Diversity of Parent Emotions and Physician Responses During End-of-Life Conversations

BACKGROUND AND OBJECTIVES

To provide support to parents of critically ill children, it is important that physicians adequately respond to parents' emotions. In this study, we investigated emotions expressed by parents, physicians' responses to these expressions, and parents' emotions after the physicians' responses in conversations in which crucial decisions regarding the child's life-sustaining treatment had to be made.

METHODS

Forty-nine audio-recorded conversations between parents of 12 critically ill children and physicians working in the neonatal and pediatric intensive care units of 3 Dutch university medical centers were coded and analyzed by using a qualitative inductive approach.

RESULTS

Forty-six physicians and 22 parents of 12 children participated. In all 49 conversations, parents expressed a broad range of emotions, often intertwining, including anxiety, anger, devotion, grief, relief, hope, and guilt. Both implicit and explicit expressions of anxiety were prevalent. Physicians predominantly responded to parental emotions with cognition-oriented approaches, thereby limiting opportunities for parents. This appeared to intensify parents' expressions of anger and protectiveness, although their anxiety remained under the surface. In response to more tangible emotional expressions, for instance, grief when the child's death was imminent, physicians provided parents helpful support in both affect- and cognition-oriented ways.

CONCLUSIONS

Our findings illustrate the diversity of emotions expressed by parents during end-of-life conversations. Moreover, they offer insight into the more and less helpful ways in which physicians may respond to these emotions. More training is needed to help physicians in recognizing parents' emotions, particularly implicit expressions of anxiety, and to choose helpful combinations of responses.

Argumentation in end-of-life conversations with families in Dutch intensive care units: a qualitative observational study

PURPOSE

In intensive care units (ICUs), decisions about the continuation or discontinuation of life-sustaining treatment (LST) are made on a daily basis. Professional guidelines recommend an open exchange of standpoints and underlying arguments between doctors and families to arrive at the most appropriate decision. Yet, it is still largely unknown how doctors and families argue in real-life conversations. This study aimed to (1) identify which arguments doctors and families use in support of standpoints to continue or discontinue LST, (2) investigate how doctors and families structure their arguments, and (3) explore how their argumentative practices unfold during conversations.

METHOD

A qualitative inductive thematic analysis of 101 audio-recorded conversations between doctors and families.

RESULTS

Seventy-one doctors and the families of 36 patients from the neonatal, pediatric, and adult ICU (respectively, N-ICU, P-ICU, and A-ICU) of a large university-based hospital participated. In almost all conversations, doctors were the first to argue and families followed, thereby either countering the doctor's line of argumentation or substantiating it. Arguments put forward by doctors and families fell under one of ten main types. The types of arguments presented by families largely overlapped with those presented by doctors. A real exchange of arguments occurred in a minority of conversations and was generally quite brief in the sense that not all possible arguments were presented and then discussed together.

CONCLUSION

This study offers a detailed insight in the argumentation practices of doctors and families, which can help doctors to have a sharper eye for the arguments put forward by doctors and families and to offer room for true deliberation.

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.

A monoclonal antibody-based immunoperoxidase monolayer (micro-isolation) assay for detection of type 1 and type 2 bovine viral diarrhea viruses

A monoclonal antibody (mAb)-based immunoperoxidase monolayer assay (IPMA) for detection of bovine viral diarrhea virus (BVDV) was developed and compared with an existing bovine polyclonal antibody (pAb)-based IPMA. A pool of 5 mAbs, 4 mAbs produced to a type 1 BVDV and 1 mAb produced to a type 2 BVDV, was utilized in the mAb-IPMA. The mAbs were chosen for inclusion in the pool because of their broad cross-reactivities with type 1 and/or type 2 BVDV, their apparent avidities for antigen, their reactivity to different BVDV proteins, and their lack of competition for binding sites or their binding to unusual BVDV isolates. The mAb-IPMA outperformed the pAb-IPMA in staining, ease of reading test results, and relative sensitivity with a panel of known BVDV positive and negative sera. The relative sensitivities of the mAb-IPMA and pAb-IPMA were 100% and 93.5%, respectively, for 62 positive samples including several that were known to contain type 2 BVDV. With retesting, the pAb-IPMA gave a similar level of sensitivity as that of the mAb-IPMA. Both tests gave a specificity of 100% for 40 negative serum samples obtained from a BVDV-free herd.

