their child makes it hard for parents to step away from a call for 'everything to be done'. Involvement of an interprofessional periviability team drawing on the experiences and viewpoints of nurses and neonatologists in decision-making is needed to protect both infants and parents against undue parental push for treatment and enable parents to make good decisions regarding their child.
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Affiliation(s)
- Lars Ursin
- Norwegian University of Science and Technology, Norway
| | - Janicke Syltern
- St. Olav's University Hospital, Norway; Norwegian University of Science and Technology, Norway
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Ursin L, Syltern J. In the Best Interest of the. . .Parents: Norwegian Health Personnel on the Proper Role of Parents in Neonatal Decision-making. Pediatrics 2018; 142:S567-S573. [PMID: 30171143 DOI: 10.1542/peds.2018-0478h] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The role of parents in life-and-death decision-making for infants born at the border of viability is challenging. Some argue that parents should have the final say in decisions about life-sustaining treatment. Others disagree. In this article, we report views from health care personnel (HCP) on the appropriate parental role. METHODS Focus group interviews with 5 different groups of HCP (neonatal nurses, midwifes, obstetricians, mother-fetal specialists, and neonatologists) dealing with life-and-death decisions throughout pregnancy and birth were performed at the Norwegian University of Science and Technology and at St Olav's Hospital in Trondheim, Norway in 2014-2017. Interviews were taped and transcribed. Inductive analysis was performed for each group discussion for emergent ethical themes. A summary of the transcribed discussion was sent to the relevant focus group participants for comments. RESULTS Our participants felt strongly that doctors, not parents, should have the final say. They did not think parents should have to live with the burden of the decision. The possible disagreement between parents, lack of necessary knowledge, experience, time, and emotional stability all point toward the neonatologist as the optimal decision-maker, within a model of "Patient Preference-Satisfaction Paternalism." CONCLUSIONS The general attitude of our groups was that parents should have a say and be included in a thorough information and decision-making process. The doctor, or a team of HCP, however, should make the final decision, being in the best position both epistemologically and normatively to promote the best interest of both parents and the child.
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Affiliation(s)
- Lars Ursin
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway; and
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Syltern J, Markestad T, Saugstad OD, Støen R. NICU Dialects: Understanding Norwegian Practice Variation. Pediatrics 2018; 142:S545-S551. [PMID: 30171140 DOI: 10.1542/peds.2018-0478e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
In Norway, a national consensus-based guideline used to address thresholds for offering life support at extreme preterm birth was issued in 1998. Since then, therapeutic advances may have changed attitudes and expectations to treatment, both within the medical community and the public, and there are concerns that systematic variations in treatment practices may exist. With this article, we describe current practices and relate them to other ethical and legal comparable areas in health care. We conclude that a revision of the 1998 guideline is warranted to obtain a common understanding of prognoses and appropriate decision processes at the limit of viability.
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Affiliation(s)
- Janicke Syltern
- Department of Neonatology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway;
| | - Trond Markestad
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.,Innlandet Hospital Trust, Brumunddal, Norway
| | - Ola Didrik Saugstad
- Department of Pediatric Research, Oslo University Hospital, University of Oslo, Oslo, Norway; and
| | - Ragnhild Støen
- Department of Neonatology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Amorim M, Alves E, Barros H, Silva S. [Parental roles and needs in neonatal intensive care: a review of Portuguese guidelines]. CIENCIA & SAUDE COLETIVA 2018; 21:2583-94. [PMID: 27557031 DOI: 10.1590/1413-81232015218.07292015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 07/04/2015] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Mariana Amorim
- ISPUP-EPIUnit,, Universidade do Porto. R. das Taipas 135. 4050-600 Porto Portugal.
| | - Elisabete Alves
- ISPUP-EPIUnit,, Universidade do Porto. R. das Taipas 135. 4050-600 Porto Portugal.
| | - Henrique Barros
- ISPUP-EPIUnit,, Universidade do Porto. R. das Taipas 135. 4050-600 Porto Portugal.
| | - Susana Silva
- ISPUP-EPIUnit,, Universidade do Porto. R. das Taipas 135. 4050-600 Porto Portugal.
