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Mariani GL, Konikoff LL. Withdrawing Assisted Nutrition in Neonates: A Survey on Attitudes and Insights in Argentina. Am J Perinatol 2024; 41:1417-1423. [PMID: 37003254 DOI: 10.1055/a-2067-5248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
OBJECTIVE This study aimed to assess beliefs and attitudes of Argentinean neonatologists and neonatal nurses regarding end-of-life care of newborn infants, including withdrawal of clinically assisted nutrition and hydration (CANH). STUDY DESIGN A five-domain survey was sent to 465 neonatal health care workers, which included demographic data, general ethical concepts, participation in end-of-life decisions, beliefs about end-of-life care practices, and presentation of four clinical scenarios. Standard statistical tests were used, and a multivariable analysis was done to evaluate variables independently associated with rejecting the withdrawal of CANH. RESULTS A total of 227 questionnaires were anonymously completed, 60% by physicians and 40% by nurses. More respondents agreed to withdraw mechanical ventilation in comparison to CANH in patients under certain circumstances (88 vs. 62%, p < 0.01). The most accepted variables when deciding to withdraw care were the quality of life perceived by parents (86%) and their religious beliefs (73%). A total of 93% agreed that parents should be included in the decision, but only 74% acknowledged they are included in real practice. Considering the scenario of a newborn with severe and irreversible neurological compromise, 46% of respondents were opposed to suspending enteral nutrition. No independent variables were found to be associated with opposing the withdrawal of CANH. Of those agreeing to withdraw enteral feeds under certain circumstances, for the severely neurologically affected neonate 58% would either refuse to limit enteral feeds or consult with an ethics committee before doing so. When given the scenario of their own severe and irreversible neurological compromise, 68% agreed to have enteral feeds withdrawn to themselves, and they were more likely to agree with withdrawing feeds for the severely compromised neonate (odds ratio: 7.2; 95% confidence interval: 2.7-24.1). CONCLUSION While most health care providers agreed to withdraw life-sustaining support under certain conditions, many were reluctant to suspend CANH. Many responses differed when being asked as general statements versus actual clinical scenarios. KEY POINTS · Withdrawal of assisted nutrition is supported by the American Academy of Pediatrics in certain scenarios.. · Many neonatal intensive care units health care providers from Argentina are reluctant to suspend assisted nutrition.. · There is a need to learn how to deal with complex bioethical issues..
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Affiliation(s)
- Gonzalo L Mariani
- Division of Neonatology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Departamento de Postgrado, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Laura L Konikoff
- Division of Neonatology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Departamento de Postgrado, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Mariani GL, Contrera PJ, Virasoro MDLA, Portela MC, Urquizu Handal MI, Ávila AS, Fernández AL, Fernandez Riera P, Cardigni G, Vain NE. End-of-Life Care for Newborn Infants: A Multicenter Real-Life Prospective Study. Neonatology 2024:1-9. [PMID: 38801819 DOI: 10.1159/000538814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/07/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Most neonatal deaths in industrialized countries follow a process of redirection of care. The objectives of this study were to describe how neonates die in a middle-income country, whether there was redirection of care, and the reason for this decision. METHODS This was a prospective, multicenter, cross-sectional study. Neonates who died in the delivery room or in the neonatal intensive care unit in 97 hospitals over a 6-month period were included. After each neonatal death, one investigator interviewed a member of the healthcare team who had been involved in the end-of-life care process. Perinatal data, conditions that led to death, whether there was redirection of care, and details of the end-of-life process were recorded. RESULTS Data from 697 neonatal deaths were analyzed, which represent 80% of the total deaths occurring in Argentina in that period. The main causes of death were complications of prematurity (47%) and congenital anomalies (27%). Overall, 32% of neonates died after a process of redirection of care, and this was less frequent in the neonatal intensive care unit (28%) than in the delivery room (70%, p < 0.001). The reasons for withholding/withdrawing care were inevitable death (75%) and severe compromise of expected quality of life (25%). Redirection of care consisted in withholding therapies in 66% and withdrawal in 34%. A diagnosis of a major congenital anomaly increased the odds of redirection of care (OR 5.45; 95% CI: 3.59-8.27). CONCLUSION Most neonates who die in Argentina do so while receiving full support. Redirection of care mainly follows a condition of inevitable death.
