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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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2
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Montes Bueno MT, Muñoz C, Rodríguez S, Sola A. End-of-life care in neonatal intensive care units in Iberoamerica: A look from the nursing perspective. An Pediatr (Barc) 2024; 100:97-103. [PMID: 38212240 DOI: 10.1016/j.anpede.2024.01.001] [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] [Received: 08/24/2023] [Accepted: 11/24/2023] [Indexed: 01/13/2024] Open
Abstract
INTRODUCTION End-of-life care (ELC) represents a quality milestone in neonatal intensive care units (NICU). The objective of this study was to explore how ELC are carried out in NICUs in Iberoamerica. METHODS Cross-sectional study, through the administration of an anonymous survey sent to neonatal nursing professionals. The survey included general data and work activity data; existence and contents of ELC protocols in the NICU and training received. The survey was distributed by email and published on official SIBEN social networks. REDCap and STATA 14.0 software were used for data collection and analysis. RESULTS We obtained 400 responses from nurses from 11 countries in the Ibero-American region. 86% of the respondents are directly responsible for providing ELC, although 48% of them said they had not received training on this subject. Only 67 (17%) state that the NICU in which they work has a protocol that establishes a strategy for performing the ELC. Finally, the actions that are implemented during the ELC are globally infrequent (≤50%) in all the items explored and very infrequent (<20%) in relation to allowing free access to family members, having privacy, providing psychological assistance, register the process in the medical record, assist with bureaucratic processes or grant a follow-up plan for grief. CONCLUSION Most of the nursing professionals surveyed are directly responsible for this care, do not have protocols, have not received training, and consider that the ELC could be significantly improved. Strategies for ELCs in the Ibero-American region need to be optimized.
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Affiliation(s)
- María Teresa Montes Bueno
- Cuidados Intensivos Neonatales (CIN), Hospital Universitario La Paz, Madrid, Spain; Sociedad Iberoamericana de Neonatología (SIBEN), Buenos Aires, Argentina
| | - Cristian Muñoz
- Sociedad Iberoamericana de Neonatología (SIBEN), Buenos Aires, Argentina
| | - Susana Rodríguez
- Sociedad Iberoamericana de Neonatología (SIBEN), Buenos Aires, Argentina.
| | - Augusto Sola
- Sociedad Iberoamericana de Neonatología (SIBEN), Buenos Aires, Argentina
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3
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Morillo Palomo A, Esquerda Aresté M, Riverola de Veciana A, Cambra Lasaosa FJ. End-of-life decision-making in the neonatal intensive care unit. Front Pediatr 2024; 11:1352485. [PMID: 38259598 PMCID: PMC10800896 DOI: 10.3389/fped.2023.1352485] [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: 12/08/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Most paediatric deaths occur in the neonatal period, many of them in neonatal intensive care units after withdrawal of life support or the decision not to initiate new treatments. In these circumstances, discussions with families and decision-making are fundamental elements of the care and attention given to newborn babies. In this context, bioethical deliberation can help us to identify the values at stake, the different courses of action to be taken, and the means to ensure that family-shared decision-making is appropriate to the patient's situation and in accordance with the family's values.
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Affiliation(s)
- Ana Morillo Palomo
- Neonatal Intensive Care Unit, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Montse Esquerda Aresté
- Institut Borja de Bioètica, Universitat Ramon Llull, Barcelona, Spain
- School of Medicine, University of Lleida, Lleida, Spain
| | | | - Francisco José Cambra Lasaosa
- Institut Borja de Bioètica, Universitat Ramon Llull, Barcelona, Spain
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, Barcelona, Spain
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Tong-Hui S, Qi L, Xiao-Li R, Guo-Qin Y, Li-Ping W, Lin W. Chinese Neonatal Nurses' Lived Experiences of Providing End-of-Life Care in the NICU: A Descriptive Phenomenological Study. Adv Neonatal Care 2023; 23:532-540. [PMID: 38038670 DOI: 10.1097/anc.0000000000001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND Although end-of-life care (EOLC) has been well-studied, the experience of neonatal intensive care unit (NICU) nurses in China, where little EOLC training is provided, requires further investigation. PURPOSE To explore the lived experience of EOLC delivery among NICU nurses, to provide evidence to enhance nurses' EOLC skills and improve their overall quality. METHODS This qualitative study adopted a phenomenological approach. A total of 11 NICU nurses participated in semistructured in-depth interviews between June and July 2022 at the First Affiliated Hospital of University of Science and Technology of China (USTC). Colaizzi's 7-step method was used to analyze the data. RESULTS Five main themes were identified: (a) multiple emotions are experienced during EOLC delivery; (b) EOLC delivery is stressful from various sources for nurses; (c) expressing empathy and compassion is important; (d) ethical and clinical decision-making are key components of EOLC delivery; and (e) there are challenges in improving neonatal EOLC understanding and delivery. IMPLICATIONS FOR PRACTICE AND RESEARCH The experience of EOLC among Chinese NICU nurses is multidimensional and intensive. Institutions or units must establish and implement related protocols and guidelines to address differences between clinical practice and ideal protocols for neonatal EOLC. Educational programs that consider nurses' personal and interpersonal factors, including local culture, must be developed. Neonatal nurses in Western countries encountering Chinese-born parents who have lost their infants can gain an understanding of parents' perceptions from this study. Future research should focus on developing and testing interventions to train and support NICU nurses working with end-of-life neonates.
