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Ng PC, Fung GPG. Spiritual and cultural influences on end-of-life care and decision-making in NICU. Semin Fetal Neonatal Med 2023; 28:101437. [PMID: 37105859 DOI: 10.1016/j.siny.2023.101437] [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
Understanding and respecting the spiritual beliefs, ethnic roots, cultural norms and customs of individual families is essential for neonatologists to provide clinically appropriate and humane end-of-life care. This review describes the religious/philosophical principles, cultural-related practices/rituals, and traditions in end-of-life care in major spiritual groups of today's multi-cultural, multi-faith societies. The spiritual groups include Christians, Muslims, Jewish Judaism believers and Asian religious/philosophy followers such as Buddhists, Hindus, Taoists, Confucianism devotees and ancestral worshippers. It is vital to understand that substantial variation in views and practices may exist even within the same religion and culture in different geographic locations. Ethical views and cultural practices are not static elements in life but behave in a fluidic and dynamic manner that could change with time. Interestingly, an evolving pattern has been observed in some Asian and Middle East countries that more parents and/or religious groups are beginning to accept a form of redirection of care most compatible with their spiritual belief and culture. Thus, every family must be assessed and counseled individually for end-of-life decision-making. Also, every effort should be made to comply with parents' requests and to treat infants/parents of different religions and cultures with utmost dignity so that they have no regret for their irreversible decisions.
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Affiliation(s)
- Pak C Ng
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| | - Genevieve P G Fung
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Christiansson Y, Moberg M, Rakow A, Stjernholm YV. Increased Survival Concomitant with Unchanged Morbidity and Cognitive Disability among Infants Born at the Limit of Viability before 24 Gestational Weeks in 2009-2019. J Clin Med 2023; 12:4048. [PMID: 37373741 DOI: 10.3390/jcm12124048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION The aim was to determine risk factors among mothers and outcomes for their children born at the limit of viability in 2009-2019, before and after the introduction of extended interventionist guidelines. METHODS A retrospective cohort study of births at 22 + 0-23 + 6 gestational weeks in a Swedish Region in 2009-2015 (n = 119), as compared to 2016-2019 (n = 86) after the introduction of new national interventionist guidelines. Infant mortality, morbidity, and cognitive functions at 2 years corrected age according to the Bayley-III Screening Test were monitored. RESULTS Maternal risk factors for extreme preterm birth were identified. The intrauterine fetal death rates were comparable. Among births at 22 weeks, the neonatal mortality tended to decrease (96 vs. 76% of live births (p = 0.05)), and the 2-year survival tended to increase (4 vs. 24% (p = 0.05)). Among births at 23 weeks, the neonatal mortality decreased (56 vs. 27% of live births (p = 0.01)), and the 2-year survival increased (42 vs. 64% (p = 0.03)). Somatic morbidity and cognitive disability at 2 years corrected age were unchanged. CONCLUSION We identified maternal risk factors that emphasize the need for standardized follow-up and counseling for women at increased risk of preterm birth at the limit of viability. The increased infant survival concomitant with unchanged morbidity and cognitive disability highlight the importance of ethical considerations regarding interventionist approaches at threatening preterm birth before 24 weeks.
