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Goossens L, Dombrecht L, Chambaere K, Beernaert K, Cools F. Cause of death and making end-of-life decisions in preterm infants has not changed over time: A mortality follow-back survey. Acta Paediatr 2024; 113:1257-1263. [PMID: 38345111 DOI: 10.1111/apa.17153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/27/2024] [Accepted: 02/05/2024] [Indexed: 08/24/2024]
Abstract
AIM This study aimed to evaluate changes over time in cause of death and making end-of-life decisions in preterm infants. METHODS A follow-back survey was conducted of all preterm infants who died between September 2016 and December 2017 in Flanders and Brussels, Belgium. Cause of death was obtained from the death certificate and information on end-of-life decisions (ELDs) through an anonymous questionnaire of the certifying physician. Results were compared with a previous study performed between August 1999 and July 2000. RESULTS In the cohort 1999-2000 and 2016-2017, respectively, 150 and 135 deaths were included. A significantly higher proportion of infants born before 26 weeks of gestation was found in the 2016-2017 cohort (53% vs. 24% in 1999-2000, p < 0.001). Extreme immaturity (<26 weeks) remained the most prevalent cause with a significant increase in the 2016-2017 cohort (48% vs. 28% in 1999-2000, p < 0.001). The overall prevalence of ELDs was similar across study periods (61%). Non-treatment decisions remained the most common ELD (36% and 37%). CONCLUSION Infants born at the limits of viability have become more prevalent among infant deaths, possibly due to a change in attitude towards periviable births. Neither the process of making ELDs nor the cause of death has changed over time.
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Affiliation(s)
- Linde Goossens
- Department of Neonatal Intensive Care, Ghent University Hospital, Gent, Belgium
| | - Laure Dombrecht
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Department of Public Health and Primary Care, Ghent University, Gent, Belgium
| | - Filip Cools
- Department of Neonatal Intensive Care, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussel, Belgium
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Dombrecht L, Chambaere K, Beernaert K, Roets E, De Vilder De Keyser M, De Smet G, Roelens K, Cools F. Components of Perinatal Palliative Care: An Integrative Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:482. [PMID: 36980040 PMCID: PMC10047326 DOI: 10.3390/children10030482] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/17/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023]
Abstract
When a severe diagnosis is made before or after birth, perinatal palliative care (PPC) can be provided to support the infant, parents and involved healthcare providers. An integrative and systematic overview of effectiveness and working components of existing PPC programs was needed. An integrative search was conducted in MEDLINE, Embase, CENTRAL, CINAHL, PsycInfo and Web of Science. Study designs examining the effect of PPC compared to regular care, and (empirical) articles describing the components of care included in existing PPC initiatives were included. Three independent authors reviewed titles, abstracts and full texts against eligibility criteria. PRISMA guidelines were followed; 21.893 records were identified; 69 publications met inclusion criteria. Twelve publications (17.4%) discussed the effect of a PPC program. Other publications concerned the description of PPC programs, most often by means of a program description (22/69; 31.9%), guidelines (14/769; 20.3%) or case study (10/69; 14.5%). Outcome measures envisioned four main target categories: care coordination, parents and family members, care for the fetus/neonate and healthcare providers. No trials exist to date. Analysis of working components revealed components related to changes directed to the policy of the hospital wards and components involving actual care being provided within the PPC program, directed to the fetus or infant, the family, involved healthcare providers or external actors. PPC is a growing research field where evidence consists mainly of descriptive studies and guidelines. The extensive list of possible PPC components can serve as a checklist for developing future initiatives worldwide. PPC includes several important actors: the fetus/infant and their family and included healthcare providers on both maternity and neonatal wards. This leads to a large variety of possible care components. However, while some studies show proof of concept, an evidence base to determine which components are actually effective is lacking.
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Affiliation(s)
- Laure Dombrecht
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, 1090 Brussels, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, 1090 Brussels, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, 1090 Brussels, Belgium
| | - Ellen Roets
- Department of Obstetrics, Women’s Clinic, University Hospital Ghent, 9000 Ghent, Belgium
| | | | - Gaëlle De Smet
- Faculty of Medicine and Health Sciences, Ghent University, 9000 Ghent, Belgium
| | - Kristien Roelens
- Department of Obstetrics, Women’s Clinic, University Hospital Ghent, 9000 Ghent, Belgium
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, 1090 Brussels, Belgium
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Dombrecht L, Cools F, Cohen J, Deliens L, Goossens L, Naulaers G, Beernaert K, Chambaere K. Consultation of parents and healthcare professionals in end-of-life decision-making for neonates and infants: a population-level mortality follow-back physician survey. BMC Pediatr 2022; 22:597. [PMID: 36241989 PMCID: PMC9561315 DOI: 10.1186/s12887-022-03653-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background End-of-life decisions with potential life-shortening effect in neonates and infants are common. We aimed to evaluate how often and in what manner neonatologists consult with parents and other healthcare providers in these cases, and whether consultation is dependent on the type of end-of-life decision made. Methods Based on all deaths under the age of one that occurred between September 2016 and December 2017 in Flanders, Belgium, a nationwide mortality follow-back survey was performed. The survey asked about different types of end-of-life decisions, and whether and why parents and/or other healthcare providers had or had not been consulted. Results Response rate was 83% of the total population. End-of-life decisions in neonates and infants were consulted both with parents (92%) and other healthcare providers (90%), and agreement was reached between parents and healthcare providers in most cases (96%). When medication with an explicit life-shortening intent was administered parents were always consulted prior to the decision; however when medication without explicit life-shortening intention was administered parents were not consulted in 25% of the cases. Conclusions Shared decision-making between parents and physicians in case of neonatal or infant end-of-life decision-making is the norm in daily practice. All cases without parental consultation concerned non-treatment decisions or comfort medication without explicit life-shortening intention where physicians deemed the medical situation clear and unambiguous. However, we recommend to at least inform parents of medical options, and to explore other possibilities to engage parents in reaching a shared decision. Physicians consult other healthcare providers before making an end-of-life decision in most cases. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03653-z.
