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Mielewczyk FJ, Boyle EM. Uncharted territory: a narrative review of parental involvement in decision-making about late preterm and early term delivery. BMC Pregnancy Childbirth 2023; 23:526. [PMID: 37464284 DOI: 10.1186/s12884-023-05845-6] [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: 01/18/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
Almost 30% of live births in England and Wales occur late preterm or early term (LPET) and are associated with increased risks of adverse health outcomes throughout the lifespan. However, very little is known about the decision-making processes concerning planned LPET births or the involvement of parents in these. This aim of this paper is to review the evidence on parental involvement in obstetric decision-making in general, to consider what can be extrapolated to decisions about LPET delivery, and to suggest directions for further research.A comprehensive, narrative review of relevant literature was conducted using Medline, MIDIRS, PsycInfo and CINAHL databases. Appropriate search terms were combined with Boolean operators to ensure the following broad areas were included: obstetric decision-making, parental involvement, late preterm and early term birth, and mode of delivery.This review suggests that parents' preferences with respect to their inclusion in decision-making vary. Most mothers prefer sharing decision-making with their clinicians and up to half are dissatisfied with the extent of their involvement. Clinicians' opinions on the limits of parental involvement, especially where the safety of mother or baby is potentially compromised, are highly influential in the obstetric decision-making process. Other important factors include contextual factors (such as the nature of the issue under discussion and the presence or absence of relevant medical indications for a requested intervention), demographic and other individual characteristics (such as ethnicity and parity), the quality of communication; and the information provided to parents.This review highlights the overarching need to explore how decisions about potential LPET delivery may be reached in order to maximise the satisfaction of mothers and fathers with their involvement in the decision-making process whilst simultaneously enabling clinicians both to minimise the number of LPET births and to optimise the wellbeing of women and babies.
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Affiliation(s)
- Frances J Mielewczyk
- Leicester City Football Club (LCFC) Research Programme, Department of Population Health Sciences, College of Life Sciences, George Davies Centre, University of Leicester, University Road, Leicester, LE1 7RH, UK.
| | - Elaine M Boyle
- Department of Population Health Sciences, College of Life Sciences, George Davies Centre, University of Leicester, University Road, Leicester, LE1 7RH, UK
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Buchholtz S, Fangmann L, Siedentopf N, Bührer C, Garten L. Perinatal Palliative Care: Additional Costs of an Interprofessional Service and Outcome of Pregnancies in a Cohort of 115 Referrals. J Palliat Med 2023; 26:393-401. [PMID: 36251802 DOI: 10.1089/jpm.2022.0172] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: An increasing number of life-limiting conditions (LLCs) is diagnosed prenatally, presenting providers with the ability to present perinatal palliative care (PnPC) services as an option. Objective: To (1) determine the profile characteristics of patients referred for prenatal palliative care counseling to Charité Universitätsmedizin Berlin, Germany; (2) evaluate pregnancy outcome; and (3) analyze the additional human resources per family required to provide specialized PnPC. Methods: Retrospective chart review of pregnant women and infants with potentially LLCs referred for prenatal palliative care counseling between 2016 and 2020. Results: A total of 115 women were referred for prenatal palliative care counseling. Most cases (57.6%) comprised trisomy 13 or 18 (n = 36) and complex congenital conditions (n = 32). Other life-limiting diagnoses included renal agenesis/severe dysplasia (n = 19), congenital heart diseases (n = 18), neurological anomalies (n = 8), and others (n = 5). In 72.0% of cases (n = 85) parents decided to continue pregnancy and plan for palliative birth. Fifty deliveries resulted in a liveborn infant: 33 of these died in the delivery room, 9 neonates died after admission to rooming-in on one of our neonatal wards, and 8 were discharged home or to a hospice. Total human resources (median, range) provided were 563 (0-2940) minutes for psychosocial and 300 (0-720) minutes for medical specialized PnPC per referral. Conclusions: Our data confirm previously observed characteristics of diagnoses, referrals, and outcomes. The provision of specialized and interprofessional PnPC services accounted for ∼14 hours per case of additional human resources.
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Affiliation(s)
- Stefan Buchholtz
- Department of Neonatology, and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Laura Fangmann
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nina Siedentopf
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Garten
- Department of Neonatology, and Charité - Universitätsmedizin Berlin, Berlin, Germany
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Pellikka HK, Axelin A, Sankilampi U, Kangasniemi M. Shared responsibility for decision-making in NICU: A scoping review. Nurs Ethics 2023; 30:462-476. [PMID: 36688269 DOI: 10.1177/09697330221134948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Shared responsibility is an essential part of family-centred care and it characterizes the relationship between parents and healthcare professionals. Despite this, little is known about their shared responsibility for decision-making in neonatal intensive care units. AIM The aim of this scoping review was to identify previous studies on the subject and to summarize the knowledge that has been published so far. METHOD The review was conducted using electronic searches in the CINAHL, PubMed, Scopus and PsycINFO databases and manual searches of the reference lists of the selected papers. The searches were limited to peer-reviewed papers that had been published in English from 2010 to September 2021. The data were selected based on inclusion and exclusion criteria and the findings were inductively summarized. We identified eight papers that met the inclusion criteria. ETHICAL CONSIDERATIONS The scoping review was conducted according to good scientific practice by respecting authorship and reporting the study processes accurately, honestly and transparently. RESULTS The results showed that shared responsibility for decision-making was based on the parents' intentions, but the degree to which they were willing to take responsibility varied. The facilitating and inhibiting factors for shared responsibility for decision-making were related to the communication between parents and professionals. The impact was related to the parents' emotions. CONCLUSION It is essential that parents and professionals negotiate how both parties will contribute to their shared responsibility for decision-making. This will enable them to reach a mutual understanding of what is in the infants' best interests and to mitigate the emotional burden of decisions in neonatal intensive care units. More research is needed to clarify the concept of shared responsibility for decision-making in this intensive care context.