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Affiliation(s)
- Yasemin Christiansson
- Karolinska University Hospital, Karolinska Institutet, Akademiska Stråket 14, 171 64 Stockholm, Sweden
| | - Maria Moberg
- Karolinska University Hospital, Karolinska Institutet, Akademiska Stråket 14, 171 64 Stockholm, Sweden
| | - Alexander Rakow
- Karolinska University Hospital, Karolinska Institutet, Akademiska Stråket 14, 171 64 Stockholm, Sweden
- Neonatal Unit, Department of Women's and Children's Health, Karolinska University Hospital, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Ylva Vladic Stjernholm
- Karolinska University Hospital, Karolinska Institutet, Akademiska Stråket 14, 171 64 Stockholm, Sweden
- Obstetric Unit, Department of Women's and Children's Health, Karolinska University Hospital, Karolinska Institutet, 171 76 Stockholm, Sweden
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De Proost L, Geurtzen R, Ismaili M'hamdi H, Reiss IKMI, Steegers EAPE, Joanne Verweij EJ. Prenatal counseling for extreme prematurity at the limit of viability: A scoping review. PATIENT EDUCATION AND COUNSELING 2022; 105:1743-1760. [PMID: 34872804 DOI: 10.1016/j.pec.2021.10.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To explore, based on the existing body of literature, main characteristics of prenatal counseling for parents at risk for extreme preterm birth. METHODS A scoping review was conducted searching Embase, Medline, Web of Science, Cochrane, CINAHL, and Google Scholar. RESULTS 46 articles were included. 27 of them were published between 2017 and 2021. More than half of them were conducted in the United States of America. Many different study designs were represented. The following characteristics were identified: personalization, parent-physician relationships, shared decision-making, physician bias, emotions, anxiety, psychosocial factors, parental values, religion, spirituality, hope, quality of life, and uncertainty. CONCLUSIONS Parental values are mentioned in 37 of the included articles. Besides this, uncertainty, shared decision-making, and emotions are most frequently mentioned in the literature. However, reflecting on the interrelation between all characteristics leads us to conclude that personalization is the most notable trend in prenatal counseling practices. More and more, it is valued to adjust the counseling to the parent(s). PRACTICE IMPLICATIONS This scoping review emphasizes again the complexity of prenatal counseling at the limit of viability. It offers an exploration of how it is currently approached, and reflects on how future research can contribute to optimizing it.
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Affiliation(s)
- Lien De Proost
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, Rotterdam, The Netherlands; Department of Neonatology, Erasmus MC, Rotterdam, The Netherlands; Department of Obstetrics & Gynecology, Erasmus MC, Rotterdam The Netherlands.
| | - Rosa Geurtzen
- Department of Neonatology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Hafez Ismaili M'hamdi
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - E A P Eric Steegers
- Department of Obstetrics & Gynecology, Erasmus MC, Rotterdam The Netherlands
| | - E J Joanne Verweij
- Department of Obstetrics & Gynecology, Erasmus MC, Rotterdam The Netherlands; Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Athalye-Jape G, Lim M, Nathan E, Sharp M. Outcomes in extremely low birth weight (≤500 g) preterm infants: A Western Australian experience. Early Hum Dev 2022; 167:105553. [PMID: 35217355 DOI: 10.1016/j.earlhumdev.2022.105553] [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: 03/17/2021] [Revised: 02/06/2022] [Accepted: 02/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIM Extremely preterm (EP) infant survival has significantly improved with advanced neonatal care; however outcomes of infants born with birth weight (BW) ≤500 g remain poor. We aimed to review outcomes of this cohort in our institution. METHODS Retrospective study of all inborn preterm infants born at ≥22 weeks gestational age (GA) and weighing ≤500 g between January 2001-December 2017. Outcomes included short-term morbidity, mortality, neurodevelopmental impairment and growth up to five years of age. RESULTS Of a total 438 eligible infants, 92 livebirths were admitted to intensive care [median (range) GA: 24 (22-30) weeks; median (IQR) BW: 427.5 (380-499) grams]. Majority [78/92 (84.7%)] were small for gestational age (SGA). In 50% of non-survivors, median (IQR) age of death was 3.5 (1-17.5) days with no late deaths. Medical morbidities were common. Follow-up, including standardised cognitive assessments, was available for 41/46 (89%) infants. At a median age of 5.06 years, 17/41 (41.5%) had moderate-severe disability; non-statistically higher in SGA compared to appropriate for gestational age/AGA (48.6% vs. 33.3%) group. Cerebral palsy (4/41; 10%), deafness needing amplification (1/41; 2.4%) were noted. Weight (32/41, 78%) and height (27/41, 66%) of most children remained at >2 SD below normal. CONCLUSIONS In a cohort of preterm infants weighing ≤500 g at birth, 50% survived after admission to intensive care. Medical morbidities were common and 54% were free from moderate to severe disability at five years. SGA infants had higher rates (48.6%) of moderate to severe disability. Ongoing suboptimal growth in childhood is common.
