Parent Involvement in End-of-Life Care and Decision Making in the Newborn Intensive Care Unit: An Integrative Review

Understanding the experience of the mothers' ability to take care of their preterm infants related to in-hospital and post-discharge: a qualitative content analysis

BACKGROUND

Preterm infants may experience many health and developmental issues, which continue even after discharge from the neonatal intensive care unit. Once home, the mother, as a non-professional and the primary caregiver will be responsible for the essential care of her preterm infant.

PURPOSE

Understanding the take care ability in mothers with preterm infants.

METHODS

The content analysis method was used. The data were collected using in-depth and semi-structured interviews from April 2021 to February 2022. Eleven mothers, two fathers, two grandmothers, one neonatal nurse, and two neonatologists with a mean age of 36.05 ± 10.88 years were selected using purposeful and snowballing sampling in Tehran, Iran. Allocating adequate time for data collection, gathering data through different methods, peer checking by two qualitative researchers, long interaction with the settings, maximum variation sampling, appropriate quotations, and showing the range of facts fairly and honestly were considered to ensure the trustworthiness of this study. The data were analyzed through Lindgren et al.'s approach using MAXQDA software.

RESULTS

Based on the findings and participants' experiences in 18 deep interviews, the mothers with desirable care ability have adequate ability as described by 17 subcategories and are categorized into five dimensions. The care ability of the mothers of preterm infants upon neonatal intensive care unit discharge consisted of five categories including maternal identity, infant's needs, cognitive ability, technical ability, and psychological ability.

IMPLICATIONS FOR PRACTICE AND RESEARCH

In the mothers of preterm infants, maternal identity and the infant's needs are antecedents of the care ability concept. The care ability of the mothers with preterm infants is distinct from those of other caregivers. This is a multi-dimensional concept and trait related to maternal cognitive ability, technical ability, and maternal psychological ability. Professional neonatal nurses should assess their care ability from multiple perspectives: cognitive, technical, and psychological abilities. They should be considered in designing empowerment and engagement programs for the improvement of the care ability of the mothers of preterm infants. Both mothers and professional neonatal nurses should take responsibility for improving the mothers' ability to take care of their preterm infants.

Exploring the Role of Genetic Testing in Decisions to Redirect Care in Critically Ill Infants

OBJECTIVE

Genetic disorders are a major determinant of morbidity and mortality within neonatal intensive care units (NICUs). Studies have found genetic testing in critically ill infants may lead to changes in clinical decisions such as pursuing end of life care. This study surveyed palliative care providers to explore the influence of genetic testing on decisions to redirect care in critically ill infants.

METHODS

This study was conducted retrospectively on cases who were admitted to the Level IV NICU at Primary Children's Hospital, underwent redirection to end of life care, and whose death date was between 2019-2023. A review of the case's electronic medical record was performed to construct a clinical case summary. The clinical summary and questionnaire were sent to the case's palliative care provider.

RESULTS

Fifty-six cases were included in this study and 73% had genetic testing completed. Our results suggest the information from genetic testing played a relatively minor role in the decision to redirect care for cases with negative or uncertain genetic testing and positive genetic testing results, although the influence appeared higher in the latter group.

CONCLUSION

Our results suggest the assumptions of several studies that genetic testing is responsible for changes in clinical management and cost savings, especially in cases of redirection of care may have been overestimated. Our results fill a critical gap in current literature and demonstrate the need for further investigation to clarify the direct role of genetic testing in clinical decisions in the NICU, especially related to redirection of care.

Maintaining Parental Roles During Neonatal End-of-Life Care: A Review of the Literature

Parents who are experiencing neonatal death need support in promoting and maintaining their parental role. This includes parenting their infant during end-of-life. Bedside nurses should partner with parents to help them maintain the parent-infant relationship by establishing effective communication, building trust, and promoting the parental role. By doing so, parents will utilize these experiences to process their grief through meaning-making.

Parent Preferences and Experiences in Advance Care Planning in the Neonatal Intensive Care Unit

OBJECTIVE

Our objective was to evaluate the preferences and experiences of bereaved parents around advance care planning (ACP) in the neonatal intensive care unit (NICU).

STUDY DESIGN

Single-center cross-sectional survey of bereaved parents who experienced the death of a child in the Boston Children's Hospital NICU between 2010 and 2021 was carried out. Chi-square, Fisher's exact, Fisher Freeman Halton, and Wilcoxin rank sum tests were used to evaluate differences between parents who did and did not receive ACP.

RESULTS

Out of eligible parents, 40 out of 146 (27%) responded to our survey. Most parents (31 out of 33, 94%) rated ACP as being very important and 27 out of 33 (82%) reported having ACP discussions during their child's admission. Parents preferred initial ACP discussions to occur early in their child's illness trajectory with members of the primary NICU team, with most parents' experiences aligning with these preferences.

CONCLUSION

Parents value ACP discussions suggesting a further role for ACP in the NICU.

KEY POINTS

· NICU parents value and participate in advance care planning discussions. · Parents prefer advance care planning with members of the primary NICU, specialty, and palliative care teams. · Parents prefer advance care planning early in their child's illness trajectory.

Advance Care Planning and Parent-Reported End-of-Life Outcomes in the Neonatal Intensive Care Unit

OBJECTIVE

This study aimed to evaluate the impact of advance care planning (ACP) on parent-reported end-of-life (EOL) outcomes in the neonatal intensive care unit (NICU).

STUDY DESIGN

Single-center, cross-sectional mixed-methods survey study of bereaved parents who experienced the death of a child in the Boston Children's Hospital NICU between 2010 and 2021. Logistic regression, chi-square test, Fisher's exact test, and Wilcoxon rank-sum test were used to evaluate the relationship between ACP and parent-reported EOL outcomes. Qualitative content was analyzed through inductive coding.

