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Diguisto C, Goffinet F, Lorthe E, Kayem G, Roze JC, Boileau P, Khoshnood B, Benhammou V, Langer B, Sentilhes L, Subtil D, Azria E, Kaminski M, Ancel PY, Foix-L'Hélias L. Providing active antenatal care depends on the place of birth for extremely preterm births: the EPIPAGE 2 cohort study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F476-F482. [PMID: 28667191 DOI: 10.1136/archdischild-2016-312322] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 11/03/2022]
Abstract
UNLABELLED Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants' likelihood of survival. OBJECTIVE Our aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births. METHODS The population included 1020 singleton births between 220/6 and 260/6 weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was 'active antenatal care' defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics. RESULTS Among the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks' gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care. CONCLUSION Even after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.
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Affiliation(s)
- Caroline Diguisto
- 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.,Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France.,Université François Rabelais, Tours, France
| | - François Goffinet
- 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.,DHU Risk in Pregnancy, Maternité Port Royal Paris Descartes University Cochin Broca Hotel Dieu Hospitals Assistance publique des hopitaux de Paris, Paris, France
| | - Elsa Lorthe
- 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.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France
| | - Gilles Kayem
- 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.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France.,Service de Gynécologie Obstétrique, Paris, France
| | - Jean-Christophe Roze
- Service de Néonatologie, CIC 004, INSERM, Nantes University Hospital, Nantes, France
| | - Pascal Boileau
- Service de Néonatologie, CHI Poissy St-Germain-en-Laye, University Versailles StQuentin-en-Yvelines, Versailles, France
| | - Babak Khoshnood
- 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
| | - Valérie Benhammou
- 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
| | - Bruno Langer
- Pole de Gynécologie Obstétrique, Hôpital de Hautepierre, Strasbourg, France
| | - Loic Sentilhes
- Department of Obstetrics and Gynecology, University Hospital Bordeaux, Bordeaux, France
| | - Damien Subtil
- Hôpital Jeanne de Flandre, CHRU-University, Lille Nord, France
| | - Elie Azria
- 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.,Maternité Notre Dame de Bon Secours, Groupe Hospitalier Paris Saint Joseph, ParisDescartes University, DHU Risk in Pregnancy, 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
| | - Pierre-Yves Ancel
- 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.,URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu Hopital APHP, Paris, France
| | - Laurence Foix-L'Hélias
- 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.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France.,Service de Néonatologie, Hopital Armand Trousseau, APHP, Paris, France
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Provider Perspectives Regarding Resuscitation Decisions for Neonates and Other Vulnerable Patients. J Pediatr 2017; 188:142-147.e3. [PMID: 28502606 DOI: 10.1016/j.jpeds.2017.03.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/06/2017] [Accepted: 03/27/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To use structured surveys to assess the perspectives of pediatric residents and neonatal nurses on resuscitation decisions for vulnerable patients, including neonates. STUDY DESIGN Pediatric providers were surveyed using scenarios for 6 critically ill patients of different ages with outcomes explicitly described. Providers were asked (1) whether resuscitation was in each patient's best interest; (2) whether they would accept families' wishes for comfort care (no resuscitation); and (3) to rank patients in order of priority for resuscitation. In a structured interview, each participant explained how they evaluated patient interests and when applicable, why their answers differed for neonates. Interviews were audiotaped; transcripts were analyzed using thematic analysis and mixed methods. RESULTS Eighty pediatric residents and neonatal nurses participated (response rate 74%). When making life and death decisions, participants considered (1) patient characteristics (96%), (2) personal experience/biases (85%), (3) family's wishes and desires (81%), (4) disease characteristics (74%), and (5) societal perspectives (36%). These factors were not in favor of sick neonates: of the participants, 85% reported having negative biases toward neonates and 60% did not read, misinterpreted, and/or distrusted neonatal outcome statistics. Additional factors used to justify comfort care for neonates included limited personhood and lack of relationships/attachment (73%); prioritization of family's best interest, and social acceptability of death (36%). When these preconceptions were discussed, 70% of respondents reported they would change their answers in favor of neonates. CONCLUSIONS Resuscitation decisions for neonates are based on many factors, such as considerations of personhood and family's interests (that are not traditional indicators of benefit), which may explain why decision making is different for the neonatal population.