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Affiliation(s)
| | | | - Ulla Sankilampi
- 60650Kuopio University Hospital, Finland; University of Eastern Finland, Finland
| | - Mari Kangasniemi
- 60654University of Turku, Finland; Satakunta Hospital District, Finland
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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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Palliative Care in the Delivery Room: Challenges and Recommendations. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010015. [PMID: 36670565 PMCID: PMC9856529 DOI: 10.3390/children10010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
Palliative care in the delivery room is an interprofessional and interdisciplinary challenge addressing the dying newborn and parents as well as the caregivers. It differs in some significant aspects from palliative care in the neonatal intensive care unit. Clinical experience suggests that many details regarding this unique specialized palliative care environment are not well known, which may result in some degree of insecurity and emotional distress for health care providers. This article presents basic background information regarding the provision of palliative care to newborns within the delivery room. It offers orientation along with a preliminary set of practical recommendations regarding the following central issues: (i) the basic elements of perinatal palliative care, (ii) the range of non-pharmacological and pharmacological interventions available for infant symptom control near the end of life, (iii) meeting the personal psychological, emotional, and spiritual needs of the parents, and (iv) care and self-care for medical personnel.
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Schouten ES, Beyer MF, Flemmer AW, de Vos MA, Kuehlmeyer K. Conversations About End-of-Life Decisions in Neonatology: Do Doctors and Parents Implement Shared Decision-Making? Front Pediatr 2022; 10:897014. [PMID: 35676897 PMCID: PMC9168986 DOI: 10.3389/fped.2022.897014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/20/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Advances in perinatal medicine have contributed to significantly improved survival of newborns. While some infants die despite extensive medical treatment, a larger proportion dies following medical decision-making (MDM). International guidelines about end-of-life (EOL) MDM for neonates unify in their recommendation for shared decision-making (SDM) between doctors and parents. Yet, we do not know to what extent SDM is realized in neonatal practice. OBJECTIVE We aim at examining to which extent SDM is implemented in the NICU setting. METHODS By means of Qualitative Content Analysis, audio-recorded conversations between neonatologists and parents were analyzed. We used a framework by de Vos that was used to analyze similar conversations on the PICU. RESULTS In total we analyzed 17 conversations with 23 parents of 12 NICU patients. SDM was adopted only to a small extent in neonatal EOL-MDM conversations. The extent of sharing decreased considerably over the stages of SDM. The neonatologists suggested finding a decision together with parents, while at the same time seeking parents' agreement for the intended decision to forgo life-sustaining treatment. CONCLUSIONS Since SDM was only realized to a small extent in the NICU under study, we propose evaluating how parents in this unit experience the EOL-MDM process and whether they feel their involvement in the process acceptable and beneficial. If parents evaluate their involvement in the current approach beneficial, the need for implementation of SDM to the full extent, as suggested in the guidelines, may need to be critically re-assessed.
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Affiliation(s)
- Esther S Schouten
- Division of Neonatology, LMU University Children's Hospital, Dr. v. Hauner, Munich, Germany
| | - Maria F Beyer
- Division of Neonatology, LMU University Children's Hospital, Dr. v. Hauner, Munich, Germany
| | - Andreas W Flemmer
- Division of Neonatology, LMU University Children's Hospital, Dr. v. Hauner, Munich, Germany
| | - Mirjam A de Vos
- Department of Paediatrics, Emma Children's Hospital, Amsterdam University Medical Centre, Amsterdam, Netherlands
| | - Katja Kuehlmeyer
- Institute of Ethics, History and Theory of Medicine, Medical Faculty, LMU Munich, Munich, Germany
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Banazadeh M, Khanjari S, Naddaf A, Oskouie F. Healthcare professionals-related factors affecting parents' participation in decision making for neonates with life-threatening conditions: A qualitative study. J Eval Clin Pract 2021; 27:885-897. [PMID: 33103330 DOI: 10.1111/jep.13492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Neonates with life-threatening conditions face complex clinical circumstances that confront parents and professionals with ethical decisions. Parents' participation in decision making has not gained sufficient attention in practice. Understanding factors affecting parents' participation is required. This study is part of a comprehensive project that explored the process of parents' participation in decision making for neonates with life-threatening conditions. The current study aimed to explore healthcare professionals-related factors affecting parents' participation in decision-making for neonates with life-threatening conditions. METHODS A grounded theory methodology was used in the comprehensive project. Twenty-two interviews/68 hours of observation were conducted. Data were concurrently analysed throughout data generation and constant comparative analysis. Data collected until theoretical saturation was reached, the extracted categories were coherent and the emerging theory made sense. After coding stages, the core category and the relationships with other main categories involved in the process of parents' participation in decision-making were developed. For this study, the category reflecting healthcare professionals-related factors affecting parents' participation in decision-making was reported. RESULTS Four themes were found: risk aversion including fear of litigation, fear of being accountable to the parents, and fear of bearing emotional distress; unprofessionalism including poor adherence to professional ethics, inadequate skill/knowledge, poor communication, and nurses' negligence in playing their professional role; information deficiencies including insufficient information, conflicting information, and complex and technical information, and clashes of attitudes including conflict about parents' participation in decision-making and conflict about the best interest of neonates. CONCLUSION Professionals should be aware of their role in involving parents in decision making. Training professionals on family centred care principle and communication skills contribute to support parents emotionally and respond empathically to their negative expressions. Training on ethics, development, and dissemination of guidelines and rules of conduct can make professionals more sensitive to ethical aspects of their work and may reduce their fear of litigation.