RESULTS

A total of 40/146 (27%) of eligible parents responded to our survey. There was a significant association between ACP and improved EOL care processes and parental satisfaction with communication. Parents with ACP were more likely to report goal-concordant care and higher levels of perceived shared decision-making. Qualitatively, emerging themes in parents' descriptions of goal-concordant care included misaligned expectations and communication. Emerging themes for parental preparedness included infant symptoms, logistical aspects, impact on parents, and degrees of preparedness. For decisional regret, the primary theme was reevaluating supports.

CONCLUSION

ACP is associated with improved EOL care outcomes and parents qualitatively conceptualize goal-concordant care, preparedness for their child's death, and decisional regret in nuanced ways. Families should have the opportunity to participate in ACP discussions that meet their unique communication and decision-making needs.

KEY POINTS

· ACP is associated with improved parent-reported end-of-life outcomes.. · Parents conceptualize end-of-life care outcomes in nuanced ways.. · Families should have the opportunity to participate in ACP discussions that meet their unique needs..

Parents' experiences of being involved in medical decision-making for their child with a life-limiting condition: A systematic review with narrative synthesis

BACKGROUND

Parental involvement in the decision-making processes about medical treatment for children with life-limiting conditions is recognised as good practice. Previous research highlighted factors affecting the decision-making process, but little is known about how parents experience their participation.

AIM

To explore how parents experience their participation in the process of decision-making about treatment and future care for their children with life-limiting conditions.

DESIGN

A systematically constructed review using narrative synthesis. The PRISMA guidelines were followed to report the findings. Databases Medline, EMBASE, SCOPUS, CINAHL and PsycINFO were searched up to December 2023. The study protocol was registered at PROSPERO (RN CRD42021215863).

RESULTS

From the initial 2512 citations identified, 28 papers met the inclusion criteria and were included in the review. A wide range of medical decisions was identified; stopping general or life-sustaining treatment was most frequent. Narrative synthesis revealed six themes: (1) Temporal aspects affecting the experience with decision-making; (2) Losing control of the situation; (3) Transferring the power to decide to doctors; (4) To be a 'good' parent and protect the child; (5) The emotional state of parents and (6) Sources of support to alleviate the parental experience.

CONCLUSIONS

Parental experiences with decision-making are complex and multifactorial. Parents' ability to effectively participate in the process is limited, as they are not empowered to do so and the circumstances in which the decisions are taking place are challenging. Healthcare professionals need to support parental involvement in an effective way instead of just formally asking them to participate.

The Case for Advance Care Planning in the NICU

Many NICUs have reached an inflection point where infant deaths following limitation of life-sustaining treatments outnumber those following unsuccessful resuscitations, and many infants who survive continue to require intensive supports. Families of such infants with serious illness may benefit from a standardized, process-oriented approach in decisional-support. Advance care planning (ACP), or communication that supports patients, or their surrogate decision-makers, in sharing values, goals, and preferences for future medical care, is recognized as a valuable strategy in supporting adults with serious and chronic illness. Although the role of ACP in older children and adolescents is evolving, its utility has not been systematically explored in the perinatal context. This article builds a case for formalizing a role for ACP in the NICU by defining ACP and appraising recent outcomes research, reviewing the current state of parental needs for decisional support and serious illness in the NICU, and describing how ACP may address current limitations in primary and specialty pediatric palliative care and challenges for decision-making in the newborn period.

Experience of care of hospitalized newborns and young children and their parents: A scoping review

INTRODUCTION

Several global initiatives put parent involvement at the forefront of enabling children's well-being and development and to promote quality of care for newborns and hospitalized young children aged 0-24 months. Scanty evidence on mistreatment such as delays or neglect and poor pain management among newborns exists, with even less exploring the experience of their parents and their hospitalized young children. To address this gap, authors reviewed research on experience of care for hospitalized young children and their parents, and potential interventions that may promote positive experience of care.

METHODS

A scoping review of English language articles, guidelines, and reports that addressed the experiences of care for newborns and sick young children 0-24 months in health facilities was conducted. Multiple databases: PubMed, PROSPERO, COCHRANE Library and Google Scholar were included and yielded 7,784 articles. Documents published between 2009 and November 2020, in English and with evidence on interventions that addressed family involvement and partnership in care for their sick children were included.

RESULTS

The scoping review includes 68 documents across 31 countries after exclusion. Mistreatment of newborns comprises physical abuse, verbal abuse, stigma and discrimination, failure to meet professional standards, poor rapport between providers and patients, poor legal accountability, and poor bereavement and posthumous care. No literature was identified describing mistreatment of hospitalized children aged 60 days- 24 months. Key drivers of mistreatment include under-resourced health systems and poor provider attitudes. Positive experience of care was reported in contexts of good parent-provider communication. Three possible interventions on positive experience of care for hospitalized young children (0-24 months) emerged: 1) nurturing care; 2) family centered care and 3) provider and parental engagement. Communication and counseling, effective provider-parental engagement, and supportive work environments were associated with reduced anxiety and stress for parents and hospitalized young children. Few interventions focused on addressing providers' underlying attitudes and biases that influence provider behaviors, and how they affect engaging with parents.

CONCLUSION

Limited evidence on manifestations of mistreatment, lack of respectful care, drivers of poor experience and interventions that may mitigate poor experience of care for hospitalized young children 0-24 months especially in low resource settings exists. Design and testing appropriate models that enhance socio-behavioral dimensions of care experience and promote provider-family engagement in hospitals are required.

How Physicians Discuss Uncertainty With Parents in Intensive Care Units

BACKGROUND AND OBJECTIVES

Physicians and parents of critically ill neonates and children receiving intensive care have to make decisions on the child's behalf. Throughout the child's illness and treatment trajectory, adequately discussing uncertainties with parents is pivotal because this enhances the quality of the decision-making process and may positively affect the child's and parents' well-being. We investigated how physicians discuss uncertainty with parents and how this discussion evolves over time during the trajectory.