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Abstract
OBJECTIVES Typically pediatric end-of-life decision-making studies have examined the decision-making process, factors, and doctors' and parents' roles. Less attention has focussed on what happens after an end-of-life decision is made; that is, decision enactment and its outcome. This study explored the views and experiences of bereaved parents in end-of-life decision-making for their child. Findings reported relate to parents' experiences of acting on their decision. It is argued that this is one significant stage of the decision-making process. METHODS A qualitative methodology was used. Semi-structured interviews were conducted with bereaved parents, who had discussed end-of-life decisions for their child who had a life-limiting condition and who had died. Data were thematically analysed. RESULTS Twenty-five bereaved parents participated. Findings indicate that, despite differences in context, including the child's condition and age, end-of-life decision-making did not end when an end-of-life decision was made. Enacting the decision was the next stage in a process. Time intervals between stages and enactment pathways varied, but the enactment was always distinguishable as a separate stage. Decision enactment involved making further decisions - parents needed to discern the appropriate time to implement their decision to withdraw or withhold life-sustaining medical treatment. Unexpected events, including other people's actions, impacted on parents enacting their decision in the way they had planned. Several parents had to re-implement decisions when their child recovered from serious health issues without medical intervention. Significance of results A novel, critical finding was that parents experienced end-of-life decision-making as a sequence of interconnected stages, the final stage being enactment. The enactment stage involved further decision-making. End-of-life decision-making is better understood as a process rather than a discrete once-off event. The enactment stage has particular emotional and practical implications for parents. Greater understanding of this stage can improve clinician's support for parents as they care for their child.
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Lemyre B, Moore G. Les conseils et la prise en charge en prévision d’une naissance extrêmement prématurée. Paediatr Child Health 2017. [DOI: 10.1093/pch/pxx059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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End-of-Life Decision Making for Parents of Extremely Preterm Infants. J Obstet Gynecol Neonatal Nurs 2017; 46:727-736. [DOI: 10.1016/j.jogn.2017.06.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 11/23/2022] Open
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Lemyre B, Moore G. Counselling and management for anticipated extremely preterm birth. Paediatr Child Health 2017; 22:334-341. [PMID: 29485138 DOI: 10.1093/pch/pxx058] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Counselling couples facing the birth of an extremely preterm infant is a complex and delicate task, entailing both challenges and opportunities. This revised position statement proposes using a prognosis-based approach that takes the best estimate of gestational age into account, along with additional factors, including estimated fetal weight, receipt of antenatal corticosteroids, singleton versus multiple pregnancy, fetal status and anomalies on ultrasound and place of birth. This statement updates data on survival in Canada, long-term neurodevelopmental disability at school age and quality of life, with focus on strategies to communicate effectively with parents. It also proposes a framework for determining the prognosis-based management option(s) to present to parents when initiating the decision-making process. This statement replaces the 2012 position statement.
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Affiliation(s)
- Brigitte Lemyre
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Gregory Moore
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Stokes TA, Kukora SK, Boss RD. Caring for Families at the Limits of Viability: The Education of Dr Green. Clin Perinatol 2017; 44:447-459. [PMID: 28477671 DOI: 10.1016/j.clp.2017.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Resuscitation decisions for infants born at the edges of viability are complicated moral dilemmas, and the process of making these decisions is emotionally exhausting and morally distressful for families and physicians alike. An ethical approach to making these decisions requires input from physicians and parents; individuals tasked with facilitating such decisions must possess the communication and counseling skills needed to assist families with these painful and life-altering decisions. It is incumbent on all of us to continue our investigation into how we can better assist families in this process while providing care that is in their best interest.
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Affiliation(s)
- Theophil A Stokes
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
| | - Stephanie K Kukora
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics and Communicable Diseases, Floor 8, 1540 E Hospital Dr SPC 4254, Ann Arbor, MI 48109, USA
| | - Renee D Boss
- Division of Neonatology, Johns Hopkins School of Medicine, Berman Institute of Bioethics, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Haward MF, Gaucher N, Payot A, Robson K, Janvier A. Personalized Decision Making: Practical Recommendations for Antenatal Counseling for Fragile Neonates. Clin Perinatol 2017; 44:429-445. [PMID: 28477670 DOI: 10.1016/j.clp.2017.01.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Emphasis has been placed on engaging parents in processes of shared decision making for delivery room management decisions of critically ill neonates whose outcomes are uncertain and unpredictable. The goal of antenatal consultation should rather be to adapt to parental needs and empower them through a personalized decision-making process. This can be done by acknowledging individuality and diversity while respecting the best interests of neonates. The goal is for parents to feel like they have agency and ability and are good parents, before birth, at birth, and after, either in the NICU or until the death of their child.