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Affiliation(s)
- Marjan Banazadeh
- Nursing Care Research Centre, Iran University of Medical Sciences, Tehran, Iran.,School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Sedigheh Khanjari
- Nursing Care Research Centre, Iran University of Medical Sciences, Tehran, Iran.,School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Naddaf
- Pediatric Department, Vali-Asr Hospital, Imam Khomeini Hospital Complex, Maternal-Fetal & Neonatal Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Oskouie
- Nursing Care Research Centre, Iran University of Medical Sciences, Tehran, Iran.,School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
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Lamau MC, Ruiz E, Merrer J, Sibiude J, Huon C, Lepercq J, Goffinet F, Jarreau PH. A new individualized prognostic approach to the management of women at risk of extreme preterm birth in France: Effect on neonatal outcome. Arch Pediatr 2021; 28:366-373. [PMID: 34059380 DOI: 10.1016/j.arcped.2021.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/19/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION After discussion with the parents, periviable infants can receive either active treatment or palliative care. The rate of active treatment in France is lower than in other developed countries, as is the survival rate of infants in this gestational age range. This study's main objective was to assess the effect of a standardized perinatal management protocol (EXPRIM) on the neonatal outcome of children born before 27 weeks of gestation. METHODS A before-and-after study was conducted in the two level-3 hospitals of the Risks and Pregnancy DHU to compare two 16-month periods. The EXPRIM protocol was based on routine administration of prenatal corticosteroid therapy and a scheduled combined obstetric-pediatric group prenatal prognostic evaluation, not based solely on gestational age. The study included all births between 22 weeks and 26 weeks+6 days of gestation, except in utero deaths diagnosed at admission and medical terminations of pregnancy for fetal malformation, both excluded. The principal endpoint was survival without severe neonatal morbidity. RESULTS The study included 267 women: 116 (128 newborns) in period 1 and 151 (172 newborns) in period 2. The median gestational age at admission to the maternity unit was 2.5 days younger in period 2, and the number of women admitted at 22-23 weeks doubled in period 2 (59 vs 29, respectively). Overall, the rates of live births, NICU transfer, and survival without severe morbidity were similar during the two periods. More infants were liveborn between 22 and 24 weeks in period 2 (66 vs 43). Of all newborns transferred to the NICU, 26 (29%) survived without severe morbidity in period 1 and 46 (39%) in period 2. After multivariate analysis, survival without severe morbidity did not differ significantly. CONCLUSION Implementation of the EXPRIM protocol led to active treatment of more mothers and their children at the border of viability, and increased the number of children who survived without severe morbidity even if, overall, there was no statistically significant difference in percentage.
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Affiliation(s)
- M C Lamau
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - E Ruiz
- Service de médecine et réanimation néonatales de Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - J Merrer
- Clinical Research Unit of Paris Descartes Necker Cochin, AP-HP, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France
| | - J Sibiude
- Service de Gynécologie-Obstétrique, AP-HP, Nord-Université de Paris, Hôpital Louis Mourier, DMU Gynécologie-Périnatalité, FHU PREMA, Colombes, France, IAME-INSERM, Paris, France
| | - C Huon
- Service de Néonatologie, AP-HP, APHP. Nord-Université de Paris, Hôpital Louis Mourier, DMU Gynécologie-Périnatalité, FHU PREMA, 178, rue des Renouillers, 92700 Colombes, France
| | - J Lepercq
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - F Goffinet
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France
| | - Pierre Henri Jarreau
- Service de médecine et réanimation néonatales de Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France.
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Ranchin B, Plaisant F, Demède D, Guillebon J, Javouhey E, Bacchetta J. Review: Neonatal dialysis is technically feasible but ethical and global issues need to be addressed. Acta Paediatr 2021; 110:781-788. [PMID: 33373057 DOI: 10.1111/apa.15539] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/28/2022]
Abstract
AIM Our aim was to look at the technical, ethical and global issues related to neonatal dialysis. METHODS We performed a PubMed research on manuscripts published from March 2010 to March 2020 and retrospectively reviewed all neonates who received dialysis in our French paediatric and neonatal intensive care units from April 2009 to March 2019. RESULTS Dialysis is performed on neonates with pre-existing renal diseases, acute kidney injuries or inborn errors of metabolism. It is required in 0.5%-1% of neonates admitted to the neonatal intensive care units. Peritoneal dialysis and extracorporeal blood purification are both feasible, with more complications, but the results are close to those obtained in older infants, at least in children without multi-organ dysfunction. Novel haemodialysis machines are being evaluated. Ethical issues are a major concern. Multidisciplinary teams should consider associated comorbidities, risks of permanent end-stage renal disease and provide parents with full and neutral information. These should drive decisions about whether dialysis is in child's best interests. CONCLUSION Neonatal dialysis is technically feasible, but ethically challenging, and short-term and long-term data remain limited. Prospective studies and dialysis registries would improve global management and quality of life of these patients at risk of chronic kidney disease.
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Affiliation(s)
- Bruno Ranchin
- Centre de Référence des Maladies Rénales Rares Hôpital Femme Mère Enfant Hospices Civils de Lyon Bron France
| | - Franck Plaisant
- Service de Néonatologie et réanimation néonatale Hôpital Femme Mère Enfant Hospices Civils de Lyon Bron France
| | - Delphine Demède
- Service de Chirurgie Pédiatrique Hôpital Femme Mère Enfant Hospices Civils de Lyon Bron France
| | - Jean‐Marie Guillebon
- Centre de Référence des Maladies Rénales Rares Hôpital Femme Mère Enfant Hospices Civils de Lyon Bron France
| | - Etienne Javouhey
- Service de Réanimation pédiatrique Hôpital Femme Mère Enfant Hospices Civils de Lyon Bron France
- Faculté de Médecine Lyon Est Université de Lyon Lyon France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares Hôpital Femme Mère Enfant Hospices Civils de Lyon Bron France
- Faculté de Médecine Lyon Est Université de Lyon Lyon France
- INSERM UMR 1033 Faculté de Médecine Lyon Est Université de Lyon Lyon France
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Chatziioannidis I, Iliodromiti Z, Boutsikou T, Pouliakis A, Giougi E, Sokou R, Vidalis T, Xanthos T, Marina C, Iacovidou N. Physicians' attitudes in relation to end-of-life decisions in Neonatal Intensive Care Units: a national multicenter survey. BMC Med Ethics 2020; 21:121. [PMID: 33225943 PMCID: PMC7681959 DOI: 10.1186/s12910-020-00555-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND End-of-life decisions for neonates with adverse prognosis are controversial and raise ethical and legal issues. In Greece, data on physicians' profiles, motivation, values and attitudes underlying such decisions and the correlation with their background are scarce. The aim was to investigate neonatologists' attitudes in Neonatal Intensive Care Units and correlate them with self-reported practices of end-of-life decisions and with their background data. METHODS A structured questionnaire was distributed to all 28 Neonatal Intensive Care Units in Greece. One hundred and sixty two out of 260 eligible physicians answered anonymously the questionnaire (response rate 66%). Demographic and professional characteristics, self-reported practices and opinions were included in the questionnaire, along with a questionnaire of 12 items measuring physicians' attitude and views ranging from value of life to quality of life approach (scale 1-5). RESULTS Continuation of treatment in neonates with adverse prognosis without adding further therapeutic interventions was the most commonly reported EoL practice, when compared to withdrawal of mechanical ventilation. Physicians with a high attitude score (indicative of value of quality-of-life) were more likely to limit, while those with a low score (indicative of value of sanctity-of-life) were more likely for continuation of intensive care. Physicians' educational level (p:0.097), involvement in research (p:0.093), religion (p:0.024) and position on the existing legal framework (p < 0.001) were factors that affected the attitude score. CONCLUSIONS Physicians presented with varying end-of-life practices. Limiting interventions in neonates with poor prognosis was strongly related to their attitudes. The most important predictors for physicians' attitudes were religiousness and belief for Greek legal system reform.
