Historical Perspectives: Shared Decision Making in the NICU

The ethical dilemmas and predominant frameworks surrounding decision making for critically ill newborns have evolved substantially over the last 40 years. A shared decision-making approach is now favored, involving an exchange of information between parents and clinicians that emphasizes parental values and preferences, resulting in a personalized approach to decision making. In this review, we summarize the history of clinical decision making with a focus on the NICU, highlight different models of decision making, describe the advantages and current limitations of shared decision making, and discuss the ongoing and future challenges of decision making in the NICU amidst medical innovations and emerging technologies.

Withholding and withdrawal of life-sustaining treatments for neonate in Japan: Are hospital practices associated with physicians' beliefs, practices, or perceived barriers?

OBJECTIVE

To describe the current status of withholding or withdrawal of life-sustaining interventions (LSI) for neonates in Japan and to identify physician- and institutional-related factors that may affect advance care planning (ACP) practices with parents.

STUDY DESIGN

A self-reported questionnaire was administered to assess frequency of withholding and withdrawing intensive care at the respondent's facility, the physician's degree of affirming various beliefs about end-of-life care that was compared to 7 European countries, their self-reported ACP practices and perceived barriers to ACP. Three neonatologists at all 298 facilities accredited by the Japan Society for Neonatal Health and Development were surveyed, with 572 neonatologists at 217 facilities responding.

RESULTS

At 76% of facilities, withdrawing intensive care treatments was "never" done, while withholding intensive care had been done "sometimes" or more frequently at 82% of facilities. Japanese neonatologists differed from European neonatologists regarding their degree of affirmation of 3 out of 7 queried beliefs about end-of-life care. In hospitals that were more likely to "sometimes" (or more often) withdraw treatments, respondents were less likely to affirm beliefs about doing "everything possible" or providing the "maximum of intensive care". Self-reported ACP practices did not vary between neonatologists based on their hospital's overall pattern of withholding or withdrawing treatments.

CONCLUSION

Among NICU facilities in Japan, 21% had been sometimes withdrawing LSI and 82% had been "sometimes" withholding LSI. Institutional treatment practices may have a strong association with physicians' beliefs that then affect end-of-life discussions, but not with self-reported ACP practices.

Ethical tensions in the informed consent process for randomized clinical trials in emergency obstetric and newborn care in low and middle-income countries

BACKGROUND

There is unanimous agreement regarding the need to ethically conduct research for improving therapy for patients admitted to hospital with acute conditions, including in emergency obstetric care. We present a conceptual analysis of ethical tensions inherent in the informed consent process for randomized clinical trials for emergency obstetric care and suggest ways in which these could be mitigated.

DISCUSSION

A valid consenting process, leading to an informed consent, is a cornerstone of this aspect necessary for preservation and maintenance of respect for autonomy and dignity. In emergency obstetric care research, obtaining informed consent can be problematic, leading to ethical tension between different moral considerations. Potential participants may be vulnerable due to severity of disease, powerlessness or impaired decisional capacity. Time for the consent process is limited, and some interventions have a narrow therapeutic window. These factors create ethical tension in allowing potentially beneficial research while avoiding potential harms and maintaining respect for dignity, human rights, justice and autonomy of the participants.

CONCLUSION

Informed consent in emergency obstetric care in low- and middle-income countries poses numerous ethical challenges. Allowing research on vulnerable populations while maintaining respect for participant dignity and autonomy, protecting participants from potential harms and promoting justice underlie the ethical tensions in the research in emergency obstetric and newborn care. Those involved in research conduct or oversight have a duty of fair inclusion, to avoid denying participants the right to participate and to any potential research benefits.

The Intensive Care Lifeboat: a survey of lay attitudes to rationing dilemmas in neonatal intensive care

BACKGROUND

Resuscitation and treatment of critically ill newborn infants is associated with relatively high mortality, morbidity and cost. Guidelines relating to resuscitation have traditionally focused on the best interests of infants. There are, however, limited resources available in the neonatal intensive care unit (NICU), meaning that difficult decisions sometimes need to be made. This study explores the intuitions of lay people (non-health professionals) regarding resource allocation decisions in the NICU.

METHODS

The study design was a cross-sectional quantitative survey, consisting of 20 hypothetical rationing scenarios. There were 119 respondents who entered the questionnaire, and 109 who completed it. The respondents were adult US and Indian participants of the online crowdsourcing platform Mechanical Turk. Respondents were asked to decide which of two infants to treat in a situation of scarce resources. Demographic characteristics, personality traits and political views were recorded. Respondents were also asked to respond to a widely cited thought experiment involving rationing.