METHODS

We asked physicians working in the NICU and PICU of 3 university medical centers to audio record their conversations with parents of critically ill children from the moment doubts arose whether treatment was in the child's best interests. We qualitatively coded and analyzed the anonymized transcripts, thereby using the software tool MAXQDA 2020.

RESULTS

Physicians were found to adapt the way they discussed uncertainty with parents to the specific phase of the child's illness and treatment trajectory. When treatment options were still available, physicians primarily focused on uncertainty related to diagnostic procedures, treatment options, and associated risks and effects. Particularly when the child's death was imminent, physicians had less "scientific" guidance to offer. They eliminated most uncertainty and primarily addressed practical uncertainties regarding the child's dying process to offer parents guidance.

CONCLUSIONS

Our insights may increase physicians' awareness and enhance their skills in discussing uncertainties with parents tailored to the phase of the child's illness and treatment trajectory and to parental needs in each specific phase.

Barriers and facilitators for parents in end-of-life decision-making for neonates at the Neonatal Intensive Care Unit: A qualitative study

BACKGROUND

Mortality and end-of-life decision-making can occur in newborns, especially within the Neonatal Intensive Care Unit. For parents, participating in end-of-life decision-making is taxing. Knowledge is lacking on what support is helpful to parents during decision-making.

AIM

To identify barriers and facilitators experienced by parents in making an end-of-life decision for their infant.

DESIGN

Qualitative study using face-to-face semi-structured interviews.

SETTING/PARTICIPANTS

We interviewed 23 parents with a child that died after an end-of-life decision at a Neonatal Intensive Care Unit between April and September 2018.

RESULTS

Parents stated barriers and facilitators within 4 themes: 1. Clinical knowledge and prognosis; 2. Quality of information provision; 3. Emotion regulation; and 4. Psychosocial environment. Facilitators include knowing whether the prognosis includes long-term negative quality of life, knowing all treatment options, receiving information according to health literacy level, being able to process intense emotions, having experienced counseling and practical help. Barriers include a lack of general medical knowledge, being unprepared for a poor prognosis, having an uninformed psychologist.

CONCLUSIONS

We found that clinical information and psychosocial support aid parents in decision-making. Information is best tailored to health literacy. Psychosocial support can be provided by experienced, informed counselors, social services and sibling support, distinguishing between verbal and non-verbal coping preferences, and calm, familiar architecture. Intense emotions may hinder absorption of clinical information, therefore interventions to aid emotion regulation and reduce cognitive load may be looked at in further research. Adjustment of the Situations, Opinions and Options, Parents, Information, Emotions framework based on our results can be evaluated.

Moral equivalence theory in neonatology

This article explores the ethical concept of "the equivalence thesis" (ET), or the idea that withdrawing and withholding life sustaining treatments are morally equivalent practices, within neonatology. We review the historical origins, theory, and clinical rationale behind ET, and provide an analysis of how ET relates to literature that describes neonatal mode of death and healthcare professional and parent attitudes towards end-of-life care. While ET may serve as an ethical tool to optimize resource allocation in theory, its clinical utility is limited given the complexity of end-of-life care decisions.

How doctors actually (do not) involve families in decisions to continue or discontinue life-sustaining treatment in neonatal, pediatric, and adult intensive care: A qualitative study

BACKGROUND

Intensive care doctors have to find the right balance between sharing crucial decisions with families of patients on the one hand and not overburdening them on the other hand. This requires a tailored approach instead of a model based approach.

AIM

To explore how doctors involve families in the decision-making process regarding life-sustaining treatment on the neonatal, pediatric, and adult intensive care.

DESIGN

Exploratory inductive thematic analysis of 101 audio-recorded conversations.

SETTING/PARTICIPANTS

One hundred four family members (61% female, 39% male) and 71 doctors (60% female, 40% male) of 36 patients (53% female, 47% male) from the neonatal, pediatric, and adult intensive care of a large university medical center participated.

RESULTS

We identified eight relevant and distinct communicative behaviors. Doctors' sequential communicative behaviors either reflected consistent approaches-a shared approach or a physician-driven approach-or reflected vacillating between both approaches. Doctors more often displayed a physician-driven or a vacillating approach than a shared approach, especially in the adult intensive care. Doctors did not verify whether their chosen approach matched the families' decision-making preferences.

CONCLUSIONS

Even though tailoring doctors' communication to families' preferences is advocated, it does not seem to be integrated into actual practice. To allow for true tailoring, doctors' awareness regarding the impact of their communicative behaviors is key. Educational initiatives should focus especially on improving doctors' skills in tactfully exploring families' decision-making preferences and in mutually sharing knowledge, values, and treatment preferences.

A systematic concept analysis of 'technology dependent': challenging the terminology

There are an increasing number of children who are dependent on medical technology to sustain their lives. Although significant research on this issue is taking place, the terminology used is variable and the concept of technology dependence is ill-defined. A systematic concept analysis was conducted examining the attributes, antecedents, and consequences of the concept of technology dependent, as portrayed in the literature. We found that this concept refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide ranging sequelae for the child and family, and health and social care delivery.Conclusion: The term technology dependent is increasingly redundant. It objectifies a heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. What is Known: • There are an increasing number of children who require medical technology to sustain their life, commonly referred to as technology dependent. This concept analysis critically analyses the relevance of the term technology dependent which is in use for over 30 years. What is New: • Technology dependency refers to a wide range of clinical technology to support biological functioning across a dependency continuum, for a range of clinical conditions. It is commonly initiated within a complex biopsychosocial context and has wide-ranging sequelae for the child and family, and health and social care delivery. • The paper shows that the term technology dependent is generally portrayed in the literature in a problem-focused manner. • This term is increasingly redundant and does not serve the heterogenous group of children who are assisted by a myriad of technology and who adapt to, and function with, this assistance in numerous ways. More appropriate child-centred terminology will be determined within the TechChild project.