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Affiliation(s)
- Suo Tong-Hui
- Department of Nursing & NICU, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, Anhui
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5
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Pierron C, Maillard A, Farnoux C, Grimaud M, Le Bourgeois F. Gasping in Dying Children: Health Care Professionals' Feelings and Knowledge. J Palliat Med 2023; 26:1547-1550. [PMID: 37672602 DOI: 10.1089/jpm.2023.0132] [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: 09/08/2023] Open
Abstract
Purpose: To assess the feelings and knowledge of health care professionals (HCPs) about gasping in dying patients in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs). Methods: A 9-item questionnaire addressed to 488 HCPs (physicians, nurses, and nursing assistants) of 2 NICUs and 2 PICUs. Questions were about HCPs' feelings when confronted with gasping, their knowledge, and their opinions on what to tell family members. Results: Responses were obtained from 248 staff members. Of the respondents, 43% felt that gasping was painful to the patient and most felt that witnessing gasps was distressing for the parents, and 77% reported being distressed by witnessing gasps. Conclusions: Efforts are needed to educate HCPs about the physiology of gasping, to help them to cope with gasping, and to give better support to parents.
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Affiliation(s)
- Charlotte Pierron
- Department of Neonatal and Pediatric Intensive Care, Centre Hospitalier du Luxembourg, Luxembourg, Luxembourg
- Department of Pediatrics Intensive Care Medecine, and Hôpital Robert Debré, Paris, France
| | | | | | - Marion Grimaud
- Department of Pediatrics Intensive Care Medecine, Hôpital Necker-Enfants Malades, Paris, France
| | - Fleur Le Bourgeois
- Department of Pediatrics Intensive Care Medecine, and Hôpital Robert Debré, Paris, France
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6
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Verhagen AAE. Neonatal euthanasia in the context of palliative and EoL care. Semin Fetal Neonatal Med 2023; 28:101439. [PMID: 37105858 DOI: 10.1016/j.siny.2023.101439] [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: 04/29/2023]
Abstract
Neonatal deaths can be categorized in 5 modes along the dimension of intervention and physiology. This classification can be helpful to analyze the choices that can be made in end-of-life care in the NICU. In the Netherlands, neonatal euthanasia became an optional 6th mode of death since publication and legalization of the Groningen Protocol. This paper summarizes the history, legal status and ethical justification of the Groningen Protocol, and describes end-of-life practice in the subsequent years. Since the implementation of the Groningen Protocol, the practice of neonatal euthanasia has almost disappeared. Simultaneously, there has been spectacular growth in neonatal palliative care programs in the Netherlands. Is there still a need for this last-resort option?
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Affiliation(s)
- A A Eduard Verhagen
- University Medical Center Groningen, Dept of Pediatrics, University of Groningen, PO Box 30.001, 9700RB, Groningen, the Netherlands.
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7
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van Varsseveld OC, Ten Broeke A, Chorus CG, Heyning N, Kooi EMW, Hulscher JBF. Surgery or comfort care for neonates with surgical necrotizing enterocolitis: Lessons learned from behavioral artificial intelligence technology. Front Pediatr 2023; 11:1122188. [PMID: 36925670 PMCID: PMC10011167 DOI: 10.3389/fped.2023.1122188] [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: 12/12/2022] [Accepted: 01/31/2023] [Indexed: 03/08/2023] Open
Abstract
Background Critical decision making in surgical necrotizing enterocolitis (NEC) is highly complex and hard to capture in decision rules due to case-specificity and high mortality risk. In this choice experiment, we aimed to identify the implicit weight of decision factors towards future decision support, and to assess potential differences between specialties or centers. Methods Thirty-five hypothetical surgical NEC scenarios with different factor levels were evaluated by neonatal care experts of all Dutch neonatal care centers in an online environment, where a recommendation for surgery or comfort care was requested. We conducted choice analysis by constructing a binary logistic regression model according to behavioral artificial intelligence technology (BAIT). Results Out of 109 invited neonatal care experts, 62 (57%) participated, including 45 neonatologists, 16 pediatric surgeons and one neonatology physician assistant. Cerebral ultrasound (Relative importance = 20%, OR = 4.06, 95% CI = 3.39-4.86) was the most important factor in the decision surgery versus comfort care in surgical NEC, nationwide and for all specialties and centers. Pediatric surgeons more often recommended surgery compared to neonatologists (62% vs. 57%, p = 0.03). For all centers, cerebral ultrasound, congenital comorbidity, hemodynamics and parental preferences were significant decision factors (p < 0.05). Sex (p = 0.14), growth since birth (p = 0.25), and estimated parental capacities (p = 0.06) had no significance in nationwide nor subgroup analyses. Conclusion We demonstrated how BAIT can analyze the implicit weight of factors in the complex and critical decision for surgery or comfort care for (surgical) NEC. The findings reflect Dutch expertise, but the technique can be expanded internationally. After validation, our choice model/BAIT may function as decision aid.