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Affiliation(s)
- Ilias Chatziioannidis
- 2nd Neonatal Department and Neonatal Intensive Care Unit, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece.
| | - Zoi Iliodromiti
- Neonatal Department, School of Medicine, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, School of Medicine, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Abraham Pouliakis
- 2nd Department of Pathology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Rozeta Sokou
- Neonatal Department, School of Medicine, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Takis Vidalis
- Hellenic National Bioethics Commission, Athens, Greece
| | | | - Cuttini Marina
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicoletta Iacovidou
- Neonatal Department, School of Medicine, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Lago P, Cavicchiolo ME, Rusalen F, Benini F. Summary of the Key Concepts on How to Develop a Perinatal Palliative Care Program. Front Pediatr 2020; 8:596744. [PMID: 33344387 PMCID: PMC7744474 DOI: 10.3389/fped.2020.596744] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/12/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose of review: The aim of this study is to assess the most significant Perinatal Palliative Care (PnPC) development projects in the literature and summarize the shared key principles. Recent findings: PnPC is a new concept in neonatal intensive care approach. Advancements in perinatal diagnostics and medical technology have changed the landscape of the perinatal world. The threshold of viability continues to decrease, and diagnostic information is available earlier in pregnancy and more rapidly at the bedside; overall outcomes continue to improve. This rapid technological improvement brings ethical debates on the quality of life of patients with life-limiting and life-threatening conditions and the need to involve the family in the decision-making process, according to their wishes and cultural beliefs. Although the Perinatal Hospice concept was developed in the 1980s in the US, the first recommendations on how to develop a PnPC pathway were published in the early 2000s. We considered the most relevant position statements or guidelines on PnPC published in the last two decades. Some of them were more pertinent to pediatrics but still useful for the fundamental concepts and PnPC project's development. Summary: Health care providers and institutions are encouraged to develop PnPC programs, which have the goal of maximizing the quality of life of infants with non-curable conditions. These may generally include the following: a formal prenatal consultation; development of a coordinated birth plan between obstetrician, newborn care, and family; access to other neonatal and pediatric specialties, as needed; comfort palliative care during the prenatal, birth, and postnatal periods; and psychosocial and spiritual support for families, siblings, and staff.
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Affiliation(s)
- Paola Lago
- Neonatal Intensive Care Unit, Ca' Foncello Hospital, Treviso, Italy
| | - Maria Elena Cavicchiolo
- Department of Woman and Child Health, Neonatal Intensive Care Unit, University of Padua, Padua, Italy
| | - Francesca Rusalen
- Department of Woman and Child Health, Paediatric Pain and Palliative Care Service, University of Padua, Padua, Italy
| | - Franca Benini
- Department of Woman and Child Health, Paediatric Pain and Palliative Care Service, University of Padua, Padua, Italy
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Rusalen F, Cavicchiolo ME, Lago P, Salvadori S, Benini F. Perinatal palliative care: a dedicated care pathway. BMJ Support Palliat Care 2019; 11:329-334. [PMID: 31324614 DOI: 10.1136/bmjspcare-2019-001849] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/28/2019] [Accepted: 06/05/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Ensure access to perinatal palliative care (PnPC) to all eligible fetuses/infants/parents. DESIGN During 12 meetings in 2016, a multidisciplinary work-group (WG) performed literature review (Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method was applied), including the ethical and legal references, in order to propose shared care pathway. SETTING Maternal-Infant Department of Padua's University Hospital. PATIENTS PnPC eligible population has been divided into three main groups: extremely preterm newborns (first group), newborns with prenatal/postnatal diagnosis of life-limiting and/or life-threatening disease and poor prognosis (second group) and newborns for whom a shift to PnPC is appropriate after the initial intensive care (third group). INTERVENTIONS The multidisciplinary WG has shared care pathway for these three groups and defined roles and responsibilities. MAIN OUTCOME MEASURES Prenatal and postnatal management, symptom's treatment, end-of-life care. RESULTS The best care setting and the best practice for PnPC have been defined, as well as the indications for family support, corpse management and postmortem counselling, as well suggestion for conflicts' mediation. CONCLUSIONS PnPC represents an emerging field within the paediatric palliative care and calls for the development of dedicated shared pathways, in order to ensure accessibility and quality of care to this specific population of newborns.
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Affiliation(s)
- Francesca Rusalen
- Woman's and Child's Department, Pediatric Pain and Palliative Care Service, University of Padua, Padova, Italy
| | - Maria Elena Cavicchiolo
- Woman's and Child's Department, Neonatal Intensive Care Unit, University of Padua, Padova, Veneto, Italy
| | - Paola Lago
- Woman's and Child's Department, Neonatal Intensive Care Unit, University of Padua, Padova, Veneto, Italy
| | - Sabrina Salvadori
- Woman's and Child's Department, Neonatal Intensive Care Unit, University of Padua, Padova, Veneto, Italy
| | - Franca Benini
- Woman's and Child's Department, Pediatric Pain and Palliative Care Service, University of Padua, Padova, Italy
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13
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Forner O, Schiby A, Ridley A, Thiriez G, Mugabo I, Morel V, Mulin B, Filiatre JC, Riethmuller D, Levy G, Semama D, Martin D, Chantegret C, Bert S, Godoy F, Sagot P, Rousseau T, Burguet A. Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France? Arch Pediatr 2018; 25:383-388. [PMID: 30041886 DOI: 10.1016/j.arcped.2018.06.006] [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: 02/09/2018] [Revised: 05/27/2018] [Accepted: 06/20/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU). METHODS Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week 0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU. RESULTS A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03). CONCLUSIONS This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.