RESULTS

The majority of respondents, in all except one scenario, chose the utilitarian option of directing treatment to the infant with the higher chance of survival, higher life expectancy, less severe disability, and less expensive treatment. As discrepancy between outcomes decreased, however, there was a statistically significant increase in egalitarian responses and decrease in utilitarian responses in scenarios involving chance of survival (P = 0.001), life expectancy (P = 0.0001), and cost of treatment (P = 0.01). In the classic 'lifeboat' scenario, all but two respondents were utilitarian.

CONCLUSIONS

This survey suggests that in situations of scarcity and equal clinical need, non-health professionals support rationing of life-saving treatment based on probability of survival, duration of survival, cost of treatment or quality of life. However, where the difference in prognosis or cost is very small, non-health professionals preferred to give infants an equal chance of receiving treatment.

When should resuscitation at birth cease?

It is rare for newborn infants to require prolonged resuscitation at birth. While there are detailed national and international guidelines on when and how to provide resuscitation to newborns, there is little existing guidance on when newborn resuscitation should be stopped. In this paper we review current guidance surrounding adult, paediatric and neonatal resuscitation as well as recent evidence of outcome for newborn infants requiring prolonged resuscitation. We discuss the ethical principles that can potentially guide decisions surrounding resuscitation and post-resuscitation care. We also propose a structured approach to stopping resuscitation.

Ethical issues in neonatal intensive care units

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.

Cutting the cord: Can society over-invest in extremely premature and critically impaired neonates?

This article provides a critical examination of the allocation of scarce public health care funds in relation to extremely premature and sick neonates. Decisions to withdraw or withhold life-sustaining treatment from neonates born extremely premature are generally informed by arbitrary and often subjective considerations of those involved in their care--namely parents and medical practitioners. This article argues for a sharp and immediate focus in decisions to treat such neonates based on the allocation of limited health care resources. Accordingly, decisions to save and preserve the lives of imperilled neonates should not be limited to the immediate financial costs of medical treatment. More explicitly there should be a full appreciation of the cost of disability to the family requirements for long-term care, and the benefits and associated costs of life, not only to the patient, but also to society.

[Below 26 gestational week prematurity: What support?]

Management and decision whether to begin intensive care for very preterm infants below 26 WG and at borderline viability remains controversial, and survival rates for these children vary greatly and justify discussion with regards to literature data and according to the experience of others countries. If active management is more difficult with very preterm infants 24-25 WG, mortality is increased comparing with newborns of more than 26 WG. This is partly explained by limitations of active neonatal intensive care. Nevertheless, neurocomportemental and cognitive results are not so unfavorable. This justifies a human, medical, and ethical multidiciplinary discussion including the parents' wishes for an active resuscitation or a palliative management. Using the only criteria of gestational age is not a reliable tool to predict survival and neurodevelopmental outcome of preterm infants. It is very important to identify other prenatal factors such prenatal corticosteroid administration, gender, fetal estimated weight, amniotic fluid and absent/reverse end diastolic flow umbilical doppler. Implication and listening the parents' preferences are essential after individual information, objective and a honest counseling including mortality, morbidity and risks of neurocomportmental impairments. Birth and counseling should be done in reference maternofetal center with obstetricians and neonatalogist specialized in this topic. A real difficulty is to consider the route of delivery and the possibility that caesarean section could improve survival rates. Induction of labour is very often a high risk of failure and route of delivery remains controversial and this is a real question in order to improve survival rates. Literature is poor and conflicting without randomized trials. Caesarean section presents maternal risks such as pathologic placentation, haemorrhage delivery and increasing risks for the subsequent gestation. So, if it is not a good idea to recommend a systematic caesarean delivery, it is not ethical to refuse this route of delivery only because of the gestational age even in extremely premature birth.

The ethics of an ordinary medical technology

Some routinely applied hospital technologies may have unintended consequences for patients and their families. The neonatal cardiorespiratory monitor, a computer-like display used to show an infant's vital functions, is one such technology that may become part of a parent's day-to-day being with his or her hospitalized child. In this phenomenological study, I explored how the monitor may mediate parental sensibilities, reshaping the contact of parent and child. This exploration speaks to understanding the relational ethics of even the seemingly most ordinary of medical technologies in clinical contexts.