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Affiliation(s)
- Otis C van Varsseveld
- Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - Caspar G Chorus
- Councyl, Delft, Netherlands.,Department of Engineering Systems and Services, Faculty Technology Policy and Management, Delft University of Technology, Delft, Netherlands
| | | | - Elisabeth M W Kooi
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jan B F Hulscher
- Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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8
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Syltern J, Ursin L, Solberg B, Støen R. Postponed Withholding: Balanced Decision-Making at the Margins of Viability. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:15-26. [PMID: 33998962 DOI: 10.1080/15265161.2021.1925777] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental "instinct of saving" and "withdrawal resistance" involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled "postponed withholding." In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.
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Affiliation(s)
- Janicke Syltern
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
| | - Lars Ursin
- The Norwegian University of Science and Technology
| | | | - Ragnhild Støen
- Norwegian University of Science and Technology
- St Olavs Hospital University Hospital in Trondheim
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9
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Ten Broeke A, Hulscher J, Heyning N, Kooi E, Chorus C. BAIT: A New Medical Decision Support Technology Based on Discrete Choice Theory. Med Decis Making 2021; 41:614-619. [PMID: 33783246 PMCID: PMC8191159 DOI: 10.1177/0272989x211001320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present a novel way to codify medical expertise and to make it available to support medical decision making. Our approach is based on econometric techniques (known as conjoint analysis or discrete choice theory) developed to analyze and forecast consumer or patient behavior; we reconceptualize these techniques and put them to use to generate an explainable, tractable decision support system for medical experts. The approach works as follows: using choice experiments containing systematically composed hypothetical choice scenarios, we collect a set of expert decisions. Then we use those decisions to estimate the weights that experts implicitly assign to various decision factors. The resulting choice model is able to generate a probabilistic assessment for real-life decision situations, in combination with an explanation of which factors led to the assessment. The approach has several advantages, but also potential limitations, compared to rule-based methods and machine learning techniques. We illustrate the choice model approach to support medical decision making by applying it in the context of the difficult choice to proceed to surgery v. comfort care for a critically ill neonate.
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Affiliation(s)
| | - Jan Hulscher
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | - Elisabeth Kooi
- University of Groningen, University Medical Center Groningen, Beatrix Kinder Ziekenhuis, Division of Neonatology, Groningen, Netherlands
| | - Caspar Chorus
- Councyl, Delft, Netherlands.,Faculty Technology Policy and Management, Department of Engineering Systems and Services, Delft University of Technology, Delft, Netherlands
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10
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Vileito A, Hulzebos CV, Toet MC, Baptist DH, Verhagen EAA, Siebelink MJ. Neonatal donation: are newborns too young to be recognized? Eur J Pediatr 2021; 180:3491-3497. [PMID: 34105002 PMCID: PMC8589733 DOI: 10.1007/s00431-021-04139-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/03/2021] [Accepted: 05/31/2021] [Indexed: 11/30/2022]
Abstract
Neonatal organ and tissue donation is not common practice in the Netherlands. At the same time, there is a transplant waiting list for small size-matched organs and tissues. Multiple factors may contribute to low neonatal donation rates, including a lack of awareness of this option. This study provides insight into potential neonatal organ and tissue donors and reports on how many donors were actually reported to the procurement organization. We performed a retrospective analysis of the mortality database and medical records of two largest neonatal intensive care units (NICUs) in the Netherlands. This study reviewed records of neonates with a gestational age >37 weeks and weight >3000g who died in the period from January 1, 2005 through December 31, 2016. During the study period, 259 term-born neonates died in the two NICUs. In total, 132 neonates with general contra-indications for donation were excluded. The medical records of 127 neonates were examined for donation suitability. We identified five neonates with documented brain death who were not recognized as potential organ and/or tissue donors. Of the remaining neonates, 27 were found suitable for tissue donation. One potential tissue donor had been reported to the procurement organization. In three cases, the possibility of donation was brought up by parents.Conclusion: A low proportion (2%) of neonates who died in the NICUs were found suitable for organ donation, and a higher proportion (12%) were found suitable for tissue donation. We suggest that increased awareness concerning the possibility of neonatal donation would likely increase the identification of potential neonatal donors. What is Known: • There is an urgent need for very small organs and tissues from neonatal donors What is New: • A number of neonates who died in the NICU were suitable organ or/and tissue donors but were not recognized as donors. • Knowledge on neonatal donation possibilities is also important for proper counseling of parents who sometimes inquire for the possibility of organ and tissue donation.