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Hendriks MJ, Klein SD, Bucher HU, Baumann-Hölzle R, Streuli JC, Fauchère JC. Attitudes towards decisions about extremely premature infants differed between Swiss linguistic regions in population-based study. Acta Paediatr 2017; 106:423-429. [PMID: 27880025 DOI: 10.1111/apa.13680] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 11/29/2022]
Abstract
AIM Studies have provided insights into the different attitudes and values of healthcare professionals and parents towards extreme prematurity. This study explored societal attitudes and values in Switzerland with regard to this patient group. METHODS A nationwide trilingual telephone survey was conducted in the French-, German- and Italian-speaking regions of Switzerland to explore the general population's attitudes and values with regard to extreme prematurity. Swiss residents of 18 years or older were recruited from the official telephone registry using quota sampling and a logistic regression model assessed the influence of socio-demographic factors on end-of-life decision-making. RESULTS Of the 5112 people contacted, 1210 (23.7%) participated. Of these 5% were the parents of a premature infant and 26% knew parents with a premature infant. Most participants (77.8%) highlighted their strong preference for shared decision-making, and 64.6% said that if there was dissent then the parents should have the final word. Overall, our logistic regression model showed that regional differences were the most significant factors influencing decision-making. CONCLUSION The majority of the Swiss population clearly favoured shared decision-making. The context of sociocultural demographics, especially the linguistic region in which the decision-making took place, strongly influenced attitudes towards extreme prematurity and decision-making.
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Affiliation(s)
- Manya J. Hendriks
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
- Institute of Biomedical Ethics and History of Medicine; University of Zurich; Zurich Switzerland
| | - Sabine D. Klein
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Hans Ulrich Bucher
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Ruth Baumann-Hölzle
- Dialogue Ethics Foundation; Interdisciplinary Institute for Ethics in Healthcare; Zurich Switzerland
| | - Jürg C. Streuli
- Institute of Biomedical Ethics and History of Medicine; University of Zurich; Zurich Switzerland
| | - Jean-Claude Fauchère
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
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Haines M, Wright IM, Bajuk B, Abdel-Latif ME, Hilder L, Challis D, Guaran R, Oei JL. Population-based study shows that resuscitating apparently stillborn extremely preterm babies is associated with poor outcomes. Acta Paediatr 2016; 105:1305-1311. [PMID: 27334852 DOI: 10.1111/apa.13503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/20/2016] [Accepted: 06/21/2016] [Indexed: 11/27/2022]
Abstract
AIM This population-based study determined the delivery room management and outcomes of extremely preterm infants born with Apgar scores of 0. METHODS We linked birth, neonatal intensive care unit (NICU) and death records for babies who were born between 22 + 0 and 27 + 6 weeks of gestation with a one-minute Apgar score of 0, in New South Wales, Australia, between 1998 and 2011. RESULTS We classified 2173/2262 (96%) of infants with a one-minute Apgar score of 0 as stillborn. Resuscitation was provided for 48/89 (54%) live births and 40/2173 (2%) stillbirths. Cardiac massage was given to 44 infants, including three 22-week stillborn babies. Of the 13 live births admitted to an NICU, 11 survived to hospital discharge. Most (98%) of the 2212 deaths occurred on the first day of life. One baby who was classified as stillborn lived for 51 days. Resuscitation increased the mean (95% confidence interval) duration of survival from 1 (0-2) to 45 (0-104) hours (p < 0.001). No infant with a five-minute Apgar score of 0 survived. CONCLUSION Clinicians resuscitated extremely preterm infants without a detectable heartbeat, even at 22 weeks of gestation. No infant survived without resuscitation or if their heartbeat was not regained by five minutes.