[Nutrition and Hydration in Newborns: Limiting Treatment Decisions]

Artificial hydration and nutrition are key elements in the treatment in Neonatal Units, especially in premature babies. It has led to improved survival and better clinical outcomes. Artificial nutrition is considered a medical treatment and, in such a way, a balance between burdens and benefits should be taken into consideration. Nevertheless decisions on withholding or withdrawing artificial nutrition and hydration have special and emotional considerations. In premature babies it is also necessary to consider than below the 34th week of gestational age, effective suckling is not present, and so, oral nutrition is not a possibility. Decisions regarding the end-of-life care of neonates should be made taking into account clinical facts but also values and beliefs of all concerned, and always ″in the best interest″ of infants. In order to consider all this aspects, we could respect withdrawing or withholding artificial nutrition and hydration in those babies with an ominous prognosis in a short term basis. It has not the same consideration if there is a clear life risk but a prognosis based on severe future burden, mainly because of neurologic damage. In those cases withholding or withdrawing fluids and feedings would be the direct cause of death.

[The Best Interest of the Child in Neonatology: Is It Best for the Child?]

Since its inceptions, the standard of best interest of the child was linked to decisions about suspend life-sustaining treatments in neonatal units and evaluation of treatments applied to children in terms of their quality of life. This origin has conditioned the interpretation of the standard from two extremes: a vitalistic one, and a non vitalistic interpretation that triumphed in Western bioethics and has led to the consecration of the standard of best interest of the child in the Convention on the Rights of the Child of United Nations. A detailed analysis reveals a simplistic, utilitarian and proportionalist standard, which change the basis of parenthood. We therefore believe that the standard of the best interest of the child is not the best for the child in neonatal intensive care units and especially not in the process of withhold or withdrawal life-sustaining treatments.

[Analysis of the Debate on Neonatal Euthanasia Using Present Bioethical Literature]

Nowadays, most of the deaths in neonatal ages take place in neonatal intensive care units and a significative number of these are involved in decisions of withholding or withdrawing medical care. The growing complexity of the health care in neonatal settings entails that end-of-life decision-making occurs more frequently. Personal views and attitudes on the best care of the severely ill newborns can be different, since to define objectively the ″best interests″ for the infant is not easy at all. The question of how to best care for such infants is ongoing, and there remain deep divisions within the field. The aim of this issue is to review the different criteria used in the western world, Europe, especially in the Netherlands, and the EEUU and the current debate on neonatal euthanasia. Poor vital prognosis, current and future quality of life and, after the Groningen protocol, unbearable suffering are the criteria commonly used in neonatal end-of-life decisions, including euthanasia. It is necessary to distinguish the decisions, in which euthanasia is chosen, of which they are an appropriate limit of therapeutic effort.

Prenatal Consultation for Extremely Preterm Neonates: Ethical Pitfalls and Proposed Solutions

In current practice, decisions regarding whether or not to resuscitate infants born at the limits of viability are generally made with expectant parents during a prenatal consultation with a neonatologist. This article reviews the current practice of prenatal consultation and describes three areas in which current practice is ethically problematic: (1) risks to competence, (2) risks to information, and (3) risks to trust. It then reviews solutions that have been suggested in the literature, and the drawbacks to each. Finally, it suggests that the model of prenatal consultation be altered in three ways: (1) that the prenatal consultation be viewed as a process over time, rather than a onetime event; (2) that decision making in the prenatal consultation be framed as a choice between nonresuscitation and a trial of neonatal intensive care, rather than a choice between "doing nothing" and "doing everything"; and (3) that the prenatal consultation process devote serious attention to both the transfer of information and the non-informational needs of families, rather than focus on the transfer of information alone.

How to Help Parents, Couples, and Clinicians When an Extremely Premature Infant Is Born

Parents may experience profound stress when their infant is extremely premature or has exceptionally low birth weight. This article presents several approaches that clinicians and ethics consultants can use to reduce this stress when a parent is single and alone, as well as when both parents are present. Offering parents additional options, taking preventative measures, and using approaches based on recent innovations in psychotherapies are emphasized. Since the clinicians who care for these neonates may find it exceptionally stressful and may experience "burn out," especially over time, this article also addresses what may work best for them. Finally it will discuss clinicians, who, despite their best efforts, find that caring for these infants is simply too painful to bear.