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Affiliation(s)
- Alicija Vileito
- Department of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands.
| | - Christian V. Hulzebos
- Department of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands
| | - Mona C. Toet
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dyvonne H. Baptist
- Department of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands
| | - Eduard A. A. Verhagen
- Department of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands
| | - Marion J. Siebelink
- University Medical Center Groningen Transplant Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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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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Abstract
When talking about decisionmaking for children with a life-threatening condition, the death of children with brain tumors deserves special attention. The last days of the lives of these children can be particularly harsh for bystanders, and raise questions about the suffering of these children themselves. In the Netherlands, these children are part of the group for whom a wide range of end-of-life decisions are discussed, and questions raised. What does the end-of-life for these children look like, and what motivates physicians and parents to make decisions that may affect the life and death of these children? This article highlights the story of the parents of the sisters Roos and Noor. When both their daughters were diagnosed with a hereditary brain tumor, they had to make similar decisions twice. Their story sheds light on the suffering of children in the terminal phase, and how this suffering may motivate parents and physicians to make decisions that influence the end of life of these children's lives.We argue that complete knowledge about suffering in the terminal phase of children with brain tumors is impossible. However, by collecting experiences like those of Roos and Noor, we can move toward an experienced-based understanding and better guide parents and physicians through these hardest of decisions.
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13
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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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The complexity of physicians' understanding and management of prognostic uncertainty in neonatal hypoxic-ischemic encephalopathy. J Perinatol 2019; 39:278-285. [PMID: 30568164 DOI: 10.1038/s41372-018-0296-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Prognosis of Hypoxic-Ischemic Encephalopathy (HIE) remains challenging and uncertain. This paper investigates how physicians understand and address the ethical challenges of prognostic uncertainty in the case of neonatal HIE, contextualized within the social science literature. STUDY DESIGN Semi-structured interviews were conducted with 12 Canadian neurologists and neonatologists, addressing their perspectives and clinical experiences concerning neonatal HIE prognostication. Interviews were analyzed using thematic content analysis. RESULTS Participants unanimously recognized uncertainty in their prognostication. They identified several sources contributing to uncertainty in HIE prognostication, including etiology and underlying pathophysiologic mechanisms, statistical limitations, variable clinical data, the dynamic process of neurodevelopment, or the impact of hypothermia treatment. Unlike in some other literature, some physicians in this study talked about ways to render uncertainty explicit rather than hide it. CONCLUSION Results from this study support the call for recognition of the ubiquitous uncertainty surrounding this act in medical education and training.
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Verhagen AAE. Why Do Neonatologists in Scandinavian Countries and the Netherlands Make Life-and-death Decisions So Different? Pediatrics 2018; 142:S585-S589. [PMID: 30171145 DOI: 10.1542/peds.2018-0478j] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
An examination of the policies regarding the care of extremely premature newborns reveals unexpected differences between Scandinavian countries and the Netherlands. Three topics related to decision-making at the beginning and at the end of life are identified and discussed.
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Affiliation(s)
- A A Eduard Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Wilkinson D, Verhagen E, Johansson S. Thresholds for Resuscitation of Extremely Preterm Infants in the UK, Sweden, and Netherlands. Pediatrics 2018; 142:S574-S584. [PMID: 30171144 PMCID: PMC6379058 DOI: 10.1542/peds.2018-0478i] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is widely acceptable to involve parents in decision-making about the resuscitation of extremely preterm infants (EPIs) in the gray zone. However, there are different views about where the boundaries of the gray zone should lie. Our aim in this study was to compare the resuscitation thresholds for EPIs between neonatologists in the United Kingdom, Sweden, and the Netherlands. METHODS We distributed an online survey to consultant neonatologists and neonatal registrars and fellows that included clinical scenarios in which parents requested resuscitation or nonresuscitation. Respondents were asked about the lowest gestational age and/or the worst prognosis at which they would provide resuscitation and the highest gestational age and/or the best prognosis at which they would withhold resuscitation. In additional scenarios, influence of the condition at birth or consideration of available health care resources was assessed. RESULTS The survey was completed by 162 neonatologists (30% response rate). There was a significant difference between countries; the gray zone for most UK respondents was 23 + 0/7 to 23 + 6/7 or 24 weeks' gestation, compared with 22 + 0/7 to 22 + 6/7 or 23 weeks' gestation in Sweden and 24 + 0/7 to 25 + 6/7 or 26 weeks' gestation in the Netherlands. Resuscitation thresholds were higher if an infant was born in poor condition. There was wide variation in the prognosis that warranted resuscitation or nonresuscitation. Consideration of resource scarcity did not alter responses. CONCLUSIONS In this survey, we found significant differences in approach to the resuscitation of EPIs, with a spectrum from most proactive (Sweden) to least proactive (Netherlands). Most survey respondents indicated shifts in decision-making that were associated with particular weeks' gestation. Despite the different approaches to decision-making in the 3 countries, there was relatively little difference between countries in neonatologists' prognostic thresholds for resuscitation.