Caring for Dying Infants: A Systematic Review of Healthcare Providers’ Perspectives of Neonatal Palliative Care

Objectives:

The palliative and hospice care movement has expanded significantly in the United States since the 1960s. Neonatal end of life care, in particular, is a developing area of practice requiring healthcare providers to support terminally ill newborns and their families, to minimize suffering at the end of the neonate’s life. This paper seeks to systematically summarize healthcare providers’ perspectives related to end of life, in order to identify needs and inform future directions.

Methods:

Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically reviewed the literature discussing healthcare provider perspectives of neonatal end of life care ranging from year 2009 to 2020. To be included in the review, articles had to explicitly focus on perspectives of healthcare providers toward neonatal end of life care, be published in academic peer-reviewed sources, and focus on care in the United States.

Results:

Thirty-three articles were identified meeting all inclusion criteria. The literature covers, broadly, provider personal attitudes, experiences delivering care, practice approaches and barriers, and education and training needs. The experiences of physicians, physician assistants, nurse practitioners, and nurses are highlighted, while less is discussed of other providers involved with this work (e.g., social work, physical therapy).

Conclusion:

Future research should focus on developing and testing interventions aimed at training and supporting healthcare providers working with neonates at end of life, as well as addressing barriers to the development and implementation of neonatal palliative teams and guidelines across institutions.

Developing a perinatal palliative care service package for women with fetal anomaly diagnosis: protocol for mixed methods study

Background

Diagnosis of perinatal anomalies is a stressful experience that can negatively affect mothers, families, health-care systems, and societies. Perinatal palliative care (PPC) is a new development in maternity services which focuses on emotional, spiritual, social, and symptom management and provides care for women and families with fetal anomaly diagnosis. Therefore, this study aimed to develop a service package for women with fetal anomaly diagnosis in socio-cultural context of Iran.

Methods

This research is an exploratory mixed methods study with the qualitative-quantitative sequencing design that consists of four sequential phases. In the first phase, following a qualitative approach, the researcher will explore the needs and experiences of women with fetal anomaly diagnosis, their families, health care providers and policy-makers. At the second phase, based on the review of the literature, Program, guideline, service package and protocol for care of women and their families after perinatal anomaly diagnosis will be identified in other countries. In the third phase, recommendations from qualitative phase and literature review will be combined, the initial protocol of the palliative care service package for perinatal anomaly diagnosis will be identified and prioritized. In the fourth phase, the opinion of experts about this service package will be collected by using RAND/UCLA Appropriateness Method technique and the applicability of the service package’s recommendations in clinical settings will be determined.

Discussion

The results of this Mixed Methods study are expected response the needs and experiences of the women with perinatal anomaly diagnosis being met in the socio-cultural context of Iran and a service package for palliative care of these women developed.

Thematic Analysis of Interprofessional Provider Perceptions of Pediatric Death

PURPOSE

Though provider and patient perceptions of death are characterized in the adult population literature, there is limited information related to providers' perceptions in pediatric and neonatal patients. The purpose of this study was to better understand how interprofessional care team members perceive and experience neonatal and pediatric end-of-life situations.

DESIGN AND METHODS

This survey questionnaire was administered to interprofessional providers following their participation in an institutional workshop, as part of an ongoing institutional effort to improve end-of-life experiences for patients/family and providers. Interprofessional care providers completed an electronic survey consisting of closed-ended and one open-ended question to elicit their perceptions of their participation in end of life care for a recent neonatal/pediatric patient in the period before the child's death.

RESULTS

The qualitative analysis of 306 free-text responses commenting on the deaths of 138 patients, contained within 880 completed mixed-method surveys, is described. Thematic analysis of the free text discovered three primary themes from the data: favorable aspects of the death experience, unfavorable aspects of the experience, and combined favorable and unfavorable aspects. Four subthemes contributed to the themes; namely, language, parental presence, trust/rapport in provider relationships and inclusion in decision-making, communication, and culture.

CONCLUSIONS

Multiple factors contribute to how interprofessional care providers perceive end-of-life care experiences for neonatal/pediatric patients. The same death may be perceived differently by different providers.

PRACTICE IMPLICATIONS

Understanding favorable and unfavorable aspects of providing end-of-life care will support strategies to provide resources, education and support to facilitate coping and resiliency in care providers.

Evaluating shared decision-making in periviable counseling using objective structured clinical examinations

OBJECTIVE

To develop and test an Objective Structured Clinical Examination to evaluate the use of shared decision-making (SDM) in periviable counseling among fourth-year OB/GYN residents.

METHODS

Residents counseled a standardized patient presenting with preterm premature rupture of membranes at 23 weeks' gestation. Braddock's 9-item measure of SDM was adapted to a 10-item scoring rubric; rating each: 0 (absent), 1 (partial), or 2 (complete).

RESULTS

Twenty-six residents participated. All provided "complete" discussions of the clinical issue and "complete" or 'partial' ratings for informing the woman of her prognosis (62 and 38%, respectively) and addressing her role in decision-making (42 and 50%). Discussions of her goals and preferences were often absent (69 and 62%). Only 42% discussed uncertainties.

CONCLUSION

Critical elements of SDM related to a woman's values, goals and preferences were not explored when counseling about periviable delivery. Training in SDM is needed to advance communication skills for complex clinical decision-making.