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Affiliation(s)
- O Forner
- Service maternité-obstétrique, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France.
| | - A Schiby
- Service réanimation néonatale et pédiatrique, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - A Ridley
- Service médecine pédiatrique, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - G Thiriez
- Service réanimation néonatale et pédiatrique, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - I Mugabo
- Service maternité-obstétrique, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - V Morel
- Service réanimation néonatale et pédiatrique, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - B Mulin
- Réseau périnatalité de Franche-Comté, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - J-C Filiatre
- Réseau périnatalité de Franche-Comté, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - D Riethmuller
- Service gynécologie obstétrique, hôpital Jean-Minjoz, 3, boulevard Alexandre-Fleming, 25000 Besançon, France
| | - G Levy
- Service gynécologie obstétrique, hôpital Nord Franche-Comté, 100, route de Moval, 90400 Trevenans, France
| | - D Semama
- Service réanimation néonatale et pédiatrique, hôpital d'enfants, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - D Martin
- Service réanimation néonatale et pédiatrique, hôpital d'enfants, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - C Chantegret
- Service réanimation néonatale et pédiatrique, hôpital d'enfants, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - S Bert
- Service maternité obstétrique, hôpital d'enfants, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - F Godoy
- Service réanimation néonatale et pédiatrique, hôpital d'enfants, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - P Sagot
- Service gynécologie obstétrique, CHU de Dijon, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - T Rousseau
- Service gynécologie obstétrique, CHU de Dijon, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - A Burguet
- Service réanimation néonatale et pédiatrique, hôpital d'enfants, 14, rue Paul-Gaffarel, 21000 Dijon, France
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Ethics of End of Life Decisions in Pediatrics: A Narrative Review of the Roles of Caregivers, Shared Decision-Making, and Patient Centered Values. Behav Sci (Basel) 2018; 8:bs8050042. [PMID: 29701637 PMCID: PMC5981236 DOI: 10.3390/bs8050042] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 11/18/2022] Open
Abstract
Background: This manuscript reviews unique aspects of end of life decision-making in pediatrics. Methods: A narrative literature review of pediatric end of life issues was performed in the English language. Results: While a paternalistic approach is typically applied to children with life-limiting medical prognoses, the cognitive, language, and physical variability in this patient population is wide and worthy of review. In end of life discussions in pediatrics, the consideration of a child’s input is often not reviewed in depth, although a shared decision-making model is ideal for use, even for children with presumed limitations due to age. This narrative review of end of life decision-making in pediatric care explores nomenclature, the introduction of the concept of death, relevant historical studies, limitations to the shared decision-making model, the current state of end of life autonomy in pediatrics, and future directions and needs. Although progress is being made toward a more uniform and standardized approach to care, few non-institutional protocols exist. Complicating factors in the lack of guidelines include the unique facets of pediatric end of life care, including physical age, paternalism, the cognitive and language capacity of patients, subconscious influencers of parents, and normative values of death in pediatrics. Conclusions: Although there have been strides in end of life decision-making in pediatrics, further investigation and research is needed in this field.
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15
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Bonet M, Cuttini M, Piedvache A, Boyle EM, Jarreau PH, Kollée L, Maier RF, Milligan D, Van Reempts P, Weber T, Barros H, Gadzinowki J, Draper ES, Zeitlin J. Changes in management policies for extremely preterm births and neonatal outcomes from 2003 to 2012: two population-based studies in ten European regions. BJOG 2017; 124:1595-1604. [PMID: 28294506 DOI: 10.1111/1471-0528.14639] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate changes in maternity and neonatal unit policies towards extremely preterm infants (EPTIs) between 2003 and 2012, and concurrent trends in their mortality and morbidity in ten European regions. DESIGN Population-based cohort studies in 2003 (MOSAIC study) and 2011/2012 (EPICE study) and questionnaires from hospitals. SETTING 70 hospitals in ten European regions. POPULATION Infants born at <27 weeks of gestational age (GA) in hospitals participating in both the MOSAIC and EPICE studies (1240 in 2003, 1293 in 2011/2012). METHODS We used McNemar's Chi2 test, paired t-tests and conditional logistic regression for comparisons over time. MAIN OUTCOMES MEASURES Reported policies, mortality and morbidity of EPTIs. RESULTS The lowest GA at which maternity units reported performing a caesarean section for acute distress of a singleton non-malformed fetus decreased from an average of 24.7 to 24.1 weeks (P < 0.01) when parents were in favour of active management, and 26.1 to 25.2 weeks (P = 0.01) when parents were against. Units reported that neonatologists were called more often for spontaneous deliveries starting at 22 weeks GA in 2012 and more often made decisions about active resuscitation alone, rather than in multidisciplinary teams. In-hospital mortality after live birth for EPTIs decreased from 50% to 42% (P < 0.01). Units reporting more active management in 2012 than 2003 had higher mortality in 2003 (55% versus 43%; P < 0.01) and experienced larger declines (55 to 44%; P < 0.001) than units where policies stayed the same (43 to 37%; P = 0.1). CONCLUSIONS European hospitals reporting changes in management policies experienced larger survival gains for EPTIs. TWEETABLE ABSTRACT Changes in reported policies for management of extremely preterm births were related to mortality declines.
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Affiliation(s)
- M Bonet
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - M Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - A Piedvache
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - E M Boyle
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - P H Jarreau
- Service de Médecine et Réanimation néonatales de Port-Royal, DHU Risks in Pregnancy, Université Paris Descartes and Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaire Paris Centre Site Cochin, Paris, France
| | - L Kollée
- Department of Neonatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - R F Maier
- Children's Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | - Dwa Milligan
- University of Newcastle, Newcastle-upon-Tyne, UK
| | - P Van Reempts
- Department of Neonatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium.,Study Centre for Perinatal Epidemiology Flanders, Brussels, Belgium
| | - T Weber
- Department of Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark
| | - H Barros
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - J Gadzinowki
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - E S Draper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - J Zeitlin
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
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16
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Abstract
Chronic irreversible kidney disease requiring dialysis is rare in the neonate. Many such neonates are diagnosed following antenatal ultrasound with congenital abnormalities of the kidneys and urinary tract. There is an increased incidence of prematurity and infants that are small for gestational age. Given the natural improvement in renal function that occurs in the neonatal period, some with extremely poor renal function may, with careful management of fluid and electrolytes, be kept off dialysis until the creatinine reaches a nadir when a definitive plan can be made. There is a very high incidence of comorbidity and this affects survival, which for those on dialysis is about 80% at five years. The multiple and complex ethical issues surrounding the management of these very young children are discussed.
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Affiliation(s)
- Lesley Rees
- Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, UK.
