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Galloway I, Roehr CC, Tan K. Withdrawal and withholding of life sustaining treatment (WWLST): an under recognised factor in the morbidity or mortality of periviable infants?-a narrative review. Transl Pediatr 2024; 13:459-473. [PMID: 38590374 PMCID: PMC10998991 DOI: 10.21037/tp-23-468] [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: 10/18/2023] [Accepted: 02/07/2024] [Indexed: 04/10/2024] Open
Abstract
Background and Objective The morbidity and mortality of infants born extremely preterm varies substantially across networks, within countries and throughout the globe. Most of the literature tends to focus on the management at birth and choices around active resuscitation of extremely preterm infants. Withdrawal and withholding of life sustaining treatment (WWLST) is an important and central process in the neonatal intensive care unit (NICU) and practices vary substantially. As such, our objective in this review was to explore whether end of life decisions also contribute to variations in the morbidity and mortality of periviable infants. Methods This narrative literature review is based on studies from the last 15 years found using several searches of medical databases (OVID Medline, Scopus and Cochrane Systematic Reviews) performed between March 2021 and December 2023. Key Content and Findings Just as outcomes in periviable infants vary, the rates of and processes behind WWLST differ in the periviable population. Variation increases as gestational age decreases. Parental involvement is crucial to share decision making but the circumstances and rates of parental involvement differ. Strict guidelines in end-of-life care may not be appropriate, however there is a need for more targeted guidance for periviable infants as a specific population. The current literature available relating to periviable infants or WWLST is minimal, with many datasets rapidly becoming outdated. Conclusions Further research is needed to establish the role of WWLST in variation of periviable infants' outcomes. The unification of data, acquisition of more recent datasets and inclusion of variables relating to end-of-life decisions in data collection will aid in this process.
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Affiliation(s)
- Isobel Galloway
- Department of Paediatrics, School of Clinical Sciences, Monash University, Victoria, Australia
| | - Charles Christoph Roehr
- Women’s and Children’s, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
- Faculty of Health Sciences, University of Bristol, Bristol, UK
- National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Kenneth Tan
- Department of Paediatrics, School of Clinical Sciences, Monash University, Victoria, Australia
- Monash Newborn, Monash Children’s Hospital, Victoria, Australia
- School of Medicine, Taylor’s University, Selangor, Malaysia
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Rholl E, Leuthner SR. The logistics of withdrawing life-sustaining medical treatment in the neonatal intensive care unit. Semin Fetal Neonatal Med 2023; 28:101443. [PMID: 37596126 DOI: 10.1016/j.siny.2023.101443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Withdrawal of life sustaining medical treatments is a common mode of death in the neonatal intensive care unit. Shared decision making and communication are crucial steps prior to, during and after a withdrawal of life sustaining medical treatments. Discussion should include the steps to occur during the withdrawal. Physicians should recommend appropriate withdrawal steps based on family goals. Stepwise approach should be taken only if a family requests. Care should continue for the family and staff after the withdrawal and the infant's death.
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Affiliation(s)
- Erin Rholl
- Department of Pediatrics, Medical College of Wisconsin, 999 N 92nd St, Suite C 410, Wauwatosa, Wisconsin, 53226, USA.
| | - Steven R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, 999 N 92nd St, Suite C 410, Wauwatosa, Wisconsin, 53226, USA.