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Affiliation(s)
- Dominic Wilkinson
- Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom; .,John Radcliffe Hospital, Oxford, United Kingdom
| | - Eduard Verhagen
- Dept of Pediatrics, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Stefan Johansson
- Department of Clinical Science and Education, Södersjukhuset (Karolinska Institutet SÖS), Stockholm, Sweden,Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
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Zaal-Schuller IH, Willems DI, Ewals F, van Goudoever JB, de Vos MA. Involvement of nurses in end-of-life discussions for severely disabled children. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2018; 62:330-338. [PMID: 29388276 DOI: 10.1111/jir.12473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/08/2017] [Accepted: 12/21/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND In children with profound intellectual and multiple disabilities (PIMD), discussions about end-of-life decisions (EoLDs) are comparatively common. Nurses play a crucial role in the care for these children, yet their involvement in EoLD discussions is largely unknown. The objective of this research was to investigate the involvement in the hospital of nurses in discussions with parents and physicians about EoLDs for children with PIMD. METHOD In a retrospective, qualitative study, we conducted semi-structured interviews with the nurses of 12 children with PIMD for whom an EoLD was made within the past 2 years. RESULTS Parents primarily discuss EoLDs with nurses before and after the meeting with the physician. Nurses who were involved in EoL discussions with parents and physicians assisted them by giving factual information about the child and by providing emotional support. Some nurses, especially nurses from ID-care services, were not involved in EoL discussions, even if they had cared for the child for a long period of time. Some of the nurses had moral or religious objections to carrying out the decisions. CONCLUSION Most nurses were not involved in EoL discussions with parents and physicians in the hospital. Excluding nurses from EoL discussions can cause them moral distress. The involvement of nurses in EoL discussions for children with PIMD should be improved, especially by involving nurses from ID-care services. Because these nurses are usually familiar with the child, they can be valuable sources of information about the child's quality of life.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
| | - D I Willems
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
| | - F Ewals
- Intellectual Disability Medicine, Department of Medical Practice, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - J B van Goudoever
- Department of Pediatrics, VU Medisch Centrum, Amsterdam, the Netherlands
- Academic Medical Centre, Emma's Children's Hospital, Department of Paediatrics, Amsterdam, The Netherlands
| | - M A de Vos
- Section of Medial Ethics, Department of General Practice, University of Amsterdam, Amsterdam, the Netherlands
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Snoep MC, Jansen NJ, Groenendaal F. Deaths and end-of-life decisions differed between neonatal and paediatric intensive care units at the same children's hospital. Acta Paediatr 2018; 107:270-275. [PMID: 28871637 PMCID: PMC5813263 DOI: 10.1111/apa.14061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/28/2017] [Accepted: 08/31/2017] [Indexed: 11/30/2022]
Abstract
AIM We compared neonatal deaths and end-of-life decisions in a neonatal intensive care unit (NICU) and paediatric intensive care unit (PICU) in a Dutch tertiary children's hospital. SUBJECTS All 235 full-term infants who died within 28 days of life between 2003 and 2013 in the NICU (n = 199) and PICU (n = 36) were retrospectively studied. RESULTS The median length of stay was three days in the NICU and seven days in the PICU (p = 0.003). The main reasons for NICU stays were asphyxia (52.8%) and congenital malformations (42.2%), and in the PICU, they were congenital malformations (97.2%) and primarily cardiac problems (83.3%, p < 0.001). The median age of death was three days in the NICU and eight days in the PICU (p < 0.001), and mortality despite full intensive care treatment was 4.0% and 25.0%, respectively. Intensive treatment was discontinued because of poor survival chances in 25.1% of NICU and 52.8% of PICU cases (p < 0.001), and care was redirected because of expected poor quality of life in 70.9% and 22.2%, respectively. CONCLUSION Differences between the age at death and end-of-life decisions were found between full-term infants in the NICU and PICU in the same children's hospital. Underlying disorders and doctors' attitudes may have played a role.