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Affiliation(s)
- Morgan Haines
- School of Women's and Children's Health; University of New South Wales; Randwick NSW Australia
| | - Ian M. Wright
- Illawarra Health and Medical Research Institute and Graduate School of Medicine; The University of Wollongong; Wollongong NSW Australia
- Department of Paediatrics; The Wollongong Hospital; Wollongong NSW Australia
| | - Barbara Bajuk
- New South Wales Pregnancy and Newborn Services Network; Westmead NSW Australia
| | - Mohamed E. Abdel-Latif
- Department of Neonatology; The Canberra Hospital; Garran ACT Australia
- Faculty of Medicine; The Australian National University; Deakin ACT Australia
| | - Lisa Hilder
- School of Women's and Children's Health; University of New South Wales; Randwick NSW Australia
| | - Daniel Challis
- New South Wales Pregnancy and Newborn Services Network; Westmead NSW Australia
| | - Robert Guaran
- New South Wales Pregnancy and Newborn Services Network; Westmead NSW Australia
| | - Ju Lee Oei
- School of Women's and Children's Health; University of New South Wales; Randwick NSW Australia
- Department of Newborn Care; Royal Hospital for Women; Randwick NSW Australia
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Gallagher K, Aladangady N, Marlow N. The attitudes of neonatologists towards extremely preterm infants: a Q methodological study. Arch Dis Child Fetal Neonatal Ed 2016; 101:F31-6. [PMID: 26178462 PMCID: PMC4717384 DOI: 10.1136/archdischild-2014-308071] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 06/11/2015] [Indexed: 11/14/2022]
Abstract
OBJECTIVES The attitudes and biases of doctors may affect decision making within Neonatal Intensive Care. We studied the attitudes of neonatologists in order to understand how they prioritise different factors contributing to decision making for extremely preterm babies. DESIGN Twenty-five neonatologists (11 consultants and 14 senior trainees) participated in a Q methodological study about decision making that involved the ranking of 53 statements from agree to disagree in a unimodal shaped grid. Results were explored by person factor analysis using principle component analysis. RESULTS The model of best fit comprised 23 participants contributing a three-factor model, which represented three different attitudes towards decision making and accounted for 59% of the variance. Fourteen statements were ranked in statistically significant similar positions by 23 participants; consensus statements included placing the baby and family at the centre of care, limitation of intervention based upon perceived risk and non-mandatory intervention at birth. Factor 1 participants (n=12) believed that treatment should not be limited based on gestational age and technology should be used to improve treatment. Five factor 2 participants identified strongly with a limit of 24 weeks for treatment, one of whom being polar opposite, believing in treatment at all costs at all gestations. The remaining six factor 3 participants identified strongly with statements that treatment should be withheld on quality of life grounds. CONCLUSIONS This study has identified differences in attitudes towards decision making between individual neonatologists and trainees that may impact how decisions are communicated to families.
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Affiliation(s)
- Katie Gallagher
- Florence Nightingale School of Nursing and Midwifery, King's College London, London, UK
| | - Narendra Aladangady
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK,Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Neil Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
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Using simulation to assess the influence of race and insurer on shared decision making in periviable counseling. Simul Healthc 2015; 9:353-9. [PMID: 25188489 DOI: 10.1097/sih.0000000000000049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Sociodemographic differences have been observed in the treatment of extremely premature (periviable) neonates, but the source of this variation is not well understood. We assessed the feasibility of using simulation to test the effect of maternal race and insurance status on shared decision making (SDM) in periviable counseling. METHODS We conducted a 2 × 2 factorial simulation experiment in which obstetricians and neonatologists counseled 2 consecutive standardized patients diagnosed with ruptured membranes at 23 weeks, counterbalancing race (black/white) and insurance status using random permutation. We assessed verisimilitude of the simulation in semistructured debriefing interviews. We coded physician communication related to resuscitation, mode of delivery, and steroid decisions using a 9-point SDM coding framework and then compared communication scores by standardized patient race and insurer using analysis of variance. RESULTS Sixteen obstetricians and 15 neonatologists participated; 71% were women, 84% were married, and 75% were parents; 91% of the physicians rated the simulation as highly realistic. Overall, SDM scores were relatively high, with means ranging from 6.4 to 7.9 (of 9). There was a statistically significant interaction between race and insurer for SDM related to steroid use and mode of delivery (P < 0.01 and P = 0.01, respectively). Between-group comparison revealed nonsignificant differences (P = <0.10) between the SDM scores for privately insured black patients versus privately insured white patients, Medicaid-insured white patients versus Medicaid-insured black patients, and privately insured black patients versus Medicaid-insured black patients. CONCLUSIONS This study confirms that simulation is a feasible method for studying sociodemographic effects on periviable counseling. Shared decision making may occur differentially based on patients' sociodemographic characteristics and deserves further study.