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Affiliation(s)
- Marlyse F Haward
- Department of Pediatrics, Albert Einstein College of Medicine, The Children's Hospital at Montefiore, New York, NY 10467, USA
| | - Nathalie Gaucher
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada
| | - Antoine Payot
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada; Palliative Care Unit, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Unité d'Éthique Clinique et de Partenariat Famille, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada
| | - Kate Robson
- Canadian Premature Babies Foundation, Toronto, Ontario M4N 3M5, Canada
| | - Annie Janvier
- Department of Pediatrics, CHU Sainte-Justine Research Center, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T 1J4, Canada; Clinical Ethics Unit, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec H3T-1C5, Canada; Palliative Care Unit, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Unité d'Éthique Clinique et de Partenariat Famille, Sainte-Justine Hospital, Montreal, Quebec H3T-1C5, Canada; Department of Pediatrics and Clinical Ethics, Sainte-Justine Hospital, University of Montreal, 3175 Chemin Côte-Sainte-Catherine, Montreal, Quebec H3T 1C5, Canada.
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Shaw C, Stokoe E, Gallagher K, Aladangady N, Marlow N. Parental involvement in neonatal critical care decision-making. SOCIOLOGY OF HEALTH & ILLNESS 2016; 38:1217-1242. [PMID: 27666147 DOI: 10.1111/1467-9566.12455] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The article analyses the decision-making process between doctors and parents of babies in neonatal intensive care. In particular, it focuses on cases in which the decision concerns the redirection of care from full intensive care to palliative care at the end of life. Thirty one families were recruited from a neonatal intensive care unit in England and their formal interactions with the doctor recorded. The conversations were transcribed and analysed using conversation analysis. Analysis focused on sequences in which decisions about the redirection of care were initiated and progressed. Two distinct communicative approaches to decision-making were used by doctors: 'making recommendations' and 'providing options'. Different trajectories for parental involvement in decision-making were afforded by each design, as well as differences in terms of the alignments, or conflicts, between doctors and parents. 'Making recommendations' led to misalignment and reduced opportunities for questions and collaboration; 'providing options' led to an aligned approach with opportunities for questions and fuller participation in the decision-making process. The findings are discussed in the context of clinical uncertainty, moral responsibility and the implications for medical communication training and guidance. A Virtual Abstract of this paper can be accessed at: https://www.youtube.com/watch?v=MyuymxDNupk&feature=youtu.be.
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Affiliation(s)
- Chloe Shaw
- Department of Neonatology, University College London, UK.
| | | | | | - Narendra Aladangady
- Department of Neonatology, Homerton University Hospital, London, UK
- Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, QMUL
| | - Neil Marlow
- Department of Neonatology, University College London, UK
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Raes I, Ravelingien A, Pennings G. Donor Conception Disclosure: Directive or Non-Directive Counselling? JOURNAL OF BIOETHICAL INQUIRY 2016; 13:369-379. [PMID: 27116204 DOI: 10.1007/s11673-015-9686-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 06/17/2015] [Indexed: 06/05/2023]
Abstract
It is widely agreed among health professionals that couples using donor insemination should be offered counselling on the topic of donor conception disclosure. However, it is clear from the literature that there has long been a lack of agreement about which counselling approach should be used in this case: a directive or a non-directive approach. In this paper we investigate which approach is ethically justifiable by balancing the two underlying principles of autonomy (non-directive approach) and beneficence (directive approach). To overrule one principle in favour of another, six conditions should be fulfilled. We analyse the arguments in favour of the beneficence principle, and consequently, a directive approach. This analysis shows that two conditions are not met; the principle of autonomy should not be overridden. Therefore, at this moment, a directive counselling approach on donor conception disclosure cannot be ethically justified.