Birth Planning in Uncertain or Life-Limiting Fetal Diagnoses: Perspectives of Physicians and Parents

Background: Providers often use birth plans to document parents' wishes for their fetus with a life-limiting condition. Objective: The objective of the study was to (1) discover important components of a birth plan for parents and providers who carry them out, and (2) understand the experience of parents and providers with birth plans. Methods: The study design involves mixed-methods, descriptive, exploratory survey. This involves parents (n = 20) of a pregnancy complicated by a life-limiting diagnosis and providers who care for them (n = 116). The approach involves descriptive and univariate analyses for quantitative data and thematic analysis for qualitative data. Results: Consistent components for families and physicians were diagnosis and medical management of the infant. Families gave greater emphasis on memory-making preferences. Parents feel birth plans give them a sense of control. Themes emerged from parents' experience of creating a birth plan are as follows: sense of control, therapeutic, memory making, effective communication, feeling prepared, and unexpected events. Most physicians feel comfortable discussing goals of care with families but report insufficient time. The importance of components of birth plans and perception of the parents' understanding of the prognosis varied by specialty. Discussion: Birth plans are beneficial and provide a greater sense of control for parents. Most physicians feel comfortable utilizing them. More than one-third of the physicians do not feel that they have time to complete a birth plan with parents. Communication between physicians and families about limitations of the plan and the potential trajectories could be improved. Communication between maternal and neonatal care providers regarding parent expectations and understanding could also be improved.

Parental Moral Distress and Moral Schism in the Neonatal ICU

Ethical dilemmas in critical care may cause healthcare practitioners to experience moral distress: incoherence between what one believes to be best and what occurs. Given that paediatric decision-making typically involves parents, we propose that parents can also experience moral distress when faced with making value-laden decisions in the neonatal intensive care unit. We propose a new concept-that parents may experience "moral schism"-a genuine uncertainty regarding a value-based decision that is accompanied by emotional distress. Schism, unlike moral distress, is not caused by barriers to making and executing a decision that is deemed to be best by the decision-makers but rather an encounter of significant internal struggle. We explore factors that appear to contribute to both moral distress and "moral schism" for parents: the degree of available support, a sense of coherence of the situation, and a sense of responsibility. We propose that moral schism is an underappreciated concept that needs to be explicated and may be more prevalent than moral distress when exploring decision-making experiences for parents. We also suggest actions of healthcare providers that may help minimize parental "moral schism" and moral distress.

Healthcare Professionals' Views on Parental Participation in the Neonatal Intensive Care Units

PURPOSE

To examine the associations between age, gender, and profession in relation to the perceived importance of parental participation in Neonatal Intensive Care Units.

DESIGN AND METHODS

A quantitative cross-sectional design was used. Participants were recruited consecutively from all 40 existing NICU units in Sweden. A total of 443 healthcare professionals (372 nurses and 71 physicians) participated in the study. Participants completed the Swedish version of the Empowerment of Parents in the Intensive Care-Neonatology (EMPATHIC-N) questionnaire. Data were analyzed using multiple regression analyses.

RESULTS

The findings indicated that profession and age, but not gender, had an overall perceived importance on how nurses and physicians rated specific aspects of parental participation in NICUs.

CONCLUSIONS

Being a nurse, compared to a physician, was associated with an increase in overall perceived importance of parental participation in NICUs. These differences may affect and may be crucial for how parents take a part in the care of their infant and also for how they adapt to the parental role.

PRACTICE IMPLICATIONS

Nurses and physicians require education and training that support parental participation based on age and their different roles, rather than simply conveying information about the technical medical aspects of NICU care. For a sustainable outcome all team members should be invited to discuss cases from their perspectives.

A pot of gold at the end of the rainbow? A spectrum of attitudes to assisted reproductive technologies in Ireland

OBJECTIVE

New technologies present new ethical dilemmas. Our ethical intuitions may mislead us in relation to new technologies such as nuclear power, vaccines, GMOs and assistive reproductive technologies (ART). Between 1999 and 2008 the number of ART treatment cycles increased by 265% in Ireland. The implications and potentials of such technologies are profound - challenging existing understanding of humans' relationships to reproduction. Because such technologies are comparatively unregulated, and their use has only been occurring for a single generation, detailed investigation of how awareness of ART influences understanding of personal fertility is needed.

METHOD

Data from a general Irish population of varied ages and both sexes (N = 611) were collected through an online survey which included demographics, knowledge of fertility, knowledge of ART and personal fertility.

RESULTS

Latent class analysis revealed a typology of five groups of responders to ART distinguished by their attitudes and knowledge of this technology. These groups are labelled as 'Worried Yet Willing', 'Live and Let Live', 'Disengaged', 'Judgemental' and 'Conflicted'.

CONCLUSION

Responses to the introduction of ART in Ireland fall into at least five distinct groups. Understanding of the distinguishing features of these types of responders is important for fertility healthcare professionals in terms of service development and delivery. Implications for the direction of future related research is discussed.

"You Can Only Give Warmth to Your Baby When It's Too Late": Parents' Bonding With Their Extremely Preterm and Dying Child

This study on end-of-life decisions in extremely preterm babies shows that the parents under study experience a multitude of stressors due to the immediate separation after birth, the alienating setting of the neonatal intensive care unit (NICU), the physical distance to the child, medical uncertainties, and upcoming decisions. Even though they are considered to be parents (assigned parenthood), they cannot act as primary caregivers. Instead, they depend on professional instructions for access and care. Embodied parenthood can be experienced only at the end-of-life, that is, during the dying trajectory and after the child's death. Professionally supporting parents during this compressed process (from assigned and distant to embodied parenthood) contributes fundamentally to their perception of being a family and supports their mourning. This calls for the further establishment of palliative and bereavement care concepts in neonatology.