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Affiliation(s)
- Maartje C. Snoep
- Department of Neonatology; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
- Paediatric Intensive Care; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
| | - Nicolaas J.G. Jansen
- Paediatric Intensive Care; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
| | - Floris Groenendaal
- Department of Neonatology; The Wilhelmina Children's Hospital; University Medical Center Utrecht; Utrecht University; Utrecht the Netherlands
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Children's outcomes at 2-year follow-up after 4 years of structured multi-professional medical-ethical decision-making in a neonatal intensive care unit. J Perinatol 2017; 37:869-874. [PMID: 28358379 DOI: 10.1038/jp.2017.30] [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: 10/12/2016] [Revised: 12/23/2016] [Accepted: 02/14/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We reviewed our decisions about continuation/withdrawal of life-sustaining treatments in a group of critically ill newborns who were discussed in structured medical ethical decision-making meetings, and provide the surviving children's outcomes at 2-year follow-up. STUDY DESIGN In an explorative observational study, 61 cases were evaluated. The children involved had been discussed in such a structured way from 2009 to 2012 in a level III-D neonatal intensive care unit. RESULTS Decisions made were: full treatment (n=6), earlier restriction cancelled (n=3), treatment restriction (n=30) and palliative care (n=22). Parents of six children disagreed with the decision proposed. Thirteen (54%) of the 24 children who survived (39%) had moderate to severe neurological problems; 8 (33%) had additional sequelae; only one 2-year-old child was healthy. CONCLUSIONS Decisions made varied to a large extent. The poor outcomes should be disseminated among decision makers. Future studies must explore new ways to improve outcome prediction, extend follow-up periods and consider what living with severe handicaps really means for both child and family.
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Tedesco M. Dutch Protocols for Deliberately Ending the Life of Newborns: A Defence. JOURNAL OF BIOETHICAL INQUIRY 2017; 14:251-259. [PMID: 28220355 DOI: 10.1007/s11673-017-9772-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/21/2016] [Indexed: 06/06/2023]
Abstract
The Groningen Protocol, introduced in the Netherlands in 2005 and accompanied by revised guidelines published in a report commissioned by the Royal Dutch Medical Association in 2014, specifies conditions under which the lives of severely ill newborns may be deliberately ended. Its publication came four years after the Netherlands became the first nation to legalize the voluntary active euthanasia of adults, and the Netherlands remains the only country to offer a pathway to protecting physicians who might engage in deliberately ending the life of a newborn (DELN). In this paper, I offer two lines of argument. The first is a positive argument for the Protocol, grounded in the good of the newborn as unanimously determined by those in a position to determine it. The second addresses the widely shared belief that the killing of newborns is morally prohibited, where I offer two arguments-one grounded in the fact that the kinds of cases the Protocol is meant to govern are very rare and highly unusual, and the other focused more broadly on the role of pre-theoretical beliefs in moral reasoning-meant to undermine the strong role that the critic of the Protocol affords this belief. I argue that, given this second line of argument, the beliefs underlying my positive argument for the Protocol are in fact more secure than the widely shared belief underlying the critic's position.
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21
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Lee JH, Cho SY, Kwon KA, Kim MJ. Investigation of Neonatal Staff Members' Attitudes toward End-of-Life Decision Making about Dying Newborns. NEONATAL MEDICINE 2017. [DOI: 10.5385/nm.2017.24.2.77] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jin-Hyeok Lee
- Department of Pediatrics, Dong-A University College of Medicine, Busan, Korea
| | - Sun-Young Cho
- Department of Pediatrics, Dong-A University College of Medicine, Busan, Korea
| | - Kyoung-Ah Kwon
- Department of Pediatrics, Dong-A University College of Medicine, Busan, Korea
| | - Myo-Jing Kim
- Department of Pediatrics, Dong-A University College of Medicine, Busan, Korea
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22
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Kon AA, Patel A, Leuthner S, Lantos JD. Parental Refusal of Surgery in an Infant With Tricuspid Atresia. Pediatrics 2016; 138:peds.2016-1730. [PMID: 27940784 DOI: 10.1542/peds.2016-1730] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2016] [Indexed: 11/24/2022] Open
Abstract
We present a case of a fetal diagnosis of tricuspid atresia (TA). The pregnant woman and her husband requested that the baby be treated with only palliative care. The cardiologist did not think it would be appropriate to withhold life-prolonging surgery once the infant was born. The neonatologist argued that outcomes for TA are similar to those for hypoplastic left heart syndrome, and the standard practice at the institution was to allow parents to choose surgery or end-of-life care for those infants. The team requested an ethics consultation to assist in determining whether forgoing life-prolonging interventions in this case would be ethically supportable. In this article, we ask a pediatric intensivist, a pediatric cardiologist, and a neonatologist to discuss the ethics of withholding life-sustaining treatment of a baby with TA.