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Affiliation(s)
- Inez Raes
- Bioethics Institute Ghent (BIG), Department of Philosophy and Moral Science, Ghent University, Blandijnberg 2, B-9000, Gent, Belgium.
| | - An Ravelingien
- Bioethics Institute Ghent (BIG), Department of Philosophy and Moral Science, Ghent University, Blandijnberg 2, B-9000, Gent, Belgium
| | - Guido Pennings
- Bioethics Institute Ghent (BIG), Department of Philosophy and Moral Science, Ghent University, Blandijnberg 2, B-9000, Gent, Belgium
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Doronjski A, Stojanović V. Ethical issues in the treatment of extremely low birth weight neonates. Croat Med J 2016; 57:395-7. [PMID: 27586555 PMCID: PMC5048224 DOI: 10.3325/cmj.2016.57.395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Vesna Stojanović
- Vesna Stojanović, Institute for Child and Youth Health Care of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia,
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Wilman E, Megone C, Oliver S, Duley L, Gyte G, Wright JM. The ethical issues regarding consent to clinical trials with pre-term or sick neonates: a systematic review (framework synthesis) of the empirical research. Trials 2015; 16:502. [PMID: 26537492 PMCID: PMC4634156 DOI: 10.1186/s13063-015-0957-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/14/2015] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Conducting clinical trials with pre-term or sick infants is important if care for this population is to be underpinned by sound evidence. Yet approaching parents at this difficult time raises challenges for the obtaining of valid informed consent to such research. This study asked: what light does the empirical literature cast on an ethically defensible approach to the obtaining of informed consent in perinatal clinical trials? METHODS A systematic search identified 49 studies. Analysis began by applying philosophical frameworks which were then refined in light of the concepts emerging from empirical studies to present a coherent picture of a broad literature. RESULTS Between them, studies addressed the attitudes of both parents and clinicians concerning consent in neonatal trials; the validity of the consent process in the neonatal research context; and different possible methods of obtaining consent. CONCLUSIONS Despite a variety of opinions among parents and clinicians there is a strongly and widely held view that it is important that parents do give or decline consent for neonatal participation in trials. However, none of the range of existing consent processes reviewed by the research is satisfactory. A significant gap is evaluation of the widespread practice of emergency 'assent', in which parents assent or refuse their baby's participation as best they can during the emergency and later give full consent to ongoing participation and follow-up. Emergency assent has not been evaluated for its acceptability, how such a process would deal with bad outcomes such as neonatal death between assent and consent, or the extent to which late parental refusal might bias results. This review of a large number of empirical papers, while not making fundamental changes, has refined and developed the conceptual framework from philosophy for examining informed consent in this context.
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MESH Headings
- Attitude of Health Personnel
- Clinical Trials as Topic/ethics
- Emergencies
- Emotions
- Gestational Age
- Health Knowledge, Attitudes, Practice
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/mortality
- Infant, Newborn, Diseases/therapy
- Infant, Premature
- Motivation
- Parental Consent/ethics
- Parents/psychology
- Research Design
- Risk Assessment
- Volition
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Affiliation(s)
- E Wilman
- Inter-Disciplinary Ethics Applied, University of Leeds, Leeds, UK.
| | - C Megone
- Inter-Disciplinary Ethics Applied, University of Leeds, Leeds, UK.
| | - S Oliver
- Social Science Research Unit and EPPI-Centre, Institute of Education, University of London, London, UK.
| | - L Duley
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, University of Nottingham, Nottingham, UK.
| | - G Gyte
- National Childbirth Trust, London, UK.
| | - J M Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
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Xafis V, Gillam L, Hynson J, Sullivan J, Cossich M, Wilkinson D. Caring Decisions: The Development of a Written Resource for Parents Facing End-of-Life Decisions. J Palliat Med 2015; 18:945-55. [PMID: 26418215 PMCID: PMC4638203 DOI: 10.1089/jpm.2015.0048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Written resources in adult intensive care have been shown to benefit families facing end of life (EoL) decisions. There are few resources for parents making EoL decisions for their child and no existing resources addressing ethical issues. The Caring Decisions handbook and website were developed to fill these gaps. Aim: We discuss the development of the resources, modification after reviewer feedback and findings from initial pilot implementation. Design: A targeted literature review-to identify resources and factors that impact on parental EoL decision-making; development phase-guided by the literature and the researchers' expertise; consultation process-comprised a multi-disciplinary panel of experts and parents; pilot evaluation study-hard-copy handbook was distributed as part of routine care at an Australian Children's Hospital. Setting/Participants: Twelve experts and parents formed the consultation panel. Eight parents of children with life-limiting conditions and clinicians were interviewed in the pilot study. Results: Numerous factors supporting/impeding EoL decisions were identified. Caring Decisions addressed issues identified in the literature and by the multidisciplinary research team. The consultation panel provided overwhelmingly positive feedback. Pilot study parents found the resources helpful and comforting. Most clinicians viewed the resources as very beneficial to parents and identified them as ideal for training purposes. Conclusions: The development of the resources addressed many of the gaps in existing resources. The consultation process and the pilot study suggest these resources could be of significant benefit to parents and clinicians.