Knowing nursing team care practices in relation to newborns in end-of-life situations

Abstract Objective: Understand the care practices experiences of nursing staff in relation to providing end-of-life care to newborns and their families in neonatal intensive care units (NICU). Method: Descriptive study with a qualitative approach, involving eight nursing professionals from an NICU. Results: Through the data analysis, it was possible to identify three central themes: the "obscurity of death in neonatal ICUs": coping with death at the onset of a human life; palliative care and end-of-life decisions: the challenges faced by nursing staff in neonatal ICUs; and types of nursing care in the daily activities of neonatal ICUs. Conclusion: It is essential to understand the experiences and needs of nursing staff, so that proposals can be formulated for seeking improvements in the care relationships that take place in this context.

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

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.

End-of-life care in the neonatal intensive care unit: applying comfort theory

The provision of quality end-of-life care is essential when a neonate is dying. End-of-life care delivered in a neonatal intensive care unit (NICU) must consider the needs of both the newborn and their family. The purpose of this paper is to demonstrate how comfort theory and its associated taxonomic structure can be used as a conceptual framework for nurses and midwives providing end-of-life care to neonates and their families. Comfort theory and its taxonomic structure are presented and issues related to end-of-life care in the NICU are highlighted. A case study is used to illustrate the application of comfort theory and issues related to implementation are discussed. The delivery of end-of-life care in the NICU can be improved through the application of comfort.

Spiritual Needs of Families With Bereavement and Loss of an Infant in the Neonatal Intensive Care Unit: A Qualitative Study

CONTEXT

The hospital is a place full of distress and questions about the meaning of life. The death of a child can cause a spiritual struggle and crisis. Therefore, it is necessary for health care providers in the neonatal intensive care unit (NICU) to assess the spiritual needs of families that have lost a child.

OBJECTIVES

The purpose of this study was to explore the spiritual needs of families in Iran at the end of their baby's life and through bereavement in the NICU.

METHODS

This study was an exploratory qualitative study performed using purposeful sampling and semi-structured interviews with 24 participants. Inclusion criteria for families, nurses, and physicians included having experienced at least one newborn death in the last six months in the NICU. The research environment was the NICU in Isfahan, one of the largest cities in Iran.

RESULTS

Data analysis revealed three main themes: spiritual belief in a supernatural power, the need for comfort of the soul, and human dignity for the newborn.

CONCLUSION

The results of this study created a new vision in addressing spiritual needs of Iranian families who experience the death of a newborn.

Parental needs in infant's end-of-life and bereavement in NICU: A qualitative study

BACKGROUND AND AIMS

Newborn death is an unexpected outcome for parents. Parents face with several needs in infant end-of-life. The health care team is responsible for meet these needs. This qualitative study aim was to explore of parental needs in infant end-of-life and bereavement.

MATERIALS AND METHODS

For this qualitative study, 24 single semi-structure interviews were done. A qualitative content analysis method was used. Sampling conducted on purposeful with maximum variation in five Neonatal Intensive Care Unit (NICU) environments in Isfahan city. Inclusion criteria for nurses and doctors were having at least one experience of caring for an infant and their family at end-of-life. Inclusion criteria for parents and their families were having at least one infant at end-of-life or had lost their infant for 6 months before in NICU.

RESULTS

Data analysis uncovered two main themes. Family's support needs with two subthemes (family's support needs before infant's death and family's support needs after infant's death) and family's preparatory needs upon infant's death with two subthemes (management of the bad news of infant's death by treatment team and management of the bad news of infant's death by family).

DISCUSSION

Mourning mother's need for her husband's presence by her side, getting hospitalized in a separate room, and management of infant's death news by father and family were among items rarely pointed out in other studies. Exploration of these needs cab be helpful for the health care team for providing care.

End-of-life decision-making for children with severe developmental disabilities: The parental perspective

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.

An Order Protocol for Respiratory Distress/Acute Pain Crisis in Pediatric Palliative Care Patients: Medical and Nursing Staff Perceptions

BACKGROUND

An order protocol for distress (OPD), including respiratory distress and acute pain crisis, has been established for pediatric palliative care patients at Sainte-Justine Hospital (SJH). After discussion with the patient/his or her family, the OPD is prescribed by the attending physician whenever judged appropriate. The OPD can then be initiated by the bedside nurse when necessary; the physician is notified after the first dose is administered.

OBJECTIVES

The study objectives were to evaluate the perceptions and experience of the medical/nursing staff towards the use of the OPD.

METHODS

A survey was distributed to all physicians/nurses working on wards with pediatric palliative care patients. Answers to the survey were anonymous, done on a voluntary basis, and after consent of the participant.

RESULTS

Surveys (258/548) were answered corresponding to a response rate of 47%. According to the respondents, the most important motivations in using the OPD were the desire to relieve patient's distress and the speed of relief of distress by the OPD; the most important obstacles were going against the patient's/his or her family's wishes and fear of hastening death. The respondents reported that the OPD was frequently (56%) or always (36%) effective in relieving the patient's distress. The respondents felt sometimes (16%), frequently (34%), or always (41%) comfortable in giving the OPD. They thought the OPD could never (12%), rarely (32%), sometimes (46%), frequently (8%), or always (1%) hasten death. Physicians were less favorable than nurses with the autonomy of bedside nurses to initiate the OPD before notifying the physician (p = 0.04). Overall, 95% of respondents considered that they would use the OPD in the future.

CONCLUSIONS

Data from this survey shows that respondents are in favor of using the OPD at SJH and find it effective. Further training as well as support for health care professionals are mandatory in such palliative care settings.

What information do parents need when facing end-of-life decisions for their child? A meta-synthesis of parental feedback

Background

The information needs of parents facing end-of-life decisions for their child are complex due to the wide-ranging dimensions within which such significant events unfold. While parents acknowledge that healthcare professionals are their main source of information, they also turn to a variety of additional sources of written information in an attempt to source facts, discover solutions, and find hope.