SUPPORT and the Ethics of Study Implementation: Lessons for Comparative Effectiveness Research from the Trial of Oxygen Therapy for Premature Babies

The design of SUPPORT has been widely misunderstood. This confusion has driven much of the debate about the trial - and threatens the whole enterpise of comparative effectiveness research.

A quality of life quandary: a framework for navigating parental refusal of treatment for co-morbidities in infants with underlying medical conditions

Parental refusal of a recommended treatment is not an uncommon scenario in the neonatal intensive care unit. These refusals may be based upon the parents' perceptions of their child's projected quality of life. The inherent subjectivity of quality of life assessments, however, can exacerbate disagreement between parents and healthcare providers. We present a case of parental refusal of surgical intervention for necrotizing enterocolitis in an infant with Bartter syndrome and develop an ethical framework in which to consider the appropriateness of parental refusal based upon an infant's projected quality of life.

Were There "Additional Foreseeable Risks" in the SUPPORT Study? Lessons Not Learned from the ARDSnet Clinical Trials

Even though the interventions were adapted from standard clinical practice, the way they were provided meant that the care given infants in the study was distinctly different from standard care, with different risk profiles. Parents should have been informed about those differences.

Ethical challenges in neonatal intensive care nursing

BACKGROUND

Neonatal nurses report a great deal of ethical challenges in their everyday work. Seemingly trivial everyday choices nurses make are no more value-neutral than life-and-death choices. Everyday ethical challenges should also be recognized as ethical dilemmas in clinical practice.

RESEARCH OBJECTIVE

The purpose of this study is to investigate which types of ethical challenges neonatal nurses experience in their day-to-day care for critically ill newborns.

RESEARCH DESIGN

Data were collected through semi-structured qualitative in-depth interviews. Phenomenological-hermeneutic analysis was applied to interpret the data.

PARTICIPANTS AND RESEARCH CONTEXT

Six nurses from neonatal intensive care units at two Norwegian hospitals were interviewed on-site.

ETHICAL CONSIDERATIONS

The study is designed to comply with Ethical Guidelines for Nursing Research in the Nordic Countries and the Helsinki declaration.

FINDINGS

Findings suggest that nurses experience a diverse range of everyday ethical challenges related to challenging interactions with parents and colleagues, emotional strain, protecting the vulnerable infant, finding the balance between sensitivity and authority, ensuring continuity of treatment, and miscommunication and professional disagreement.

DISCUSSION

A major finding in this study is how different agents involved in caring for the newborn experience their realities differently. When these realities collide, ethical challenges arise. Findings suggest that acting in the best interests of the child becomes more difficult in situations involving many agents with different perceptions of reality.

CONCLUSION

The study presents new aspects which increases knowledge and understanding of the reality of nursing in a neonatal intensive care unit, while also demanding increased research in this field of care.

Which newborn infants are too expensive to treat? Camosy and rationing in intensive care

Are there some newborn infants whose short- and long-term care costs are so great that treatment should not be provided and they should be allowed to die? Public discourse and academic debate about the ethics of newborn intensive care has often shied away from this question. There has been enough ink spilt over whether or when for the infant's sake it might be better not to provide life-saving treatment. The further question of not saving infants because of inadequate resources has seemed too difficult, too controversial, or perhaps too outrageous to even consider. However, Roman Catholic ethicist Charles Camosy has recently challenged this, arguing that costs should be a primary consideration in decision-making in neonatal intensive care. In the first part of this paper I will outline and critique Camosy's central argument, which he calls the 'social quality of life (sQOL)' model. Although there are some conceptual problems with the way the argument is presented, even those who do not share Camosy's Catholic background have good reason to accept his key point that resources should be considered in intensive care treatment decisions for all patients. In the second part of the paper, I explore the ways in which we might identify which infants are too expensive to treat. I argue that both traditional personal 'quality of life' and Camosy's 'sQOL' should factor into these decisions, and I outline two practical proposals.

[Omission of treatment of severely ill neonates]

For the past two decades it has been common practice in Denmark to withhold or withdraw medical care from neonates born before 28 weeks of gestation if they have poor survival chances or risk of future complications (poor quality of life). This practice is neither supported by the Danish Health Law, a law which furthermore does not include a consideration to quality of life, nor fully recognized as neonatal euthanasia. This is unacceptable as it results in a lack of proper guidelines relating to moral aspects and a failure to understand the full moral impact of neonatal euthanasia.