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Affiliation(s)
- Vicki Xafis
- 1 Discipline of Obstetrics and Gynaecology, Women's and Children's Hospital, The University of Adelaide , Adelaide, Australia .,2 The Sydney Children's Hospitals Network , Westmead, New South Wales, Australia
| | - Lynn Gillam
- 3 Children's Bioethics Centre, The Royal Children's Hospital , Melbourne, Australia .,5 Centre for Health Equity, University of Melbourne , Melbourne, Australia
| | - Jenny Hynson
- 4 Victorian Paediatric Palliative Care Program, The Royal Children's Hospital , Melbourne, Australia
| | - Jane Sullivan
- 3 Children's Bioethics Centre, The Royal Children's Hospital , Melbourne, Australia .,5 Centre for Health Equity, University of Melbourne , Melbourne, Australia
| | - Mary Cossich
- 6 Disciplines of Palliative Medicine and General Paediatrics, Women's and Children's Health Network , Adelaide, Australia
| | - Dominic Wilkinson
- 1 Discipline of Obstetrics and Gynaecology, Women's and Children's Hospital, The University of Adelaide , Adelaide, Australia .,7 Medical Ethics Department, Oxford Uehiro Centre for Practical Ethics, Oxford University , Oxford, United Kingdom .,8 John Radcliffe Hospital , Oxford, United Kingdom
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Murakami M, Yokoo K, Ozawa M, Fujimoto S, Funaba Y, Hattori M. Development of a Neonatal End‐of‐Life Care Education Program for NICU Nurses in Japan. J Obstet Gynecol Neonatal Nurs 2015; 44:481-491. [DOI: 10.1111/1552-6909.12569] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Xafis V, Wilkinson D, Gillam L, Sullivan J. Balancing obligations: should written information about life-sustaining treatment be neutral? JOURNAL OF MEDICAL ETHICS 2015; 41:234-239. [PMID: 24763219 PMCID: PMC4345516 DOI: 10.1136/medethics-2013-101965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 03/04/2014] [Accepted: 04/02/2014] [Indexed: 06/03/2023]
Abstract
Parents who are facing decisions about life-sustaining treatment for their seriously ill or dying child are supported by their child's doctors and nurses. They also frequently seek other information sources to help them deal with the medical and ethical questions that arise. This might include written or web-based information. As part of a project involving the development of such a resource to support parents facing difficult decisions, some ethical questions emerged. Should this information be presented in a strictly neutral fashion? Is it problematic if narratives, arguments or perspectives appear to favour stopping over continuing life-sustaining treatment? Similar questions might arise with written materials about decisions for adults, or for other ethically contentious decisions. This paper explores the meaning of 'balance' in information provision, focusing particularly on written information about life-sustaining treatment for children. We contrast the norm of non-directiveness in genetic counselling with the shared decision-making model often endorsed in end-of-life care. We review evidence that parents do not find neutrality from medical professionals helpful in discussions. We argue that balance in written information must be understood in the light of the aim of the document, the most common situation in which it will be used, and any existing biases. We conclude with four important strategies for ensuring that non-neutral information is nevertheless ethically appropriate.