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Affiliation(s)
- Alexander A Kon
- Naval Medical Center San Diego and the University of California San Diego School of Medicine, San Diego, California
| | | | | | - John D Lantos
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
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23
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Pal S, Jones J, Job S, Maynard L, Curley A, Clarke P. Characteristics of babies who unexpectedly survive long term after withdrawal of intensive care. Acta Paediatr 2016; 105:468-74. [PMID: 26600230 DOI: 10.1111/apa.13279] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/19/2015] [Accepted: 11/17/2015] [Indexed: 11/28/2022]
Abstract
AIM Occasional babies survive long term after withdrawal of intensive care despite a poor prognosis. We aimed to review in detail the clinical cases, characteristics, and outcomes of neonates with unexpected protracted survival following planned withdrawal of intensive cardiorespiratory support. METHODS We reviewed infants who unexpectedly survived for more than one week following planned withdrawal of intensive care in two tertiary-level NICUs over a seven-year period. RESULTS We identified eight long-term survivors (six term, two preterm) between 2007 and 2013. All had a clinical diagnosis of grade 3 hypoxic-ischaemic encephalopathy and severely abnormal electroencephalography and neuroimaging prior to intensive care withdrawal. Intensive care was withdrawn at five days postnatal age (range: two to nine days), but the possibility of protracted survival was discussed beforehand in only two cases. Three infants died before three months of age. Five infants remain alive, currently aged from 2.0 to 6.5 years, and all have significant neurodevelopmental problems. CONCLUSION Unexpected long-term survival after neonatal intensive care withdrawal occurs occasionally but unpredictably. Significant neurodevelopmental adversity was invariable in those surviving beyond infancy. Ventilator dependency along with severely abnormal electroencephalography and neuroimaging is still compatible with long-term survival. The possibility of protracted survival should be discussed routinely with parents before intensive care withdrawal.
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Affiliation(s)
- Sanchita Pal
- Neonatal Unit; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Jacqueline Jones
- Neonatal Unit; Norfolk & Norwich University Hospitals NHS Foundation Trust; Norwich Norfolk UK
| | - Sajeev Job
- Neonatal Unit; Norfolk & Norwich University Hospitals NHS Foundation Trust; Norwich Norfolk UK
| | - Linda Maynard
- East Anglia's Children's Hospices (EACH); Cambridge UK
| | - Anna Curley
- Neonatal Unit; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Paul Clarke
- Neonatal Unit; Norfolk & Norwich University Hospitals NHS Foundation Trust; Norwich Norfolk UK
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24
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Zaal-Schuller IH, de Vos MA, Ewals FVPM, van Goudoever JB, Willems DL. End-of-life decision-making for children with severe developmental disabilities: The parental perspective. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 49-50:235-246. [PMID: 26741261 DOI: 10.1016/j.ridd.2015.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 11/28/2015] [Accepted: 12/08/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND AIMS The objectives of this integrative review were to understand how parents of children with severe developmental disorders experience their involvement in end-of-life decision-making, how they prefer to be involved and what factors influence their decisions. METHODS AND PROCEDURES We searched MEDLINE, EMBASE, CINAHL and PsycINFO. The search was limited to articles in English or Dutch published between January 2004 and August 2014. We included qualitative and quantitative original studies that directly investigated the experiences of parents of children aged 0-18 years with severe developmental disorders for whom an end-of-life decision had been considered or made. OUTCOMES AND RESULTS We identified nine studies that met all inclusion criteria. Reportedly, parental involvement in end-of-life decision-making varied widely, ranging from having no involvement to being the sole decision-maker. Most parents preferred to actively share in the decision-making process regardless of their child's specific diagnosis or comorbidity. The main factors that influenced parents in their decision-making were: their strong urge to advocate for their child's best interests and to make the best (possible) decision. In addition, parents felt influenced by their child's visible suffering, remaining quality of life and the will they perceived in their child to survive. CONCLUSIONS AND IMPLICATIONS Most parents of children with severe developmental disorders wish to actively share in the end-of-life decision-making process. An important emerging factor in this process is the parents' feeling that they have to stand up for their child's interests in conversations with the medical team.
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Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital-Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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25
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Clément de Cléty S, Friedel M, Verhagen AAE, Lantos JD, Carter BS. Please Do Whatever It Takes to End Our Daughter's Suffering! Pediatrics 2016; 137:peds.2015-3812. [PMID: 26644491 DOI: 10.1542/peds.2015-3812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2015] [Indexed: 11/24/2022] Open
Abstract
What is the best way to care for a child with severe neurologic impairment who seems to be dying and is in intractable pain? Can we give sedation as we remove life support? Is it ethically permissible to hasten death? In the United States, 5 states have legalized assisted suicide (although only for competent adults). In Belgium and the Netherlands, euthanasia is legal for children under some circumstances. We present a case in which parents and doctors face difficult decisions about palliative care. Experts from Belgium, the Netherlands, and the United States then discuss how they would respond to such a case.