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17
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Durrmeyer X, Scholer-Lascourrèges C, Boujenah L, Bétrémieux P, Claris O, Garel M, Kaminski M, Foix-L'Helias L, Caeymaex L. Delivery room deaths of extremely preterm babies: an observational study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F98-F103. [PMID: 27531225 DOI: 10.1136/archdischild-2016-310718] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 07/14/2016] [Accepted: 07/25/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Many extremely preterm neonates die in the delivery room (DR) after decisions to withhold or withdraw life-sustaining treatments or after failed resuscitation. Specific palliative care is then recommended but sparse data exist about the actual management of these dying babies. The objective of this study was to describe the clinical course and management of neonates born between 22 and 26 weeks of gestation who died in the DR in France. DESIGN, SETTING, PATIENTS Prospective study including neonates, who were liveborn between 22+0 and 26+6 weeks of gestation and died in the DR in 2011, among infants included in the EPIPAGE-2 study at the 18 centres participating in this substudy of extremely preterm neonates. Data were collected by a questionnaire completed by the professional caring for each baby. RESULTS The study included 73 children, with a median (IQR) gestational age of 24 (23-24) weeks. Median (IQR) duration of life was 53 (20-82) min. All but one were both wrapped and warmed. Pain was assessed for 72%, although without using any scale. Gasping was described for 66%. Comfort medications were administered to 35 children (50%), significantly more frequently to babies with gasping (p=0.001). Mother-child contact was reported for 78%, and psychological support offered to parents of 92%. CONCLUSIONS Non-pharmacological comfort care and parental support were routinely given. Comfort medication was given much more frequently than previously reported in other DRs. These data should encourage work on the indications for comfort medication and the interpretation of gasping.
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Affiliation(s)
- Xavier Durrmeyer
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France.,Service de Médecine Néonatale, Centre Hospitalier Intercommunal de Creteil, Clinical Research Center CHI Créteil, Créteil, France
| | - Claire Scholer-Lascourrèges
- Service de Médecine Néonatale, Centre Hospitalier Intercommunal de Creteil, Clinical Research Center CHI Créteil, Créteil, France
| | - Laurence Boujenah
- Department of Néonatologie, Groupe Hospitalier Paris St Joseph 185 rue Raymond Losserand, Paris, France
| | | | - Olivier Claris
- Department of Neonatology, Hospices Civils de Lyon, Hôpital Femme mère enfants, Bron, France.,Claude Bernard University EAM 41-28, Lyon, France
| | - Micheline Garel
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Monique Kaminski
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Laurence Foix-L'Helias
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France.,Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France
| | - Laurence Caeymaex
- Service de Médecine Néonatale, Centre Hospitalier Intercommunal de Creteil, Clinical Research Center CHI Créteil, Créteil, France.,CEDITEC (Centre d'Etude des discours, images, textes, écrits, communications) Université Paris Est Creteil UPEC, Creteil, France
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18
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Pastura PSVC, Land MGP. CRIANÇAS COM MÚLTIPLAS MALFORMAÇÕES CONGÊNITAS: QUAIS SÃO OS LIMITES ENTRE OBSTINAÇÃO TERAPÊUTICA E TRATAMENTO DE BENEFÍCIO DUVIDOSO? REVISTA PAULISTA DE PEDIATRIA 2017; 35:110-114. [PMID: 28977304 PMCID: PMC5417797 DOI: 10.1590/1984-0462/;2017;35;1;00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/07/2016] [Indexed: 11/29/2022]
Abstract
Objective: Therapeutic approach of children with multiple malformations poses many dilemmas, making it difficult to build a line between the treatment of uncertain benefit and therapeutic obstinacy. The aim of this paper was to highlight possible sources of uncertainty in the decision-making process, for this group of children. Case description: An 11-month-old boy, born with multiple birth defects and abandoned by his parents, has never been discharged home. He has complex congenital heart disease, main left bronchus stenosis and imperforate anus. He is under technological support and has gone through many surgical procedures. The complete correction of the cardiac defect seems unlikely, and every attempt to wean the ventilator has failed. Comments: The first two main sources of uncertainty in the management of children with multiple birth defects are related to an uncertain prognosis. There is a lack of empirical data, due to the multiple possibilities of anatomic or functional organ involvement, with few similar cases described. Prognosis is also unpredictable for neuro-developmental evolution, as well as the capacity for the development and regeneration of other organs. Another source of uncertainty is how to qualify the present and future life as worth living, by weighing the costs and benefits. The fourth source of uncertainty is who has the decision: physicians or parents? Finally, if a treatment is defined futile then, how to limit support? No single framework exists to help these delicate decision-making processes. We propose, then, that physicians should be committed to develop their own perception skills in order to understand patient’s manifestations of needs and family values.
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19
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Pennaforte T, Moussa A, Janvier A. Parler de la vie et de la mort en néonatologie : comment optimiser la communication avec les parents ? Arch Pediatr 2017; 24:146-154. [DOI: 10.1016/j.arcped.2016.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 07/06/2016] [Accepted: 11/14/2016] [Indexed: 02/03/2023]
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20
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El Ayoubi M, Patkai J, Bordarier C, Desfrere L, Moriette G, Jarreau PH, Zeitlin J. Impact of fetal growth restriction on neurodevelopmental outcome at 2 years for extremely preterm infants: a single institution study. Dev Med Child Neurol 2016; 58:1249-1256. [PMID: 27520849 DOI: 10.1111/dmcn.13218] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2016] [Indexed: 01/28/2023]
Abstract
AIM We evaluated the impact of fetal growth restriction on neurodevelopmental outcomes at 2 years corrected age for infants born before 27 weeks gestational age. METHOD Data on infants born before 27 weeks gestational age between 1999 and 2008 (n=463), admitted to a tertiary neonatal unit in Paris, were used to compare neurological outcomes at 2 years for infants with birthweight lower than the 10th centile and birthweight of at least the 10th centile, using intrauterine reference curves. Outcomes were cerebral palsy (CP) and the Brunet-Lézine assessment of cognitive development, which provides age-corrected overall and domain-specific (global and fine motor skills, language and social interaction) developmental quotients. Models were adjusted for perinatal and social factors. RESULTS Seventy-two percent of infants were discharged alive. Eighty-three percent (n=268) were evaluated at 2 years. Six percent had CP. Fetal growth restriction was not associated with the risk of CP. After adjustment, children with a birthweight lower than the 10th centile had a global developmental quotient 4.7 points lower than those with birthweight of at least the 10th centile (p<0.001); differences were greatest for fine motor and social skills (-4.7, p=0.053 and -7.3, p<0.001 respectively). INTERPRETATION In extremely preterm children, fetal growth restriction was associated with poorer neurodevelopmental outcomes at 2 years, but not with CP.