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Affiliation(s)
- Vicki Xafis
- Perinatal Ethics Unit, Discipline of Obstetrics and Gynaecology, Robinson Institute, The University of Adelaide, North Adelaide, South Australia, Australia
| | - Dominic Wilkinson
- Department of Neonatal Medicine, Robinson Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jane Sullivan
- Centre for Health and Society, University of Melbourne, Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
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40
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de Vos MA, Bos AP, Plötz FB, van Heerde M, de Graaff BM, Tates K, Truog RD, Willems DL. Talking with parents about end-of-life decisions for their children. Pediatrics 2015; 135:e465-76. [PMID: 25560442 DOI: 10.1542/peds.2014-1903] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) from their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision-making process. METHODS We conducted a prospective exploratory study in 2 Dutch University Medical Centers. RESULTS Overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audio recorded, ranging from 1 to 8 meetings per patient. By means of a coding instrument we quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in 2 cases were parents asked to share in the decision-making. Despite their intense emotions, most parents made great effort to actively participate in the conversation. They did this by asking for clarifications, offering their preferences, and reacting to the decision being proposed (mostly by expressing their assent). In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision. CONCLUSIONS We conclude that parents are able to handle a more active role than they are currently being given. Parents' greatest concern is that their child might suffer.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands;
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Frans B Plötz
- Department of Paediatrics, Tergooiziekenhuizen, Hilversum, Netherlands
| | - Marc van Heerde
- Department of Paediatric Intensive Care, VU University Medical Centre, Amsterdam, Netherlands
| | - Bert M de Graaff
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Kiek Tates
- Department of Communication and Information Studies, Tilburg University, Tilburg, Netherlands; and
| | - Robert D Truog
- Division of Critical Care Medicine, Boston Children's Hospital; Division of Medical Ethics, Harvard Medical School, Boston, Massachusetts
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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41
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de Vos MA, Seeber AA, Gevers SKM, Bos AP, Gevers F, Willems DL. Parents who wish no further treatment for their child. JOURNAL OF MEDICAL ETHICS 2015; 41:195-200. [PMID: 24917616 DOI: 10.1136/medethics-2013-101395] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND In the ethical and clinical literature, cases of parents who want treatment for their child to be withdrawn against the views of the medical team have not received much attention. Yet resolution of such conflicts demands much effort of both the medical team and parents. OBJECTIVE To discuss who can best protect a child's interests, which often becomes a central issue, putting considerable pressure on mutual trust and partnership. METHODS We describe the case of a 3-year-old boy with acquired brain damage due to autoimmune-mediated encephalitis whose parents wanted to stop treatment. By comparing this case with relevant literature, we systematically explored the pros and cons of sharing end-of-life decisions with parents in cases where treatment is considered futile by parents and not (yet) by physicians. CONCLUSIONS Sharing end-of-life decisions with parents is a more important duty for physicians than protecting parents from guilt or doubt. Moreover, a request from parents on behalf of their child to discontinue treatment is, and should be, hard to over-rule in cases with significant prognostic uncertainty and/or in cases with divergent opinions within the medical team.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Division of Public Health and Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Antje A Seeber
- Department of Neurology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjef K M Gevers
- Department of Health Law, Division of Public Health & Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital/Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Dick L Willems
- Section of Medical Ethics, Division of Public Health and Epidemiology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
In 1965, when the first issue of Journal of Paediatrics and Child Health appeared, medical ethics was just becoming established as a discipline. The sub-speciality of paediatric ethics did not make an appearance until the late 1980s, with the first key texts appearing in the 1990s. Professional concern to practice ethically in paediatrics obviously goes much further back than that, even if not named as such. In clinical areas of paediatrics, the story of the last 50 years is essentially a story of progress - better understanding of disease, better diagnosis, more effective treatment, better outcomes. In paediatric ethics, the story of the last 50 years is a bit more complicated. In ethics, the idea of progress, rather than just change, is not so straightforward and is sometimes hotly contested. There has certainly been change, including some quite radical shifts in attitudes and practices, but on some issues, the ethical debate now looks remarkably similar to that of 40-50 years ago. This is the story of some things that have changed in paediatric ethics, some things that have stayed the same and the key ethical ideas lying beneath the surface.
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Affiliation(s)
- Lynn Gillam
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Abstract
BACKGROUND Neonatal nurses report a great deal of ethical challenges in their everyday work. Seemingly trivial everyday choices nurses make are no more value-neutral than life-and-death choices. Everyday ethical challenges should also be recognized as ethical dilemmas in clinical practice. RESEARCH OBJECTIVE The purpose of this study is to investigate which types of ethical challenges neonatal nurses experience in their day-to-day care for critically ill newborns. RESEARCH DESIGN Data were collected through semi-structured qualitative in-depth interviews. Phenomenological-hermeneutic analysis was applied to interpret the data. PARTICIPANTS AND RESEARCH CONTEXT Six nurses from neonatal intensive care units at two Norwegian hospitals were interviewed on-site. ETHICAL CONSIDERATIONS The study is designed to comply with Ethical Guidelines for Nursing Research in the Nordic Countries and the Helsinki declaration. FINDINGS Findings suggest that nurses experience a diverse range of everyday ethical challenges related to challenging interactions with parents and colleagues, emotional strain, protecting the vulnerable infant, finding the balance between sensitivity and authority, ensuring continuity of treatment, and miscommunication and professional disagreement. DISCUSSION A major finding in this study is how different agents involved in caring for the newborn experience their realities differently. When these realities collide, ethical challenges arise. Findings suggest that acting in the best interests of the child becomes more difficult in situations involving many agents with different perceptions of reality. CONCLUSION The study presents new aspects which increases knowledge and understanding of the reality of nursing in a neonatal intensive care unit, while also demanding increased research in this field of care.