Comparative study of serological methods for the detection of antibodies to porcine reproductive and respiratory syndrome virus

A comparison was made of serological diagnostic methods used for the detection of antibodies against porcine reproductive and respiratory syndrome (PRRS) virus. In the "phase I" PRRS test panel comparison, a panel of sera collected from 135 pigs of various ages, from North American herds with and without PRRS histories, were sent to 4 different laboratories and tested by an indirect immunofluorescent assay (IFA), an immunoperoxidase monolayer assay (IPMA) and an indirect enzyme-linked immunosorbent assay (iELISA). In the "phase II" PRRS test panel comparison, a panel of 382 sera collected from pigs of various ages, PRRS histories, and from various locations in North America and France, were divided into 2 panels (A & B) and sent to 3 Canadian laboratories and tested by the IFA and iELISA. In the phase I comparison, agreement between the IFA of laboratory 4 and the iELISA and IPMA of laboratory 3 was excellent (kappa values of 95% and 98%, respectively). This contrasted with the poor agreement between these laboratories and the IFA results of laboratories 1 and 2 in the phase I trial. In the phase II comparison, the results demonstrated good agreement between various tests both within and between laboratories. The overall performance of the iELISA was superior in the combination of sensitivity (96.1%) and specificity (100%) relative to the reference classification of the serum samples and repeatability (kappa value 98%). The iELISA is technically superior to IFA and IPMA, time efficient, cost effective and suitable for testing of a large number of samples over a short period of time. Thus, the iELISA may be a better alternative to IFA or IPMA for routine detection of PRRS viral antibodies in swine sera.

Rapid detection of bovine herpesvirus 1 in the semen of infected bulls by a nested polymerase chain reaction assay

A nested polymerase chain reaction (PCR) assay was developed for the detection of bovine herpesvirus 1 (BHV-1) in bovine semen and compared with the virus isolation method. When extended semen, commonly used in the bovine artificial insemination industry, was inoculated with BHV-1, the PCR assay detected BHV-1 DNA in semen inoculated at 0.25-2.5 TCID50 per 0.5 mL. In contrast, the lower limit of detection for virus isolation was 250 TCID50 of BHV-1 inoculated in 0.5 mL of extended semen. These methods were also used to detect BHV-1 in the semen of four bulls which were experimentally infected with BHV-1. All infected bulls demonstrated balanitis at 3 d post-inoculation (DPI) and severe balanoposthitis at 4 DPI. BHV-1 was detected in raw semen by virus isolation and PCR at 2 DPI, before balanitis was evident. For virus isolation, the last day that BHV-1 was detected during primary infection was 7 DPI for two bulls and 9 and 11 DPI for the other two bulls. In contrast, PCR detected BHV-1 in the bulls' semen until 14 or 18 DPI. For individual animals, PCR detected BHV-1 during primary infection for at least 1-10 d longer than virus isolation. Reactivation of BHV-1 from latency without the presence of visible lesions was promoted twice by two series of 5 d dexamethasone injections. For the first series of dexamethasone treatments, a positive virus isolation result was obtained on the 5th d of treatment for only one bull. In contrast, two bulls demonstrated evidence of viral reactivation on this day by PCR. All bulls shed BHV-1 in semen on d 4 after dexamethasone treatment, as evidenced by positive virus isolation and PCR results. One bull was still PCR positive 13 d later. For the second series of dexamethasone treatments, a small amount of virus was isolated from semen collected on d 3 or 4 after treatment for two bulls but not from the other two bulls. In contrast, semen samples from all bulls were PCR positive for either or both of these 2 d. In total, from 80 semen samples, 45 were PCR positive and 26 were virus isolation positive. Thus, the PCR assay detected BHV-1 shedding in bulls earlier, more often, and for a longer duration, than did the virus isolation method.