Implementing structured, multiprofessional medical ethical decision-making in a neonatal intensive care unit

BACKGROUND

In neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical case deliberations do take place, participants may not always know how to perform to the fullest.

SETTING

A level-IIID neonatal intensive care unit of a paediatric teaching hospital in the Netherlands.

METHODS

Structured multiprofessional medical ethical decision-making (MEDM) was implemented to help overcome problems experienced. Important features were: all professionals who are directly involved with the patient contribute to MEDM; a five-step procedure is used: exploration, agreement on the ethical dilemma/investigation of solutions, analysis of solutions, decision-making, planning actions; meetings are chaired by an impartial ethicist. A 15-item questionnaire to survey staff perceptions on this intervention just before and 8 months after implementation was developed.

RESULTS

Before and after response rates were 91/105 (87%) and 85/113 (75%). Factor analysis on the questionnaire suggested a four-factor structure: participants' role; structure of MEDM; content of ethical deliberation; and documentation of decisions/conclusions. Effect sizes were 1.67 (p<0.001), 0.69 (p<0.001) and 0.40 (p<0.01) for the first three factors respectively, but only 0.07 (p=0.65) for the fourth factor. Nurses' perceptions of improvement did not significantly exceed those of physicians.

CONCLUSION

Professionals involved in ethical case deliberation perceived that the process of decision-making had improved; they were more positive about the structure of meetings, their own role and, to some extent, the content of ethical deliberation. Documentation of decisions/conclusions requires further improvement.

Report of an international conference on the medical and ethical management of the neonate at the edge of viability: a review of approaches from five countries

Current United States guidelines for neonatal resuscitation note that there is no mandate to resuscitate infants in all situations. For example, the fetus that at the time of delivery is determined to be so premature as to be non-viable need not be aggressively resuscitated. The hypothetical case of an extremely premature infant was presented to neonatologists from the United States and four other European countries at a September 2006 international meeting sponsored by the World Health Organization Collaborating Center in Reproductive Health of Atlanta (currently, the Global Collaborating Center in Reproductive Health). Responses to the case varied by country, due to differences in legal, ethical and related practice parameters, rather than differences in medical technology, as similar medical technology was available within each country. Variations in approach seemed to stem from physicians' perceptions of their ability to remove the neonate from life support if this appeared non-beneficial. There appears to be a desire for greater convergence in practice options and more open discussion regarding the practical problems underlying the variability. Specifically, the conference attendees identified four areas that need to be addressed: (1) lack of international consensus guidelines in viability and therapeutic options, (2) lack of bodies capable of generating these guidelines, (3) variation in laws between countries, and (4) the frequent failure of physicians and families to confront death at the beginning of life.

Ethical care for infants with conditions not curable with intensive care

Offering intensive care to neonates who have conditions that carry extremely poor prognoses is a source of great contention amongst neonatologists. The concept of best interests is commonly used as a rationale for refusing such care, despite the fact that parents of these infants often have a different view of what best interests means. This article takes up the question of what best interests should incorporate for infants with lethal conditions not curable with intensive care, and how and who should decide which treatment options should be implemented. Based on our recommendation that parents be apprised of the basis upon which physicians are evaluating treatment options, we offer a framework that allows all relevant parties to approach the issue of what is appropriate treatment from a similar place. We maintain that this approach will increase transparency, dialogue, understanding, and trust, which, in turn, may result in greater consensus.

Regulation of treatment of infants at the edge of viability in Italy: the role of the medical profession?

In the last few years there has been intense debate in Italy on administration of life-prolonging treatment to premature babies at the edge of viability. In 2006, a group of experts based in Florence drafted recommendations known as Carta di Firenze (CdF) for responsible use of intensive care for premature infants between 22 and 25&emsp14;weeks of gestational age (GA). The CdF was later endorsed by several medicoprofessional associations, but was followed by recommendations by the Ministry of Health mandating resuscitation for all premature babies regardless of GA and parental consent. Recent statements from medicoprofessional bodies seem to show that the 'always resuscitate rule' is not supported by many Italian doctors. We argue that ethically sensitive issues in medicine should be regulated with, and not against, the medical profession and its representative bodies.

[Ethics of the care given to premature newborns]

The treatment of premature newborns has evolved a lot in France over the last decade. It can be examined with regard to the four main principles of biomedical ethics: beneficence, non-maleficence, autonomy and justice. Consequently the combination of medical-nursing vigilance and individualised developmental care enables the premature baby to benefit from truly "ethical" healthcare.