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Affiliation(s)
- Mayass El Ayoubi
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.,Service de Médecine et Réanimation Néonatales de Port-Royal, Hôpitaux Universitaire Paris Centre Site Cochin, Université Paris V René Descartes and Assistance Publique Hôpitaux de Paris, Paris, France
| | - Juliana Patkai
- Service de Médecine et Réanimation Néonatales de Port-Royal, Hôpitaux Universitaire Paris Centre Site Cochin, Université Paris V René Descartes and Assistance Publique Hôpitaux de Paris, Paris, France
| | - Cécile Bordarier
- Service de Médecine et Réanimation Néonatales de Port-Royal, Hôpitaux Universitaire Paris Centre Site Cochin, Université Paris V René Descartes and Assistance Publique Hôpitaux de Paris, Paris, France
| | - Luc Desfrere
- Service de Médecine et Réanimation Néonatales - Maternité de Louis Mourier, Hôpitaux Universitaires Paris Nord-Val de Seine, Paris, France
| | - Guy Moriette
- Service de Médecine et Réanimation Néonatales de Port-Royal, Hôpitaux Universitaire Paris Centre Site Cochin, Université Paris V René Descartes and Assistance Publique Hôpitaux de Paris, Paris, France
| | - Pierre-Henri Jarreau
- Service de Médecine et Réanimation Néonatales de Port-Royal, Hôpitaux Universitaire Paris Centre Site Cochin, Université Paris V René Descartes and Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jennifer Zeitlin
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
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21
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Perlbarg J, Ancel PY, Khoshnood B, Durox M, Boileau P, Garel M, Kaminski M, Goffinet F, Foix-L'Hélias L. Delivery room management of extremely preterm infants: the EPIPAGE-2 study. Arch Dis Child Fetal Neonatal Ed 2016; 101:F384-90. [PMID: 26837310 DOI: 10.1136/archdischild-2015-308728] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 01/06/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To analyse the delivery room management of babies born between 22 and 26 weeks of completed gestational age and to identify the factors associated with the withholding or withdrawal of intensive care. STUDY DESIGN Population-based cohort study. PATIENTS AND METHODS Our study population comprised 2145 births between 22 and 26 completed weeks enrolled in the EPIPAGE-2 study, a French cohort of very preterm infants born in 2011. The primary outcome measure was withholding or withdrawal of intensive care in the delivery room. RESULTS Among infants born alive at 22-23 weeks, intensive care was withheld or withdrawn for >90%. At 24 weeks, resuscitative measures were withheld or withdrawn for 38%, at 25 weeks for 8% and at 26 weeks for 3%. Other factors besides gestational age at birth associated with this withholding or withdrawal for infants born at 24-26 weeks were birth weight <600 g, emergency delivery (within 24 h of the mother's admission) and singleton pregnancy. Although rates of withholding or withdrawal of intensive care varied substantially between maternity units (from 0% to 100%), the variability was primarily explained by differences in distributions of gestational age at birth. CONCLUSIONS Although gestational age is only one factor predicting survival of preterm infants, practices in France appear to be based primarily on this factor, which thus has direct effects on the survival of extremely preterm infants. The ethical implications of basing life and death decisions only on gestational age before 25 weeks require further examination.
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Affiliation(s)
- J Perlbarg
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - P Y Ancel
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France URC-CIC P1419, DHU Risk in Pregnancy, Cochin Hôtel-Dieu Hospital, APHP, Paris, France
| | - B Khoshnood
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - M Durox
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - P Boileau
- Neonatal Intensive Care Unit, CHI Poissy Saint-Germain-en-Laye, Poissy, France EA 7285, Versailles Saint-Quentin-en-Yvelines University, Versailles, France
| | - M Garel
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - M Kaminski
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France
| | - F Goffinet
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France Maternité Port-Royal, Paris-Descartes University, Cochin Broca Hôtel-Dieu Hospital, Assistance Publique-Hôpitaux de Paris, DHU Risk in Pregnancy, Paris, France
| | - L Foix-L'Hélias
- Obstetrical Perinatal and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France
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Kuhlen M, Höll JI, Sabir H, Borkhardt A, Janßen G. Experiences in palliative home care of infants with life-limiting conditions. Eur J Pediatr 2016; 175:321-7. [PMID: 26411975 DOI: 10.1007/s00431-015-2637-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/18/2015] [Indexed: 11/29/2022]
Abstract
UNLABELLED The aim of this study was to determine the distinct issues neonates/infants with life-limiting conditions and their families face during palliative home care and to enable physicians/caregivers to carefully address their needs. Data on home-based palliative care of all neonates and infants, who were being taken care of by our paediatric palliative care team between 2007 and 2014, was analysed. A total of 31 patients (pts) were analysed. The majority of patients (n = 17) were diagnosed with congenital malformations or chromosomal abnormalities. Twenty pts died, five of them in hospital. A high percentage of pts presented with swallowing incoordination (83.9%) and was fed either by nasogastric tube or percutaneous endoscopic gastrostomy. Of the pts, 71.0% were treated with analgesics, 45.2% were oxygen dependent, and 9.7% required mechanical ventilation. Highest mortality was seen in pts with perinatal complications (75%). In four (12.9%) pts, palliative home care could come to an end as their conditions substantially improved. CONCLUSIONS Palliative treatment of neonates/very young infants with terminal conditions at home seems to be similar to that of older children and feasible in children even with unstable conditions. The spectrum of diagnoses, signs and symptoms varies from older children with swallowing incoordination and artificial nutrition being of particular importance.