Much has been written about the needs of parents faced with end-of-life decisions for their child but little is known about the written information needs such parents have. Research in the adult intensive care context has shown that written resources impact positively on the understanding of medical facts, including diagnoses and prognoses, communication between families and healthcare professionals, and the emotional wellbeing of families after their relative’s death.

Methods

A meta-synthesis of predominantly empirical research pertaining to features which assist or impede parental end-of-life decisions was undertaken to provide insight and guidance in our development of written resources (short print and online comprehensive version) for parents.

Results

The most prominently cited needs in the literature related to numerous aspects of information provision; the quantity, quality, delivery, and timing of information and its provision impacted not only on parents’ ability to make end-of-life decisions but also on their emotional wellbeing. The meta-synthesis supports the value of written materials, as these provide guidance for both parents and healthcare professionals in pertinent content areas.

Conclusions

Further research is required to determine the impact that written resources have on parental end-of-life decision-making and on parents’ wellbeing during and after their experience and time in the hospital environment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0024-0) contains supplementary material, which is available to authorized users.

Strategies to promote uptake and use of intimate partner violence and child maltreatment knowledge: an integrative review

BACKGROUND

Intimate partner violence (IPV) and child maltreatment (CM) are major social and public health problems. Knowledge translation (KT) of best available research evidence has been suggested as a strategy to improve the care of those exposed to violence, however research on how best to promote the uptake and use of IPV and CM evidence for policy and practice is limited. Our research asked: 1) What is the extent of IPV/CM-specific KT research? 2) What KT strategies effectively translate IPV/CM knowledge? and 3) What are the barriers and facilitators relevant to translating IPV/CM-specific knowledge?

METHODS

We conducted an integrative review to summarize and synthesize the available evidence regarding IPV/CM-specific KT research. We employed multiple search methods, including database searches of Embase, CINAHL, ERIC, PsycInfo, Sociological Abstracts, and Medline (through April, 2013). Eligibility and quality assessments for each article were conducted by at least two team members. Included articles were analyzed quantitatively using descriptive statistics and qualitatively using descriptive content analysis.

RESULTS

Of 1230 identified articles, 62 were included in the review, including 5 review articles. KT strategies were generally successful at improving various knowledge/attitude and behavioural/behavioural intention outcomes, but the heterogeneity among KT strategies, recipients, study designs and measured outcomes made it difficult to draw specific conclusions. Four key themes were identified: existing measurement tools and promising/effective KT strategies are underused, KT efforts are rarely linked to health-related outcomes for those exposed to violence, there is a lack of evidence regarding the long-term effectiveness of KT interventions, and authors' inferences about barriers, facilitators, and effective/ineffective KT strategies are often not supported by data. The emotional and sometimes contested nature of the knowledge appears to be an important barrier unique to IPV/CM KT.

CONCLUSIONS

To direct future KT in this area, we present a guiding framework that highlights the need for implementers to use/adapt promising KT strategies that carefully consider contextual factors, including the fact that content in IPV/CM may be more difficult to engage with than other health topics. The framework also provides guidance regarding use of measurement tools and designs to more effectively evaluate and report on KT efforts.

Neonatal bioethical perspectives: practice considerations

Over the past 30 years, there has been a modest improvement in the survival rates of U.S. infants.The public health impact of associated economic and technological advances raises questions regarding neonatal care and end-of-life decisions for those caring for this population. Nurses have an obligation to remain abreast of neonatal ethical standards because they are intimately involved in caring for these patients. Therefore, the aim of this article is to (a) summarize the extant neonatal bioethical literature to appreciate the complex ethical issues that translate into practice challenges, (b) present a framework that guides the assessment of the benefits and burdens of neonatal intensive care in the clinical setting to solicit and provoke dialogue, and (c) provide examples that advocate for educational training for neonatal healthcare providers in support of ethically sound care to affected families and infants.

The educational needs of neonatal nurses regarding neonatal palliative care

BACKGROUND

Studies have shown that education can improve the knowledge, attitudes, and beliefs of neonatal nurses regarding neonatal palliative care. However, no study has investigated the need for neonatal nurse education in neonatal palliative care in Taiwan.

OBJECTIVE

The purpose of this study was to explore neonatal nurses' experiences in caring for dying neonates and their educational backgrounds regarding palliative care, as well as to assess their educational needs.

METHODS

A cross-sectional survey was used for this research. A research structural questionnaire was used to investigate the research goals.

RESULTS

One hundred fifteen nurses participated in this survey. Few participants indicated having received neonatal palliative care education (13%), but most responded that palliative care is necessary in neonatal nursing education (97.4%). Participants also responded that they were often or always exposed to death in NICU (62.6%), but few reported providing pain management to dying neonates (8.7%) and few had experience providing symptomatic care for dying neonates (19.1%). Fifty percent ranked "pain control" as the area in which they most required training. Another high-ranked need was in discussing with parents and families the outcomes of CPR and their neonate's progress.

CONCLUSION

Research indicates that the education currently provided to neonatal nurses does not meet their distinctive needs. Neonatal nurses in Taiwan expressed an urgent desire for training in pain control and communication. Research suggests that the most important topics to trainees are pain management and end-of-life communication. Additionally, non-pharmacological pain control interventions are valuable and should be included in an educational program.

Communication about life-sustaining therapy: insights from the Adaptive Leadership Framework

OBJECTIVE

Effective provider and caregiver communication is central to quality care during treatment for life-threatening illnesses. The study aim was to analyze communication patterns between providers and a parent of an infant with a life-threatening disease using the Adaptive Leadership Framework, which is an activity that involves mobilizing others to adapt to a difficult situation.