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Affiliation(s)
- Gonzalo Luis Mariani
- Servicio de Neonatología Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pamela Judith Contrera
- Servicio de Neonatología, Sanatorio de la Trinidad San Isidro, Provincia de Buenos Aires, Buenos Aires, Argentina
| | | | - María Constanza Portela
- Servicio de Neonatología Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" (CEMIC), sede Saavedra, Buenos Aires, Argentina
| | - María Ines Urquizu Handal
- Servicio de Neonatología, Sanatorio de la Trinidad San Isidro, Provincia de Buenos Aires, Buenos Aires, Argentina
- Servicio de Neonatología, Sanatorio de la Trinidad Ramos Mejía, Provincia de Buenos Aires, Buenos Aires, Argentina
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Aldana Soledad Ávila
- Servicio de Neonatología, Sanatorio de la Trinidad Ramos Mejía, Provincia de Buenos Aires, Buenos Aires, Argentina
- Dirección de Salud Perinatal y Niñez, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | | | - Patricia Fernandez Riera
- Dirección de Salud Perinatal y Niñez, Ministerio de Salud de la Nación, Buenos Aires, Argentina
- Servicio de Neonatología, Hospital Británico, Buenos Aires, Argentina
| | - Gustavo Cardigni
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Néstor Eduardo Vain
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
- Facultad de Medicina Universidad de Buenos Aires, Buenos Aires, Argentina
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Schneider K, Roll S, Tissen-Diabaté T, Bührer C, Garten L. Public Attitudes Toward Ethics and Practices in End-of-Life Decision-Making for Neonates. JAMA Netw Open 2024; 7:e2353264. [PMID: 38270948 PMCID: PMC10811557 DOI: 10.1001/jamanetworkopen.2023.53264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/05/2023] [Indexed: 01/26/2024] Open
Abstract
Importance Attitudes toward end-of-life decision-making in neonatology have been studied in physicians and other health care professionals and are mostly shaped by their clinical education and work experiences. In contrast, attitudes among the general public have not yet been investigated. Objective To assess (1) attitudes in the general public toward euthanasia and withdrawal of life-prolonging treatment in neonates with severe life-limiting conditions, (2) knowledge of current German recommendations, and (3) values in the German society regarding ethical issues and proxy decisions at the beginning of life. Design, Setting, and Participants This cross-sectional study was performed in Germany and used an exploratory design to analyze responses to an interview conducted by an independent, established commissioned polling institute in March and April 2022. Participants were 16 years or older, with German language fluency and comprehension and living in Germany. Main Outcomes and Measures Knowledge about recommendations for euthanasia and withdrawal of life-prolonging treatment as well as personal attitudes toward (1) euthanasia and withdrawal of life-prolonging treatment and (2) surrogate end-of-life decision-making for newborn infants were assessed. Results The study included 2116 participants (1077 females [50.9%]; mean [SD] age 52.1 [18.7] years). Of the participants, 16.8% (311 of 1851) reported knowing the German recommendations for euthanasia and withdrawal of life-prolonging treatment for neonates. Euthanasia and withdrawal of life-prolonging treatment were supported by 64.7% (1369 of 2116) and 77.9% (1649 of 2116) of respondents, respectively. Shared decision-making between parents and physicians for neonates in end-of-life situations was supported by 65.6% of participants (1388). In situations where shared decision-making was not possible, 73.4% of respondents (1019 of 1388) put the ultimate decision to the parents. The magnitude of the associations was low between sociodemographic factors and views on ethical issues and customary practices involved in end-of-life decisions for neonates. Conclusions and Relevance Results of this cross-sectional study suggested that most respondents were not aware of the national German recommendations for euthanasia and withdrawal of life-prolonging treatment for sick and extremely preterm newborns. When counseling parents of periviable newborns, clinicians may need to exert more effort in explaining the legal and ethical framework; a highly individualized approach is warranted.
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Affiliation(s)
- Katja Schneider
- Department of Neonatology, Gemeinnützige Gesellschaft der Franziskanerinnen zu Olpe, Marien-Hospital, Bonn, Germany
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Stephanie Roll
- Institute of Social Medicine, Epidemiology and Health Economics, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Tatjana Tissen-Diabaté
- Institute of Social Medicine, Epidemiology and Health Economics, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Garten
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Silberberg A, Etchegaray A, Juárez Peñalva S, Villar MJ, Musante G. Attitudes of Argentinean Neonatologists toward Resuscitation of Infants with Trisomies 21, 18, and 13: A Multicenter Survey. Am J Perinatol 2022; 39:1248-1253. [PMID: 33454946 DOI: 10.1055/s-0040-1722602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE This study was aimed to explore the attitude of Argentinean neonatologists in the delivery room on resuscitating infants with trisomies. STUDY DESIGN An anonymous questionnaire was completed by neonatologists staffing level-III neonatal intensive care units (NICUs) on resuscitation of children with trisomies 21, 18, and 13. Potential sociocultural factors influencing the decision to resuscitate were included. RESULTS Overall, 314 neonatologists in 34 units in the Buenos Aires region participated (response rate of 54%). The position of neonatologists regarding the resuscitation in the delivery room was that 98% would resuscitate newborns with trisomy 21, and 47% with trisomy 18 or trisomy 13. Resuscitation of newborns with trisomy 18 or trisomy 13 by neonatologists was significantly associated with working in the public sector, religious beliefs, and legal framework. CONCLUSION With improvement in the management and treatment of infants with trisomies 18 and 13, Argentinean neonatologists showed a favorable attitude toward resuscitating them in the delivery room. KEY POINTS · We explored the attitudes of Argentinean neonatologists on resuscitation of children with trisomies.. · Half of neonatologists would resuscitate newborns with trisomies18 and 13.. · These results suggest an ongoing paradigm shift of the most severe trisomies..