[Ethics in neonatal intensive care]

Work summarises current data ideas of problems of ethical thinking and decision making in neonatology. Primary objective ethical questions of administration resuscitative and intensive care are outlined, as well as administration of care for babies, delivered on limit of viability, in the same way for children with high probability of serious damage in case of survival. Role of parents in decision making about to other administration care is discussed, some recommendation and instructions for communication with parents are handed up. Findings of extensive european study named EURONIC are shortly mentioned, study concerns problems of ethical dilemmas in neonatology in 8 European countries. Finally the categorization of newborns in ethical thinking is mentioned and present circumstances in Czech republic are remarked.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

Neonatal end-of-life decisions and bioethical perspectives

In the nineties the EURONIC project documented the staff views and practices regarding ethical decision-making in neonatal intensive care units of eight Western Europe countries: France, Germany, Great Britain, Italy, Luxembourg, Netherlands, Spain and Sweden. This paper reviews the changes occurred in the ethical and legal background of these countries, and discusses possible influences on neonatal care practices. To a certain extent, many of these changes appear to be in line with the neonatal physicians' views and attitudes previously documented by the EURONIC project, while some are not. Large differences persist within Western Europe on what constitutes appropriate neonatal end-of-life care.

When neonatal ICU infants participate in research: special protections for special subjects

Neonatal ICU research poses unique concerns for infants and parents. Children are considered a vulnerable research population. Federal regulations specify special protections when children participate in research. These regulations determine the types of research approvable for children based on the balance of risks and benefit. Risk also determines whether one or both parents' consent is required for their infant's participation in research.

End-of-life decisions in the newborn period: attitudes and practices of doctors and nurses

The aim of our study was to assess the attitudes and practices of doctors and nurses about end-of-life decisions and compare our results with those observed in different European countries. The data was collected from nurses and doctors, using a standardized questionnaire adapted from the EURONIC study. A total of 250 structured questionnaires were delivered, and 135 (77%) of them were accepted for analysis. The end-of-life decision was taken in 39.4% of the hospitals and personal involvement was 40%. Although an ethical committee was present in the hospitals of 61.5% of responders, a written policy was present in only 3.1% of the units. The mean attitude score was 6.5. Seventy-five percent of the contributors agreed that everything possible should be done to ensure a neonate's survival regardless of the prognosis and 65.2% of responders believed that costs of health care should not affect nontreatment decisions. Most of the responders (65.2%) agreed that severe mental disability as an outcome was equal to or worse than death. In patients in whom medical intervention would be futile, or would not offer sufficient benefit to justify the burdens imposed, hospitals should set up a functional ethical committee in order to decide in matters of withholding or withdrawing intervention.

Flaws in the assessment of the best interests of the newborn

We examined the literature on ethical decisions regarding neonates, to assess whether personal beliefs and prejudices influence end-of-life decisions taken by caregivers. Studies show that religion and familiarity with disability influence caregivers' decisions, whereas the influx of already being a parent, age, sex and professional experience is controverse. Caregivers' attitudes towards end-of-life decisions are also affected by personal concerns about litigation, prejudices and their view of disability. The concept of 'poor quality of life' is widely used as a reference in end-of-life decisions, but this can be interpreted differently, leaving room for a wide range of personal viewpoints. In most cases, parents' opinions are considered important and are sometimes the main determinant in decision making. However, it is unclear whether parents' decisions are based on their own wishes or on the best interests of the newborn.

CONCLUSION

In neonatal end-of-life decisions, patients may not receive cures based only on their best interests.

[Extreme prematurity--medical and social problem]

The survival rate for extremely preterm newborns born at the threshold of viability (25 or fewer completed weeks of gestation) improved in the early 1990s, largely as the result of a greater use of assisted ventilation in the delivery room and surfactant therapy. This led WHO in 1993 to define the perinatal period as commencing at 22 completed weeks of gestation. Infants born at 22-28 weeks gestation have been termed as having "threshold viability", though in developed countries this term is more often used in reference to infants of < 26 weeks. However, this improvement in survival has not been associated with an equal improvement in morbidity The increasing potential risk of residual disability or early death associated with decreasing gestational age raises serious medical, social and ethical problems in respect to appropriate management. These include whether elective delivery for fetal indication is appropriate or whether intensive care should be provided following delivery.