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Mahgoub L, van Manen M, Byrne P, Tyebkhan JM. Policy change for infants born at the "cusp of viability": a Canadian NICU experience. Pediatrics 2014; 134:e1405-10. [PMID: 25311605 DOI: 10.1542/peds.2014-0904] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Resuscitation and life-support treatments for infants born at the "cusp of viability" continue to be subject to clinical and ethical debate. Reported positive outcomes for these infants led our Neonatal Program to critically review our historic practice of discouraging resuscitation of infants born at <24 weeks' gestational age. This practice change required a multifaceted, collaborative approach including neonatal, perinatal, and obstetric efforts. An exceptional experience was the formation of a dedicated working group that included invaluable input from parents who had lived the NICU experience. The inclusion of family members in the development of clinical policy was a novel experience for NICU staff, which we feel ultimately resulted in a more ethically sound approach to the care of these infants and their families. In this article, we explore our experience of the process of policy change, which although detailed and transparent was also complex and challenging in development and implementation.
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Affiliation(s)
- Linda Mahgoub
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, and
| | - Michael van Manen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, and John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada; and
| | - Paul Byrne
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, and John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada; and
| | - Juzer M Tyebkhan
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, and Neonatal and Infant Follow Up Clinic, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
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Abstract
Decisions about neonatal end-of-life care have been studied intensely over the last 20 years in The Netherlands. Nationwide surveys were done to quantify these decisions, provide details and monitor the effect of guidelines, new regulations and other interventions. One of those interventions was the Groningen Protocol for newborn euthanasia in severely ill newborns, published in 2005. Before publication, an estimated 20 cases of euthanasia per year were performed. After publication, only two cases in five years were reported. Studies suggested that this might be partly caused by the lack of consensus about the dividing line between euthanasia and palliative care. New recommendations about paralytic medication use in dying newborns were issued to increase transparency and to improve reporting of euthanasia. New surveys will be needed to measure the effects of these interventions. This cycle of interventions and measurements seems useful for continuous improvement of end-of-life care in newborns.
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Affiliation(s)
- A A Eduard Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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Sullivan J, Gillam L, Monagle P. Parents and end-of-life decision-making for their child: roles and responsibilities. BMJ Support Palliat Care 2014; 5:240-8. [PMID: 24644205 DOI: 10.1136/bmjspcare-2013-000558] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 12/28/2013] [Indexed: 11/03/2022]
Abstract
BACKGROUND Whether parents want to be and should be the decision-maker for their child in end-of-life matters are contested clinical and ethical questions. Previous research outcomes are equivocal. METHOD A qualitative interview method was used to examine the views and experiences of 25 bereaved parents in end-of-life decision-making for their child. Data were analysed thematically. RESULTS Three types of decision-making roles were identified: self-determined, guided (both involving active decision-making) and acquiescent (passive).The majority of parents had been active in the decision-making process for their child. They perceived themselves as the ultimate end-of-life decision-maker. This was perceived as part of their parental responsibility. A minority of parents did not consider that they had been an active, ultimate decision-maker. Generally, parents in the self-determined and guided groups reported no negative consequences from their decision-making involvement. Importantly, parents in the acquiescent group described their experience as difficult at the time and subsequently, although not all difficulties related directly to decision-making. Parents considered that in principle parents should be the end-of-life decision-maker for their child, but understood personal characteristics and preference could prevent some parents from taking this role. CONCLUSIONS This study unequivocally supports parents' desire to fulfil the end-of-life decision-making role. It provides a nuanced understanding of parents' roles and contributes evidence for the ethical position that parents should be the end-of-life decision-makers for their child, unless not in the child's best interests. On the whole, parents want this role and can manage its consequences. Indeed, not being the end-of-life decision-maker could be detrimental to parents' well-being.