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Affiliation(s)
- Agustín Silberberg
- Department of Bioethics, Hospital Universitario Austral, Universidad Austral, Buenos Aires, Argentina
| | - Adolfo Etchegaray
- Division of Fetal Medicine, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Sofía Juárez Peñalva
- Division of Fetal Medicine, Hospital Universitario Austral, Buenos Aires, Argentina.,Division of Genetics, Hospital Universitario Austral, Universidad Austral, Buenos Aires, Argentina
| | - Marcelo J Villar
- Institute of Translational Research, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina
| | - Gabriel Musante
- Division of Neonatology, Hospital Universitario Austral, Universidad Austral, Buenos Aires, Argentina
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Silberberg A, Herich LC, Croci I, Cuttini M, Villar MJ, Requena Meana P. Limitation of life-sustaining treatment in NICU: Physicians' beliefs and attitudes in the Buenos Aires region. Early Hum Dev 2020; 142:104955. [PMID: 32006786 DOI: 10.1016/j.earlhumdev.2020.104955] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/02/2020] [Accepted: 01/13/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To explore the ethical beliefs and attitudes of Argentinean neonatologists regarding limitation of life-sustaining treatment (LST) for very sick infants. METHODS We used an anonymous questionnaire including direct questions and hypothetical clinical cases (inevitable demise and anticipated survival with severe long-term disability). Multivariable analysis was carried out to assess the relation between type of clinical case and physicians' LST attitudes. RESULTS Overall, 315 neonatologists in 34 units in the Buenos Aires region participated (response rate 54%). Most responders would agree with decisions to start or continue LST. In both clinical cases, continuing current treatment with no therapeutic escalation was the only form of LST limitation acceptable to a substantial proportion (about 60%) of neonatologists. Agreement with LST limitation was slightly but significantly more likely when death was inevitable. CONCLUSION Argentinean neonatologists showed a conservative attitude regarding LST limitation. Patient prognosis and options of non-treatment decision significantly influenced their choices.
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Affiliation(s)
- Agustín Silberberg
- Department of Bioethics, Hospital Universitario Austral and Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina.
| | - Lena Carolin Herich
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Ileana Croci
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Marcelo José Villar
- Institute of Translational Research, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina.
| | - Pablo Requena Meana
- Department of Moral Theology, Pontificia Università della Santa Croce, Rome, Italy.
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Silberberg A, Robetto J, Grimaux G, Nucifora L, Moreno Villares JM. Ethical issues about the paradigm shift in the treatment of children with trisomy 18. Eur J Pediatr 2020; 179:493-497. [PMID: 31814050 DOI: 10.1007/s00431-019-03531-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
Abstract
Until recently, trisomy 18 was considered a disease incompatible with life, with a high percentage of electively terminated pregnancies. The usual behavior was denial of treatment. But some medical interventions have changed the survival of children. A search for articles published in the PubMed database on the latest medical decisions in newborns with trisomy 18 was done. Two main subjects were examined: (1) the chances of survival and (2) the perception of quality of life. Trisomy 18 is no longer considered a disease incompatible with life, and the discussion has shifted towards the type of treatment that is appropriate to initiate at birth. There are two medical attitudes towards these children: either palliative care or life-prolonging interventions. With medical intervention, the survival is as high as 23% at 5 years of age. Regarding the quality of life, all decision-makers emphasize the possibility of taking the child home. The physicians' perception is more pessimistic than that of the parents. Only a few children benefit from medical interventions.Conclusion: There is a rethinking of treatment behavior in children with trisomy 18. The possible quality of life achieved should be further investigated. It seems inappropriate to simply dismiss medical interventions.What is Known• Until recently, trisomy 18 was considered a disease incompatible with life. The most common behavior was abortion and denial of treatment.What is New• It is no longer considered a lethal disease. The type of medical intervention that is appropriate to perform is now being discussed. Selected children benefit from an interventionist approach.
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Affiliation(s)
- Agustín Silberberg
- Department of Bioethics, Hospital Universitario Austral, Universidad Austral, Av. Juan Perón 1500 (ex Ruta 234), B1629AHJ, Pilar, Buenos Aires, Argentina.
| | - Josefina Robetto
- Chair of Pathophysiology, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina
| | - Guadalupe Grimaux
- Department of Bioethics, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina
| | - Laura Nucifora
- Medical Student, Facultad de Ciencias Biomédicas, Universidad Austral, Buenos Aires, Argentina
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