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Cambonie G, Desage C, Thaller P, Lemaitre A, de Balanda KB, Combes C, Gavotto A. Context of a neonatal death affects parental perception of end-of-life care, anxiety and depression in the first year of bereavement. BMC Palliat Care 2023; 22:58. [PMID: 37173678 PMCID: PMC10182590 DOI: 10.1186/s12904-023-01183-8] [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: 10/22/2022] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Neonatal death is often preceded by end-of-life medical decisions. This study aimed to determine whether the context of death - after a decision of withholding or withdrawing life-sustaining treatment (WWLST) or despite maximum care - was associated with subsequent risk of parental anxiety or depression. The secondary objective was to assess parents' perceptions of end-of-life care according to death context. METHODS Prospective single center observational study of all neonatal deaths in a neonatal intensive care unit over a 5-year period. Data were collected during hospitalization and from face-to-face interviews with parents 3 months after the infant's death. Anxiety and depression were assessed using Hospital Anxiety and Depression Scale (HADS) questionnaires, completed by parents 5 and 15 months after death. RESULTS Of 179 deaths, 115 (64%) occurred after the WWLST decision and 64 (36%) despite maximum care. Parental satisfaction with newborn care and received support by professionals and relatives was higher in the first condition. Sixty-one percent of parents (109/179) attended the 3-month interview, with the distribution between groups very close to that of hospitalization. The completion rates of the HADS questionnaires by the parents who attended the 3-month interview were 75% (82/109) at 5 months and 65% (71/109) at 15 months. HADS scores at 5 months were consistent with anxiety in at least one parent in 73% (60/82) of cases and with depression in 50% (41/82). At 15 months, these rates were, respectively, 63% (45/71) and 28% (20/71). Risk of depression at 5 months was lower after a WWLST decision (OR 0.35 [0.14, 0.88], p = 0.02). Explicit parental agreement with the WWLST decision had an equivocal impact on the risk of anxiety at 5 months, being higher when expressed during hospitalization, but not at the 3-month interview. CONCLUSIONS Context of death has a significant impact on the emotional experience of parents after neonatal loss, which underlines the importance of systematic follow-up conversations with bereaved parents.
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Affiliation(s)
- Gilles Cambonie
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France.
- Pathogenesis and Control of Chronic Infection, UMR 1058, INSERM, University of Montpellier, Montpellier, France.
| | - Chloé Desage
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Pénélope Thaller
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Anne Lemaitre
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Karine Bertran de Balanda
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Clémentine Combes
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Arthur Gavotto
- Department of Neonatal Medicine and Paediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, 371 Avenue du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France
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Fortney CA, Baughcum AE, Garcia D, Winning AM, Humphrey L, Cistone N, Moscato EL, Keim MC, Nelin LD, Gerhardt CA. Characteristics of Critically Ill Infants at the End of Life in the Neonatal Intensive Care Unit. J Palliat Med 2023; 26:674-683. [PMID: 36480799 PMCID: PMC11079611 DOI: 10.1089/jpm.2022.0408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives: About 16,000 infants die in the neonatal intensive care unit (NICU) each year with many experiencing invasive medical treatments and high number of symptoms.1 To inform better management, we characterized diagnoses, symptoms, and patterns of care among infants who died in the NICU. Method: Retrospective electronic medical record (EMR) review of 476 infants who died following admission to a large regional level IV NICU in the United States over a 10-year period. Demographic, symptom, diagnosis, treatment, and end-of-life characteristics were extracted. Results: About half of infants were male (55.9%, n = 266), average gestational age was 31.3 weeks (standard deviation [SD] = 6.5), and average age at death was 40.1 days (SD = 84.5; median = 12; range: 0-835). Race was documented for 65% of infants, and most were White (67.0%). One-third of infants (n = 138) were seen by fetal medicine. Most infants experienced pain through both the month and week before death (79.6%), however, infants with necrotizing enterocolitis had more symptoms in the week before death. Based on EMR, infants had more symptoms, and received more medical interventions and comfort measures during the week before death compared with the month prior. Only 35% (n = 166) received a palliative care referral. Conclusions: Although the medical profiles of infants who die in the NICU are complex, the overall number of symptoms was less than in older pediatric populations. For infants at high risk of mortality rate, providers should assess for common symptoms over time. To manage symptoms as effectively as possible, both timely and continuous communication with parents and early referral to palliative care are recommended.