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Affiliation(s)
| | - Marie Friedel
- Haute Ecole Vinci and Université catholique de Louvain, Brussels, Belgium
| | - A A Eduard Verhagen
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; and
| | - John D Lantos
- Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
| | - Brian S Carter
- Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
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Abstract
On one hand, advances in neonatal care and rescue technology allow for the healthy survival or prolonged survival time of critically ill newborns who, in the past, would have been non-viable. On the other hand, many of the surviving critically ill infants have serious long-term disabilities. If an infant eventually cannot survive or is likely to suffer severe disability after surviving, ethical issues in the treatment process are inevitable, and this problem arises not only in developed countries but is also becoming increasingly prominent in developing countries. In addition, ethical concerns cannot be avoided in medical research. This review article introduces basic ethical guidelines that should be followed in clinical practice, including respecting the autonomy of the parents, giving priority to the best interests of the infant, the principle of doing no harm, and consent and the right to be informed. Furthermore, the major ethical concerns in neonatal intensive care units (NICUs) in China are briefly introduced.
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Affiliation(s)
- Jing Liu
- a Department of Neonatology and NICU of Bayi Children's Hospital and
| | - Xin-Xin Chen
- a Department of Neonatology and NICU of Bayi Children's Hospital and
| | - Xin-Ling Wang
- b Department of Information , Beijing Military General Hospital , Beijing , China
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27
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ten Cate K, van de Vathorst S, Onwuteaka-Philipsen BD, van der Heide A. End-of-life decisions for children under 1 year of age in the Netherlands: decreased frequency of administration of drugs to deliberately hasten death. JOURNAL OF MEDICAL ETHICS 2015; 41:795-798. [PMID: 26272986 DOI: 10.1136/medethics-2014-102562] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 07/23/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To assess whether the frequency of end-of-life decisions for children under 1 year of age in the Netherlands has changed since ultrasound examination around 20 weeks of gestation became routine in 2007 and after a legal provision for deliberately ending the life of a newborn was set up that same year. METHODOLOGY This was a recurrent nationwide cross-sectional study in the Netherlands. In 2010, a sample of death certificates from children under 1 year of age was derived from the central death registry. All 223 deaths that occurred in a 4-month study period were included. Physicians who had reported a non-sudden death (n=206) were sent a questionnaire on the end-of-life decisions made. 160 questionnaires were returned (response 78%). FINDINGS In 2010, 63% of all deaths of children under 1 year of age were preceded by an end-of-life decision-a percentage comparable to other times when this study was conducted (1995, 2001, 2005). These end-of-life decisions were mainly decisions to withdraw or withhold potentially life-sustaining treatment. In 2010, the percentage of cases in which drugs were administered with the explicit intention to hasten death was 1%, while in 1995 and 2001, this was 9% and in 2005, this was 8%. DISCUSSION AND CONCLUSION There has been a reduction of infant deaths that followed administration of drugs with the explicit intention to hasten death. One explanation for this reduction relates to the introduction of routine ultrasound examination around 20 weeks of gestation. In addition, the introduction of legal criteria and a review process for deliberately ending the life of a newborn may have left Dutch physicians with less room to hasten death.
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Affiliation(s)
- Katja ten Cate
- Department of General Practice, Section Medical Ethics, Academic Medical Centre/University of Amsterdam, Amsterdam, The Netherlands
| | - Suzanne van de Vathorst
- Department of General Practice, Section Medical Ethics, Academic Medical Centre/University of Amsterdam, Amsterdam, The Netherlands Department of Medical Ethics and Philosophy, Erasmus Medical Centre/Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute, VU Medical Centre/VU University Amsterdam, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus Medical Centre/Erasmus University Rotterdam, Rotterdam, The Netherlands
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de Boer JC, van Rosmalen J, Bakker AB, van Dijk M. Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurements. Nurs Crit Care 2015; 21:e19-27. [DOI: 10.1111/nicc.12206] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/23/2015] [Accepted: 07/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Jacoba Coby de Boer
- Department of Pediatrics; Erasmus University Medical Centre, Sophia Children's Hospital; Rotterdam The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics; Erasmus University Medical Centre; Rotterdam The Netherlands
| | - Arnold B. Bakker
- Department of Work and Organizational Psychology; Erasmus University Rotterdam; Rotterdam The Netherlands
| | - Monique van Dijk
- Department of Pediatrics; Erasmus University Medical Centre, Sophia Children's Hospital; Rotterdam The Netherlands
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29
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Abstract
Decisions about neonatal end-of-life care have been studied intensely over the last 20 years in The Netherlands. Nationwide surveys were done to quantify these decisions, provide details and monitor the effect of guidelines, new regulations and other interventions. One of those interventions was the Groningen Protocol for newborn euthanasia in severely ill newborns, published in 2005. Before publication, an estimated 20 cases of euthanasia per year were performed. After publication, only two cases in five years were reported. Studies suggested that this might be partly caused by the lack of consensus about the dividing line between euthanasia and palliative care. New recommendations about paralytic medication use in dying newborns were issued to increase transparency and to improve reporting of euthanasia. New surveys will be needed to measure the effects of these interventions. This cycle of interventions and measurements seems useful for continuous improvement of end-of-life care in newborns.
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Affiliation(s)
- A A Eduard Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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