Opinions of paediatricians who teach neonatal resuscitation about resuscitation practices on extremely preterm infants in the delivery room

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

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

The Ethics and Practice of Periviability Care

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

Resuscitation of preterm infants in Nigeria - A national survey on practice

Introduction and Aims

Preterm births constitute a major clinical problem associated with significant morbidity and mortality in the perinatal, neonatal, and childhood periods. Decisions around initiating and/or continuing resuscitation and treatment of preterm infants (PI) both at birth and afterwards need careful consideration. While the developed countries have published guidelines for the resuscitation and care of the PI, this is not the case in developing countries where availability of resources and the absence of a published guidelines impacts on practice. Our study was therefore carried out to access the practice and decision-making that surrounds the resuscitation of PIs by neonatologists and neonatal nurses working in neonatal intensive care units (NICU) across Nigeria.

Subjects and Methods

We conducted an online national survey on neonatal care providers working in level 2 and level 3 neonatal units (NICU) across Nigeria. Around 190 participants were selected from the six geopolitical zones of the country and they were asked about current practices relating to resuscitation and stopping life-sustaining treatment as well as estimated survival rates at different gestational ages (GA).

Results

In total, 138 clinicians responded to our survey. Of this, 73% completed the survey. Majority (83%) of the respondents worked in government-funded public hospitals while the remaining 17% worked in the private hospitals. 74% of the respondents' report having a guideline on the PI. Resuscitation practice varied amongst different neonatologists and neonatal nurses with 48% of the clinicians providing resuscitation at 23-26 weeks and the remainder providing resuscitation at a GA >26 weeks with a median GA threshold for initiating resuscitation at 27 weeks. From an institutional perspective, 75% of PIs <26 weeks were resuscitated in public hospitals while the remaining 25% were resuscitated in private hospital, however this is not statistically significant (P = 0.385). In situations when the GA is unknown, we found a median fetal weight of 700 g as the threshold for providing active treatment. We noticed wide variations in responses on the estimated survival rates of the PIs, however a common finding is the increased chances of survival with increasing GA. Also, PIs across all GAs had higher chances of survival in public hospitals than in private hospitals, however, this is not statistically significant (P = 0.385-0.956). The major factor influencing a clinicians' decision to limit resuscitation was the "risk of poor quality of life" (50%) and the prevalent way of palliating the newborn amongst respondents is by stopping life-sustaining treatment (34%).

Conclusion

Our survey revealed considerable variation in resuscitation practices amongst different neonatal care providers. Having a framework that will formulate and publish a national guideline based on factors like local survival rates, societal norms, and resources and ensuring that it is adopted by all NICUs will generate greater consistency of care.

Barriers and facilitators to shared decision-making in neonatal medicine: A systematic review and thematic synthesis of parental perceptions

OBJECTIVES

Systematically review parental perceptions of shared decision-making (SDM) in neonatology, identifying barriers and facilitators to implementation.

METHODS

Electronic database (Medline, PsycINFO, CINAHL and Scopus) and follow-up searches were conducted to identify qualitative studies. Data were extracted, thematically analysed and synthesised.

RESULTS

Searches yielded 2445 papers, of which 25 were included. Thematic analysis identified six key themes. Key barriers included emotional crises experienced in the NICU setting, lack of medical information provided to parents to inform decision-making, inadequate communication of information, poor relationships with caregivers, lack of continuity in care, and perceived power imbalances between HCPs and parents. Key facilitators included clear, honest and compassionate communication of medical information, caring and empathetic caregivers, continuity in care, and tailored approaches that reflected parent's desired level of involvement.

CONCLUSION

The highly specialised environment, and the emotional crises experienced by parents impact significantly on their perceived capacity to engage in surrogate decision-making.

PRACTICE IMPLICATIONS

Complex and multi-factorial interventions that address the training needs of HCPs, and the emotional, informational and decision support needs of parents are needed. SDM skills training, improved information delivery, and integrated emotional and decisional support could help parents to become more involved in SDM for their infant.

Neonatologists' decision-making for resuscitation and non-resuscitation of extremely preterm infants: ethical principles, challenges, and strategies-a qualitative study

Background

Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists’ clinical–ethical decision-making for resuscitation of EPIs.

Methods

We conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven.

Results

The main principles guiding participants’ decision-making were EPIs’ best interest and respect for parents’ autonomy. Participants agreed that justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs’ best interest and respect for parents’ autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24–25 weeks). Participants’ coping strategies included setting limits on extent of EPI care provided and rigidly following established guidelines. However, these strategies were not always feasible or successful. Although rare, these situations often led to long-lasting moral distress.

