Attitudes of Obstetric and Pediatric Health Care Providers Toward Resuscitation of Infants Who Are Born at the Margins of Viability (original) (raw)
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Provider Perspectives Regarding Resuscitation Decisions for Neonates and Other Vulnerable Patients
The Journal of Pediatrics, 2017
Objectives To use structured surveys to assess the perspectives of pediatric residents and neonatal nurses on resuscitation decisions for vulnerable patients, including neonates. Study design Pediatric providers were surveyed using scenarios for 6 critically ill patients of different ages with outcomes explicitly described. Providers were asked (1) whether resuscitation was in each patient's best interest; (2) whether they would accept families' wishes for comfort care (no resuscitation); and (3) to rank patients in order of priority for resuscitation. In a structured interview, each participant explained how they evaluated patient interests and when applicable, why their answers differed for neonates. Interviews were audiotaped; transcripts were analyzed using thematic analysis and mixed methods. Results Eighty pediatric residents and neonatal nurses participated (response rate 74%). When making life and death decisions, participants considered (1) patient characteristics (96%), (2) personal experience/biases (85%), (3) family's wishes and desires (81%), (4) disease characteristics (74%), and (5) societal perspectives (36%). These factors were not in favor of sick neonates: of the participants, 85% reported having negative biases toward neonates and 60% did not read, misinterpreted, and/or distrusted neonatal outcome statistics. Additional factors used to justify comfort care for neonates included limited personhood and lack of relationships/attachment (73%); prioritization of family's best interest, and social acceptability of death (36%). When these preconceptions were discussed, 70% of respondents reported they would change their answers in favor of neonates. Conclusions Resuscitation decisions for neonates are based on many factors, such as considerations of personhood and family's interests (that are not traditional indicators of benefit), which may explain why decision making is different for the neonatal population. (J Pediatr 2017;■■:■■-■■). See editorial, p ••• T he majority of pediatric deaths occur in intensive care units, 1,2 most often after a decision to limit life-support. 3-7 These decisions, made by parents and providers, are among the hardest decisions in pediatrics. Evaluating the interest of children is complex. 8,9 Some authors invoke their best interests, 10 others "good enough" or "not unreasonable" interests, 11 and for others, avoiding harm is the main goal. 12 When an intervention is in the interest of a child and nonintervention places a child at significant harm, the intervention is generally considered as being legally and ethically preferable. Empirical investigations have demonstrated that neonates are treated differently when life and death decisions are made. 13-25 In questionnaire studies, scenarios of critically ill incompetent patients of different ages were presented with outcomes explicitly described. Although many respondents evaluated that resuscitation was in the interest of neonates, a larger proportion estimated that resuscitation was in the interest of older patients with similar or worse outcomes. 14-22 For older patients, a family's request for comfort care was rarely accepted when respondents evaluated resuscitation to be in a patient's interest. On the other hand, comfort care was generally accepted for neonates, despite estimating that resuscitation was in their interest. 14-22 This differential treatment seems to transcend culture and has been demonstrated in 7 culturally different countries, 18 in a large nonmedical population, 14 among pediatricians who do not work in neonatology 16 and among physicians who do not work in pediatrics. 20 In none of these studies were participants asked to explain their answers. The goal of this study was to investigate how providers evaluate the interests of vulnerable patients and why their decision making differs for neonates. Methods A mixed methods sequential explanatory design was used. First, participants answered a questionnaire that has been validated, widely used, and systematically NICU Neonatal intensive care unit
Antenatal Counseling Regarding Resuscitation and Intensive Care Before 25 Weeks of Gestation
Pediatrics, 2015
The anticipated birth of an extremely low gestational age (<25 weeks) infant presents many difficult questions, and variations in practice continue to exist. Decisions regarding care of periviable infants should ideally be well informed, ethically sound, consistent within medical teams, and consonant with the parents' wishes. Each health care institution should consider having policies and procedures for antenatal counseling in these situations. Family counseling may be aided by the use of visual materials, which should take into consideration the intellectual, cultural, and other characteristics of the family members. Although general recommendations can guide practice, each situation is unique; thus, decision-making should be individualized. In most cases, the approach should be shared decision-making with the family, guided by considering both the likelihood of death or morbidity and the parents' desires for their unborn child. If a decision is made not to resuscitate,...
BMC pediatrics, 2018
In the last 20 years, the chances for intact survival for extremely preterm infants have increased in high income countries. Decisions about withholding or withdrawing intensive care remain a major challenge in infants born at the limits of viability. Shared decision-making regarding these fragile infants between health care professionals and parents has become the preferred model today. However, there is an ongoing ethical debate on how decisions regarding life-sustaining treatment should be reached and who should have the final word when health care professionals and parents do not agree. We designed a survey among neonatologists and neonatal nurses to analyze practices, difficulties and parental involvement in end-of-life decisions for extremely preterm infants. All 552 physicians and nurses with at least 12 months work experience in level III neonatal intensive care units (NICU) in Switzerland were invited to participate in an online survey with 50 questions. Differences between...
HEC Forum, 2011
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
Journal of Obstetric, Gynecologic, & Neonatal Nursing, 2009
To describe the knowledge, attitudes/beliefs, and care practices of neonatal intensive care unit nurses concerning do not resuscitate status for hospitalized neonates and to assess differences based on years of neonatal intensive care unit experience and educational background. Comparative descriptive design. Level 3 neonatal intensive care unit located in the northeastern United States. A convenience sample of 66 neonatal intensive care unit nurses. Nurses responded anonymously to an adapted pen and paper questionnaire assessing knowledge, attitudes/beliefs, and care practices regarding the care of hospitalized neonates with do not resuscitate status. There was much ambiguity concerning the legal meaning of the term &amp;quot;do not resuscitate.&amp;quot; Three fourths of respondents did not recognize do not resuscitate by its legal definition. A variety of attitudes/beliefs and care practices related to do not resuscitate designation was reported. Nurses with increased years of experience were less supportive of initiating certain aggressive care modalities for do not resuscitate patients. Responses regarding knowledge, attitudes/beliefs, and care practices related to do not resuscitate designation for neonates did not appear to be influenced by the educational background of neonatal intensive care unit nurses. Neonatal intensive care unit nurses need further education regarding the legal definition and scope of do not resuscitate orders in the clinical care of terminally ill neonates.