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Affiliation(s)
- Jane Sullivan
- The Children's Bioethics Centre, The Royal Children's Hospital, Parkville, Australia The Centre for Health & Society, The University of Melbourne, Melbourne, Australia
| | - Lynn Gillam
- The Children's Bioethics Centre, The Royal Children's Hospital, Parkville, Australia The Centre for Health & Society, The University of Melbourne, Melbourne, Australia
| | - Paul Monagle
- The Royal Children's Hospital, Melbourne, Australia Department of Paediatrics, The University of Melbourne, Melbourne, Australia Critical Care and Neurosciences Theme, Murdoch Children's Research Institute, Melbourne, Australia
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Ramai D, Goldin S. Humanities in medicine: preparing for practice. PERSPECTIVES ON MEDICAL EDUCATION 2013; 2:332-334. [PMID: 24092544 PMCID: PMC3824758 DOI: 10.1007/s40037-013-0086-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Daryl Ramai
- School of Medicine, St. George’s University, True Blue, Grenada, West Indies
| | - Shoshanna Goldin
- Department of Interdisciplinary Studies - Global Health, Wake Forest University, Winston-Salem, NC 27109 USA
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Jefferies AL, Kirpalani HM. Counselling and management for anticipated extremely preterm birth. Paediatr Child Health 2013; 17:443-6. [PMID: 24082807 DOI: 10.1093/pch/17.8.443] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Extremely preterm birth (birth between 22(0/7) and 25(6/7) weeks' gestational age [GA]) often requires parents to make complex choices about the care of their infant. Health professionals have a significant role in providing information, guidance and support. Parents facing the birth of an extremely preterm infant should have the chance to meet with both obstetrical and paediatric/neonatal care providers to receive accurate information about their infant's prognosis, provided with clarity and compassion. Decision making between parents and health professionals should be an informed and shared process, with documentation of all management decisions. Consultation with and transfer to tertiary perinatal centres are important for the care of both mother and fetus. As the survival of infants born before or at 22 completed weeks' GA remains uncommon, a noninterventional approach is recommended, whereas at 23, 24 and 25 weeks' GA, counselling about outcomes and decision making should be individualized for each infant and family, using factors which influence prognosis. All extremely preterm infants who are not resuscitated, or for whom resuscitation is not successful, must receive compassionate palliative care.
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Abstract
Active ending of the life of a newborn baby is a crime. Yet its clandestine practise is a reality in several European countries. In this paper, we defend the necessity to institute a proper legal frame for what we define as active neonatal euthanasia. The only legal attempt so far, the Dutch Groningen protocol, is not satisfactory. We critically analyse this protocol, as well as several other clinical practises and philosophical stances. Furthermore, we have tried to integrate our opinions as clinicians into a law project, with the purpose of pinpointing several issues, specific of perinatality that should be addressed by such a law. In conclusion, we argue that the legalisation of neonatal euthanasia under exceptional circumstances is the only way to avoid all the "well-intentioned" malpractices associated with ending life at the very dawn of it.
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Affiliation(s)
- Serge Vanden Eijnden
- Neonatal Intensive Care Unit, CHU Charleroi, Belgium ; Fetal Medicine Department, CHU Charleroi, Belgium
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50
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Review on Neonatal End-of-Life Decision-Making: Medical Authority or Parental Autonomy? PROCEEDINGS OF SINGAPORE HEALTHCARE 2013. [DOI: 10.1177/201010581302200210] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
As advances in medical technology are constantly re-defining the lower limit of newborn viability, the practice of withholding/withdrawing treatment in neonatal care is increasingly prevalent. Now more than ever, physicians working in neonatal intensive care units have to constantly face the ethical dilemma of terminating the neonates' life support, sometimes against the parents' desire. Traditionally and legally, parents have the duty to make decisions on behalf of their infants because they are the ones to whom the consequences matter the most. Physicians, on the other hand, often claim for themselves the role of the child's advocate, with the growing acceptance of the patient's “best interest” standard as the guiding principle. In this mini literature review, the authors examined the issue of medical authority versus parental autonomy in neonatal end-of-life (EoL) decision-making and found that consultations with parents were made in the majority (79–100%) of cases. Furthermore, conflicts between doctors and family were shown to occur quite frequently due to barriers to effective communication such as strong religious convictions and disagreements within medical team members. Only by encouraging active parental participation and overcoming some of these barriers, physicians and the patient's family could arrive at an ethically sound EoL decision.
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