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Affiliation(s)
- Gayatri Athalye-Jape
- Neonatal Follow-up Program, King Edward Memorial Hospital, United States of America; Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Perth, Western Australia, Australia; Neonatal and Life Course Health Program Team, Telethon Kids Institute, Perth, Western Australia, Australia.
| | - Mei'En Lim
- Neonatal Follow-up Program, King Edward Memorial Hospital, United States of America; Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Perth, Western Australia, Australia. mei'
| | - Elizabeth Nathan
- Women and Infants Research Foundation, King Edward Memorial Hospital for Women, Perth, Australia; Division of Obstetrics and Gynaecology, University of Western Australia, Australia.
| | - Mary Sharp
- Neonatal Follow-up Program, King Edward Memorial Hospital, United States of America; Centre for Neonatal Research and Education, School of Medicine, University of Western Australia, Perth, Western Australia, Australia; Neonatal and Life Course Health Program Team, Telethon Kids Institute, Perth, Western Australia, Australia.
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Geurtzen R, van den Heuvel JFM, Huisman JJ, Lutke Holzik EM, Bekker MN, Hogeveen M. Decision-making in imminent extreme premature births: perceived shared decision-making, parental decisional conflict and decision regret. J Perinatol 2021; 41:2201-2207. [PMID: 34285357 DOI: 10.1038/s41372-021-01159-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 07/09/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To describe levels of perceived shared decision making (SDM), decisional conflict (DC), and decision regret (DR) in prenatal counseling by pregnant women, partners, neonatologists, and obstetricians regarding decision-making around imminent extreme premature birth in which a decision about palliative comfort care versus early intensive care had to be made. STUDY DESIGN Multicenter, cross-sectional study using surveys to determine perceived SDM at imminent extreme premature birth in parents and physicians, and to determine DC and DR in parents. RESULTS In total, 73 participants from 22 prenatal counseling sessions were included (21 pregnant women, 20 partners, 14 obstetricians, 18 neonatologists). High perceived levels of SDM were found (median 82,2), and low levels of DC (median 23,4) and DR at one month (median 12, 5). CONCLUSIONS Reported levels of self-perceived SDM in the setting of prenatal counseling in extreme prematurity were high, by both the parents and the physicians. Levels of DC and DR were low.
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Affiliation(s)
- R Geurtzen
- Amalia Children's Hospital, department of neonatology, Radboud university medical center, Nijmegen, The Netherlands.
| | - J F M van den Heuvel
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - J J Huisman
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - E M Lutke Holzik
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - M N Bekker
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - M Hogeveen
- Amalia Children's Hospital, department of neonatology, Radboud university medical center, Nijmegen, The Netherlands
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De Proost L, Verweij EJT, Ismaili M'hamdi H, Reiss IKM, Steegers EAP, Geurtzen R, Verhagen AAE. The Edge of Perinatal Viability: Understanding the Dutch Position. Front Pediatr 2021; 9:634290. [PMID: 33598441 PMCID: PMC7882530 DOI: 10.3389/fped.2021.634290] [Citation(s) in RCA: 10] [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: 11/27/2020] [Accepted: 01/08/2021] [Indexed: 11/17/2022] Open
Abstract
The current Dutch guideline on care at the edge of perinatal viability advises to consider initiation of active care to infants born from 24 weeks of gestational age on. This, only after extensive counseling of and shared decision-making with the parents of the yet unborn infant. Compared to most other European guidelines on this matter, the Dutch guideline may be thought to stand out for its relatively high age threshold of initiating active care, its gray zone spanning weeks 24 and 25 in which active management is determined by parental discretion, and a slight reluctance to provide active care in case of extreme prematurity. In this article, we explore the Dutch position more thoroughly. First, we briefly look at the previous and current Dutch guidelines. Second, we position them within the Dutch socio-cultural context. We focus on the Dutch prioritization of individual freedom, the abortion law and the perinatal threshold of viability, and a culturally embedded aversion of suffering. Lastly, we explore two possible adaptations of the Dutch guideline; i.e., to only lower the age threshold to consider the initiation of active care, or to change the type of guideline.
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Affiliation(s)
- L. De Proost
- Department of Medical Ethics, Philosophy and History of Medicine, Rotterdam, Netherlands
- Department of Neonatology, Rotterdam, Netherlands
- Department of Obstetrics and Gynecology, Rotterdam, Netherlands
| | - E. J. T. Verweij
- Department of Obstetrics and Gynecology, Rotterdam, Netherlands
- Department of Obstetrics, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - H. Ismaili M'hamdi
- Department of Medical Ethics, Philosophy and History of Medicine, Rotterdam, Netherlands
| | | | | | - R. Geurtzen
- Department of Neonatology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, Netherlands
| | - A. A. E. Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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