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Affiliation(s)
- Laure Dombrecht
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Corneel Heymanslaan 10, K3, 6th floor, room 011, 9000, Ghent, Belgium. .,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Jette, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Corneel Heymanslaan 10, K3, 6th floor, room 011, 9000, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Corneel Heymanslaan 10, K3, 6th floor, room 011, 9000, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Linde Goossens
- Department of Neonatology, Ghent University Hospital, Ghent, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Corneel Heymanslaan 10, K3, 6th floor, room 011, 9000, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Corneel Heymanslaan 10, K3, 6th floor, room 011, 9000, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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Dombrecht L, Deliens L, Chambaere K, Baes S, Cools F, Goossens L, Naulaers G, Roets E, Piette V, Cohen J, Beernaert K. Neonatologists and neonatal nurses have positive attitudes towards perinatal end-of-life decisions, a nationwide survey. Acta Paediatr 2020; 109:494-504. [PMID: 30920064 DOI: 10.1111/apa.14797] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/06/2019] [Accepted: 03/25/2019] [Indexed: 11/29/2022]
Abstract
AIM Perinatal death is often preceded by an end-of-life decision (ELD). Disparate hospital policies, complex legal frameworks and ethically difficult cases make attitudes important. This study investigated attitudes of neonatologists and nurses towards perinatal ELDs. METHODS A survey was handed out to all neonatologists and neonatal nurses in all eight neonatal intensive care units in Flanders, Belgium in May 2017. Respondents indicated agreement with statements regarding perinatal ELDs on a Likert-scale and sent back questionnaires via mail. RESULTS The response rate was 49.5% (302/610). Most neonatologists and nurses found nontreatment decisions such as withholding or withdrawing treatment acceptable (90-100%). Termination of pregnancy when the foetus is viable in cases of severe or lethal foetal problems was considered highly acceptable in both groups (80-98%). Physicians and nurses do not find different ELDs equally acceptable, e.g. nurses more often than physicians (74% vs 60%, p = 0.017) agree that it is acceptable in certain cases to administer medication with the explicit intention of hastening death. CONCLUSION There was considerable support for both prenatal and neonatal ELDs, even for decisions that currently fall outside the Belgian legal framework. Differences between neonatologists' and nurses' attitudes indicate that both opinions should be heard during ELD-making.
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Affiliation(s)
- Laure Dombrecht
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Luc Deliens
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Kenneth Chambaere
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Saskia Baes
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Filip Cools
- Department of Neonatology Universitair Ziekenhuis Brussel Vrije Universiteit Brussel Brussel Belgium
| | - Linde Goossens
- Department of Neonatology Ghent University Hospital Ghent Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration KU Leuven Leuven Belgium
| | - Ellen Roets
- Department of Obstetrics Women's Clinic University Hospital Ghent Ghent Belgium
| | - Veerle Piette
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Joachim Cohen
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Kim Beernaert
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
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Dombrecht L, Piette V, Deliens L, Cools F, Chambaere K, Goossens L, Naulaers G, Cornette L, Beernaert K, Cohen J. Barriers to and Facilitators of End-of-Life Decision Making by Neonatologists and Neonatal Nurses in Neonates: A Qualitative Study. J Pain Symptom Manage 2020; 59:599-608.e2. [PMID: 31639496 DOI: 10.1016/j.jpainsymman.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/09/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Making end-of-life decisions (ELDs) in neonates involves ethically difficult and distressing dilemmas for health care providers. Insight into which factors complicate or facilitate this decision-making process could be a necessary first step in formulating recommendations to aid future practice. OBJECTIVES This study aimed to identify barriers to and facilitators of the ELD-making process as perceived by neonatologists and nurses. METHODS We conducted semistructured face-to-face interviews with 15 neonatologists and 15 neonatal nurses, recruited through four neonatal intensive care units in Flanders, Belgium. They were asked what factors had facilitated and complicated previous ELD-making processes. Two researchers independently analyzed the data, using thematic content analysis to extract and summarize barriers and facilitators. RESULTS Barriers and facilitators were found at three distinct levels: the case-specific context (e.g., uncertainty of the diagnosis and specific characteristics of the child, parents, and health care providers, which make decision making more difficult), decision-making process (e.g., multidisciplinary consultations and advance care planning, which make decision making easier), and overarching structure (e.g., lack of privacy and complex legislation making decision making more challenging). CONCLUSION Barriers and facilitators found in this study can lead to recommendations, some simpler to implement than others, to aid the complex ELD-making process. Recommendations include establishing regular multidisciplinary meetings to include all health care providers and reduce unnecessary uncertainty, routinely implementing advance care planning in severely ill neonates to make important decisions beforehand, creating privacy for bad-news conversations with parents, and reviewing the complex legal framework of perinatal ELD making.
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Affiliation(s)
- Laure Dombrecht
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Veerle Piette
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Linde Goossens
- Department of Neonatology, Ghent University Hospital, Ghent, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Luc Cornette
- Department of Neonatology, AZ Sint-Jan Brugge-Oostende, Bruges, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
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- Ghent University Hospital, Brussels University Hospital, Leuven University Hospital, Antwerp University Hospital, Hospital Oost-Limburg Genk, Hospital GZA St Augustinus, AZ St Jan Brugge, ZNA Middelheim, Belgium
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