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Rosenstock A, van Manen M. Adolescent parenting in the neonatal intensive care unit. J Adolesc Health 2014; 55:723-9. [PMID: 25287982 DOI: 10.1016/j.jadohealth.2014.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/16/2014] [Accepted: 08/01/2014] [Indexed: 11/26/2022]
Abstract
This review presents data from studies that report on adolescent parents as part of larger neonatal intensive care unit (NICU) parent populations, as well as studies where adolescent parents are given central consideration. A systematic search for English publications from 1990 onward relevant to adolescent parenting in the NICU was conducted. Most studies reporting on adolescent parents focus on parental stress or parenting practices in the NICU. A few studies examine parent-staff communication, parental needs, and parent intervention programs. One study presents a qualitative examination of teenage mothers' experiences in the NICU. Areas for further research include experiences of younger adolescent parents, adolescent fathers, and same-sex partners; issues unique to adolescent parents; and support programs for adolescent parents in the NICU.
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Affiliation(s)
- Amanda Rosenstock
- John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Michael van Manen
- John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada; Neonatal-Perinatal Medicine, Department of Paediatrics, University of Alberta, Edmonton, Alberta, Canada.
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9
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Gallagher K, Martin J, Keller M, Marlow N. European variation in decision-making and parental involvement during preterm birth. Arch Dis Child Fetal Neonatal Ed 2014; 99:F245-9. [PMID: 24554563 DOI: 10.1136/archdischild-2013-305191] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Preterm birth is a major global public health issue due to its prevalence, impact upon morbidity and mortality, and subsequent cost implications. Yet, policy analysis has not been undertaken to understand the different approaches across Europe to treatment decisions, and parental involvement in these decisions. METHODS A European survey and national guidance documentation analysis was undertaken with national neonatal or paediatric societies in Europe, exploring treatment decisions and parental involvement in decision-making for babies born at 22 to 25 completed weeks of gestation. RESULTS Responses were obtained from 19 European countries of 28 contacted. At 25 weeks of gestation there was universal initiation of active care at birth. At 24 weeks policy varied from initiating interventions (9), interventions dependent upon infant condition (8) and resuscitation restrictions (2). At 23 weeks and below, policy varied from no active intervention (7), individualised decision-making (8), parental permission required (3) and universal initiation of interventions (1). There were significant variations in the involvement of parents in the development of policy and in 16 countries the final decision regarding interventions rested with the attending doctor. IMPLICATIONS There was little consensus as to how active intervention after birth at 22 to 25 weeks of gestation is managed, nor were parents included in the development of policy in many countries. At extremely low gestational ages, the criteria for or against active intervention at birth vary widely between different health systems in Europe.
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Affiliation(s)
- Katie Gallagher
- Florence Nightingale School of Nursing and Midwifery, King's College London, , London, UK
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Bellieni CV, Tei M, Coccina F, Buonocore G. Why do we treat the newborn differently? J Matern Fetal Neonatal Med 2012; 25 Suppl 1:73-5. [PMID: 22324397 DOI: 10.3109/14767058.2012.663178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
End-of-life decisions are often taken in neonatology, based on widely accepted guidelines, to avoiding futile therapies. Usually, the criteria upon which these guidelines rely are different from those used for older patients, even when patients require a guardian to decide on their behalf. Main differences are the weight of parental interests and the probabilistic base of the choice. A careful analysis of the literature found three main reasons of this difference: the obsolescence of the guidelines criteria, the difficulty to distinguish between parents' and babies' interests and the neonatologist's responsibility to prolong a life with the prospective of severe disability. In conclusion, the future guidelines for newborn end-of-life decisions should follow at least the same moral criteria used for older patients.
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Affiliation(s)
- Carlo V Bellieni
- Department of Pediatrics, Obstetrics and Reproduction Medicine, University of Siena, Siena, Italy
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Messner H, Gentili L. Reconciling ethical and legal aspects in neonatal intensive care. J Matern Fetal Neonatal Med 2011; 24 Suppl 1:126-8. [PMID: 21888497 DOI: 10.3109/14767058.2011.607672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
During the last two decades there has been an enormous development in treatment possibilities for the extremely premature infants and the Neonatologists have to face in their daily practice many decisional problems and ethical, moral and legal dilemmas. These concern decisions to initiate or withhold treatment directly at birth, decision to withdrawn treatment with the possible consequence that the child will die. The debate between "sanctity" and "quality" of life, aggressive treatment in relation to discrimination toward the disabled, the principle of "beneficence" and the question of "proportionality" of treatment, the concept of the newborn's "best interest" are the ethical issues discussed. According to our opinion, ethical questions should not be regulated by law and the legal system should not interfere in the relationship patient - physician. Today more than ever, every neonatologist needs to become familiar with basic ethical concepts and the legal aspects in neonatal intensive care.
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