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Affiliation(s)
- Michaela Kuhlen
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Medical Faculty, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
| | - Jessica I Höll
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Medical Faculty, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
| | - Hemmen Sabir
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
| | - Arndt Borkhardt
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Medical Faculty, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
| | - Gisela Janßen
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Medical Faculty, Centre for Child and Adolescent Health, University of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
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Limitación del esfuerzo terapéutico en pacientes hospitalizados en el Servicio de Medicina Interna. ACTA ACUST UNITED AC 2016; 31:70-5. [DOI: 10.1016/j.cali.2015.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 11/18/2022]
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Soins palliatifs en néonatologie : analyse et évolution des pratiques sur 5ans dans un centre de niveau 3. Arch Pediatr 2014; 21:177-83. [DOI: 10.1016/j.arcped.2013.10.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 07/08/2013] [Accepted: 10/16/2013] [Indexed: 11/23/2022]
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25
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Silberberg AA, Gallo JE. Managing end-of-life decisions in critical infants: a survey of neonatologists in Cordoba, Argentina. Acta Paediatr 2013; 102:e475-7. [PMID: 23808648 DOI: 10.1111/apa.12333] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 06/12/2013] [Accepted: 06/25/2013] [Indexed: 11/29/2022]
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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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27
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Ho LY, Tan TK, Goh PSJ. Advocating for the Best Interests of Critically Ill Newborn Infants. PROCEEDINGS OF SINGAPORE HEALTHCARE 2013. [DOI: 10.1177/201010581302200309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This bioethics article deals with the conflict and difficulty in quality of life judgements. The importance and roles of the various stakeholders in determining the management of critically ill infants are described. This is an in-depth insider perspective of one of the most difficult medical decision making processes when dealing with infants with poor prognoses. The complex treatment options often fraught with ethical dilemmas and conflict are discussed from the viewpoints of patient, family, and physician. The role of the ethics committee and legislation in the decision making process is discussed.
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Affiliation(s)
- Lai Yun Ho
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
| | - Tong Khee Tan
- Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital, Singapore
| | - Pheck Suan June Goh
- Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital, Singapore
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28
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Einaudi MA, Gire C, Loundou A, Le Coz P, Auquier P. Quality of life assessment in preterm children: physicians' knowledge, attitude, belief, practice--a KABP study. BMC Pediatr 2013; 13:58. [PMID: 23601174 PMCID: PMC3637183 DOI: 10.1186/1471-2431-13-58] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 04/15/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The sequelae of extremely preterm birth have an impact on the quality of life (QoL) of these children. Standardized assessment of their QoL is rarely done in France. The aim of this study is to examine among all the types of physicians involved in the management of children born extremely preterm, their knowledge, use in routine practice and expectations concerning QoL assessment of these children using standardized questionnaires. METHODS Prospective survey among heads of obstetric, neonatal medicine and paediatric neurology departments, by means of questionnaires. Two qualitative methods were used: focus groups and Delphi method. RESULTS Seventy-eight physicians participated (obstetricians 24%, neonatologists 58%, paediatric neurologists 18%). The physicians considered QoL a relevant concept which they assessed subjectively. They expressed a need for information on methods of assessment. An ideal QoL questionnaire was described. Expectations regarding availability of QoL data were expressed from a medical, family and societal perspective. The impact of QoL measurement on the ethical aspect of decision-making was approached, in particular the potential impact of this tool on the decision made. Expectations were found to differ between specialties. CONCLUSION This original study reports the perspective of experts on taking into consideration the QoL of children born extremely preterm. This is a subjective notion that is difficult to implement and which may influence therapeutic choices.
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Affiliation(s)
- Marie-Ange Einaudi
- Timone University Hospital, Espace Ethique Méditerranéen; Aix-Marseille University, UMR 7268 Anthropologie bio-culturelle, Droit, Éthique & Santé (ADÉS), Marseille, France.
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29
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Affiliation(s)
- Umberto Simeoni
- Department of Neonatology, AP-HM & Aix-Marseille Université, Marseille, France.
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Noseda C, Mialet-Marty T, Basquin A, Letourneur I, Bertorello I, Charlot F, Le Bouar G, Bétrémieux P. Hypoplasies sévères du ventricule gauche : soins palliatifs après un diagnostic prénatal. Arch Pediatr 2012; 19:374-80. [DOI: 10.1016/j.arcped.2012.01.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 12/22/2011] [Accepted: 01/24/2012] [Indexed: 11/28/2022]
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Caeymaex L, Speranza M, Vasilescu C, Danan C, Bourrat MM, Garel M, Jousselme C. Living with a crucial decision: a qualitative study of parental narratives three years after the loss of their newborn in the NICU. PLoS One 2011; 6:e28633. [PMID: 22194873 PMCID: PMC3237456 DOI: 10.1371/journal.pone.0028633] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Accepted: 11/11/2011] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The importance of involving parents in the end-of-life decision-making-process (EOL DMP) for their child in the neonatal intensive care unit (NICU) is recognised by ethical guidelines in numerous countries. However, studies exploring parents' opinions on the type of involvement report conflicting results. This study sought to explore parents' experience of the EOL DMP for their child in the NICU. METHODS The study used a retrospective longitudinal design with a qualitative analysis of parental experience 3 years after the death of their child in four NICUs in France. 53 face-to-face interviews and 80 telephone interviews were conducted with 164 individuals. Semi-structured interviews were conducted to explore how parents perceived their role in the decision process, what they valued about physicians' attitudes in this situation and whether their long-term emotional well being varied according to their perceived role in the EOL DMP. FINDINGS Qualitative analysis identified four types of perceived role in the DMP: shared, medical, informed parental decision, and no decision. Shared DM was the most appreciated by parents. Medical DM was experienced as positive only when it was associated with communication. Informed parental DM was associated with feelings of anxiousness and abandonment. The physicians' attitudes that were perceived as helpful in the long term were explicit sharing of responsibility, clear expression of staff preferences, and respectful care and language toward the child. INTERPRETATION Parents find it valuable to express their opinion in the EOL DMP of their child. Nonetheless, they do need continuous emotional support and an explicit share of the responsibility for the decision. As involvement preferences and associated feelings can vary, parents should be able to decide what role they want to play. However, our study suggests that fully autonomous decisions should be misadvised in these types of tragic choices.
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Affiliation(s)
- Laurence Caeymaex
- Centre Hospitalier Intercommunal de Creteil, Newborn Intensive Care Unit, Department of Research in Ethics EA 1610 Studies on Science and Techniques, Paris-South University, Creteil, France.
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Saugstad OD. A time to be born and a time to die: ethical challenges in the neonatal intensive care unit. Neonatology 2011; 100:215-6. [PMID: 21654182 DOI: 10.1159/000329089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 04/30/2011] [Indexed: 11/19/2022]
Affiliation(s)
- Ola Didrik Saugstad
- Department of Pediatric Research, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway.
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