Conclusions

Participants’ clinical–ethical reasoning for resuscitation of EPIs can be mainly characterized as an attempt to balance EPIs’ best interest and respect for parents’ autonomy. This approach could explain why neonatologists considered conflicts between these principles as their main ethical challenge and why lack of resolution increases the risk of moral distress. Therefore, more research is needed to better understand moral distress in EPI resuscitation decisions.

Clinical Trial Registration: The study received ethical approval from the ethics committee of UZ/KU Leuven (S62867). Confidentiality of personal information and anonymity was guaranteed in accordance with the General Data Protection Regulation of 25 May 2018.

Resuscitation of preterm infants in the Philippines: a national survey of resources and practice

OBJECTIVE

There is a high incidence of preterm birth in low-income and middle-income countries where healthcare resources are often limited and may influence decision making. We aimed to explore the interplay between resource limitations and resuscitation practices for extremely preterm infants (EPIs) in neonatal intensive care units (NICUs) across the Philippines.

METHODS

We conducted a national survey of NICUs in the Philippines. Institutions were classified according to sector (private/public), region and level. Respondents were asked about unit capacity, availability of ventilators and surfactant, resuscitation practices and estimated survival rates for EPIs of different gestational ages.

RESULTS

Respondents from 103/228 hospitals completed the survey (response rate 45%). Public hospitals reported more commonly experiencing shortages of ventilators than private hospitals (85%vs23%, p<0.001). Surfactant was more likely to be available in city hospitals than regional/district hospitals (p<0.05) and in hospitals classified as Level III/IV than I/II (p<0.05). The financial capacity of parents was a major factor influencing treatment options. Survival rates for EPIs were estimated to be higher in private than public institutions. Resuscitation practice varied; active treatment was generally considered optional for EPIs from 25 weeks' gestation and usually provided after 27-28 weeks' gestation.

CONCLUSION

Our survey revealed considerable disparities in NICU resource availability between different types of hospitals in the Philippines. Variation was observed between hospitals as to when resuscitation would be provided for EPIs. National guidelines may generate greater consistency of care yet would need to reflect the variable context for decisions in the Philippines.

Decision-making around resuscitation of extremely preterm infants in the Philippines: A consensus guideline

While the vast majority of preterm births globally occur in low- and middle-income countries, existing published guidelines relating to the decision-making and resuscitation of extremely preterm infants (EPIs) largely focus on high-income countries. In 2018-2019, a working group of the Philippine Society of Newborn Medicine aimed to develop the first national guideline relating to the care of EPIs. The working group reviewed data on the outcomes of EPIs in the Philippines, surveyed paediatricians and neonatologists in the Philippines about current practice and held a consensus workshop. This paper describes the guideline development process and presents a summary of the guidelines. The national guidelines endorse consistency in decision-making. Health professionals should take into consideration the views and wishes of the infant's parents and the availability of resources to treat the newborn infant. Active management would be appropriate to provide for potentially viable preterm infants at moderate to high risk of poor outcomes, where parents have expressed their wish for this management (and where there are resources available to provide this treatment). For such infants, where parents have expressed their wish to withhold active management, palliative management would also be appropriate to provide. The guideline endorses a grey zone for neonatal resuscitation from approximately 24 to 28 weeks' gestation in the Philippines, reflecting the context for resuscitation in low- and middle-income countries. Disparities in resource availability are themselves an ethical concern for neonatologists and should be a stimulus for advocacy and improvements in health-care delivery.

Latent class analysis shows that paediatricians' opinions about the advanced resuscitation of extremely preterm infants were diverse and influenced by personal beliefs

AIM

The aim of this study was to survey paediatricians, who taught neonatal resuscitation in Brazil, about when they would apply advanced resuscitation in the delivery room for newborn infants born at 23-26 weeks of gestational age.

METHODS

This cross-sectional study focused on an electronic questionnaire that was sent to paediatricians who acted as instructors for the Brazilian Neonatal Resuscitation Program from December 2011 to September 2013. The primary outcome was the gestational age at which the respondent would apply advanced resuscitation in the delivery room. Latent class analysis identified the profiles of the instructors, and logistic regression identified the variables associated with belonging to one of the derived classes.

RESULTS

The 560 (82%) instructors who agreed to participate fell into three latent classes: pro-resuscitation, intermediate and pro-limitation, with high, intermediate and low probabilities of performing advanced resuscitation in neonates born at 23-26 weeks. In the multivariate model, group membership was associated with the paediatrician's age, years of practice and personal importance of religion and the patient's birthweight, future quality of life and probability of death.

CONCLUSION

The opinions of paediatricians performing advanced resuscitation on extremely preterm infants in the delivery room were diverse and influenced by personal beliefs.