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Affiliation(s)
- Christine A. Fortney
- College of Nursing, Martha S. Pitzer Center for Women, Children, and Youth, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amy E. Baughcum
- College of Medicine, Department of Pediatrics, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio USA
| | - Dana Garcia
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Lisa Humphrey
- College of Medicine, Department of Pediatrics, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Hospice and Palliative Medicine, Nationwide Children's Hospital, Columbus, Ohio USA
| | - Nicole Cistone
- College of Nursing, Martha S. Pitzer Center for Women, Children, and Youth, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
| | - Emily L. Moscato
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Madelaine C. Keim
- Department of Psychology, University of Washington, Seattle, Washington, USA
| | - Leif D. Nelin
- College of Medicine, Department of Pediatrics, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio USA
| | - Cynthia A. Gerhardt
- College of Medicine, Department of Pediatrics, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- College of Medicine, Department of Psychology, The Ohio State University, Columbus, Ohio, USA
- Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital, Columbus, Ohio USA
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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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Comparison of End-of-Life Care Practices Between Children With Complex Chronic Conditions and Neonates Dying in an ICU Versus Non-ICUs: A Substudy of the Pediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) Project. Pediatr Crit Care Med 2020; 21:e236-e246. [PMID: 32091504 DOI: 10.1097/pcc.0000000000002259] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe and compare characteristics of care provided at the end of life for children with chronic complex conditions and neonates who died in an ICU with those who died outside an ICU. DESIGN Substudy of a nation-wide retrospective chart review. SETTING Thirteen hospitals, including 14 pediatric and neonatal ICUs, two long-term institutions, and 10 community-based organizations in the three language regions of Switzerland. PATIENTS One hundred forty-nine children (0-18 yr) who died in the years 2011 or 2012. Causes of death were related to cardiac, neurologic, oncological, or neonatal conditions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and clinical characteristics, therapeutic procedures, circumstances of death, and patterns of decisional processes were extracted from the medical charts. Ninety-three (62%) neonates (median age, 4 d) and children (median age, 23 mo) died in ICU, and 56 (38%) with a median age of 63 months outside ICU. Generally, ICU patients had more therapeutic and invasive procedures, compared with non-ICU patients. Changes in treatment plan in the last 4 weeks of life, such as do-not-resuscitate orders occurred in 40% of ICU patients and 25% of non-ICU patients (p < 0.001). In the ICU, when decision to withdraw life-sustaining treatment was made, time to death in children and newborns was 4:25 and 3:00, respectively. In institutions where it was available, involvement of specialized pediatric palliative care services was recorded in 15 ICU patients (43%) and in 18 non-ICU patients (78%) (p = 0.008). CONCLUSIONS This nation-wide study demonstrated that patients with a complex chronic condition who die in ICU, compared with those who die outside ICU, are characterized by fast changing care situations, including when to withdraw life-sustaining treatment. This highlights the importance of early effective communication and shared decision making among clinicians and families.
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Abdel Razeq NM, Alduraidi H, Halasa S, Cuttini M. Clinicians' Self-Reported Practices Related to End-of-Life Care for Infants in NICUs in Jordan. J Obstet Gynecol Neonatal Nurs 2019; 49:78-90. [PMID: 31811824 DOI: 10.1016/j.jogn.2019.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2019] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To examine how clinical decisions are made at the end of life for infants born with specific fatal and disabling conditions in NICUs in Jordan from the perspectives of neonatal health care providers. DESIGN A cross-sectional survey of neonatal nurses and physicians. SETTING Twenty-four NICUs in Jordan. PARTICIPANTS Participants included 213 nurses and 75 physicians who provided direct care for infants in NICUs. METHODS Using the EURONIC questionnaire, we asked participants to recall the last experiences of end-of-life decision making in which they were involved. The participants described factors and outcomes related to those experiences, and we used descriptive and inferential statistics to examine these factors. RESULTS In 83% of the recalled situations, the physicians in charge of the infants' care or who were on duty were the primary decision makers. Parents, nurses, ethics committees, and NICU heads were less involved. The infants' primary diagnoses were significantly associated with the nature of decisions regarding end-of-life care (p < .001). Age, importance of religion, having their own children, and involvement in research activities were factors that significantly predicted nurses' perceived levels of involvement in decision making (χ2[4] = 23.140, p < .001). CONCLUSION Our results suggest the need to improve clinical approaches to decision making regarding end-of-life care for infants in NICUs in Jordan to be more family focused and team based. This process should include parents, physicians, neonatal nurses, and ethics committees.
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