METHOD

A secondary analysis was conducted on one case using 23 interviews with providers and mother of an infant diagnosed with Hurler's syndrome. The interviews focused on decision-making challenges in regard to the infant's treatment and were conducted over a 1-year period (pre-transplant, study entry, monthly, after a life-threatening event or substantial change in treatment and at 1-year post enrollment). Content analysis was used to identify and categorize communication patterns using concepts from the Adaptive Leadership Framework.

RESULTS

Infant illness events and parent-provider caregiving were chronicled across a 1-year trajectory. Despite the life-threatening nature of Hurler's disease, the parent and providers did not discuss palliative care or end-of-life. The parent sought direction and answers from the providers. The Adaptive Leadership Framework suggested how communication approaches were often mismatched with the needs of the parent.

DISCUSSION

The results of the study accentuate the need to improve communication between provider and parents about end-of-life for their child. Adaptive Leadership illuminates how providers can influence a parent's behavior when facing a challenging situation. This study suggests that Adaptive Leadership is a useful framework to guide research about healthcare communication in dealing with challenging issues.

Differences in parents', nurses' and physicians' views of NICU parent support

AIM

To measure the perceptions of parent support by parents, nurses and physicians.

METHODS

Perceptions were compared among parents (n = 227), nurses (n = 178) and physicians (n = 43) in four neonatal intensive care units (NICU) using two versions of the Nurse Parent Support Tool (NPST and NPSTpro).

RESULTS

Overall, parents reported receiving support from nurses some or most of the time and their perceptions were correlated with aspects of their NICU experience. Nurses reported giving support to parents almost all of the time. The mean difference between parent and nurse ratings was smallest for instrumental support (0.26, 0.16-0.36; p < 0.001) and greatest for emotional support (0.82, 0.67-0.97; p < 0.001). Physicians overall reported that they gave support to parents most of the time, significantly less frequently than nurses (mean difference 0.58, 0.45-0.71; p < 0.001). They rated their support as most frequent on answering parents' questions satisfactorily and as least frequent on teaching parents how to give care to their baby.

CONCLUSION

NICU nurses and physicians should be encouraged to critically reflect on whether the type and consistency of support they provide to parents is in line with parents' perceptions and needs. Further research is needed on effective methods for health professionals to support parents of NICU infants.

Enfermagem e a relação com as mães de neonatos em Unidade de Terapia Intensiva Neonatal

As relações estabelecidas com a enfermagem frente à experiência do nascimento prematuro de um filho influencia a vivência da mulher. O objetivo deste estudo foi delinear a relação entre a equipe de enfermagem e as mães com bebês internados na Unidade de Terapia Intensiva Neonatal, apresentada em artigos publicados entre 2005 e 2010. Foram utilizadas as bases de dados CINAHL, MEDLINE e LILACS, com estudos publicados entre 2005 e 2010 com os descritores: Neonatal Nursing, Premature, Mothers and Nursing Care, totalizando 21 artigos organizados nas categorias: Fases Enfrentadas pelos Pais durante a Estadia do Bebê na UTIN; Relação entre Enfermeira e Mãe; Suporte da Enfermagem; Descuidado na Relação entre Enfermeira e Mãe e Ações de Educação em Saúde. Os estudos apontam a necessidade das mães por suporte o que inclui apoio emocional, envolvimento nos cuidados ao bebê, disponibilidade para estar e conversar.

Cultural practices and end-of-life decision making in the neonatal intensive care unit in Taiwan

The purpose of this research was to describe conditions of decision making for dying infants and cultural effects on the process of infant death in the neonatal intensive care unit. A retrospective chart review was used in this research. Fifty charts were reviewed; the major cause of death for the research subjects was complications of prematurity (52%). Eighty-two percent of the charts documented a do not resuscitate order, and 16% of parents allowed discontinuation of ventilator support when they realized the futility of continued care. In 30 nursing records, parents and their dying infants were offered a quiet place in which to grieve. In 10 cases, nurses accompanied these parents and allowed them to express their emotions. Research findings showed great outward expression of religion at the time of death. Various cultural issues affected both the grieving process of the families and the dying process of their infants.

Return of the "intimate outsider": current trends and issues in family nursing research revisited

This article reviews family nursing research published from 1996 to 2011. This is a follow-up to a review published in the Journal of Family Nursing in 1995. Findings from the first review are compared with this one, trends in family nursing scholarship are identified, and predictions and suggestions for future directions are offered. The latest generation of family nursing scholarship is conceptually and methodologically sound, and there is evidence of more multidisciplinary and interdisciplinary research conducted by family nursing researchers. Scholars are paying more attention to issues of diversity and family context at present than in the past, although there are still aspects of diversity that need more attention. Strong research programs in family nursing exist worldwide; an international synergism has helped promote rapid expansion of family nursing research and theory development. A vigorous movement to promote research to practice initiatives and greater attention to family interventions are exciting developments.

Parent decision making for life support for extremely premature infants: from the prenatal through end-of-life period

Most deaths of extremely premature infants occur in the perinatal period. Yet, little is known about how parents make life support decisions in such a short period of time. In the paper, how parents make life support decisions for extremely premature infants from the prenatal period through death from the perspectives of parents, nurses, and physicians is described. Five cases, comprised of five mothers, four neonatologists, three nurses, and one neonatal nurse practitioner, are drawn from a larger collective case study. Prenatal, postnatal and end-of-life interviews were conducted, and medical record data were obtained. In an analysis by two research team members, mothers were found to exhibit these characteristics: desire for and actual involvement in life support decisions, weighing pain, suffering and hope in decision making, and wanting everything done for their infants. All mothers received decision making help and support from partners and family, but relationships with providers were also important. Finally, external resources impacted parental decision making in several of the cases. By understanding what factors contribute to parents' decision making, providers may be better equipped to prepare and assist parents when making life support decisions for their extremely premature infants.