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Voultsos P, Arabatzi M, Deligianni M, Tsaroucha AK. Extending the concept of moral distress to parents of infants hospitalized in the NICU: a qualitative study in Greece. BMC Psychol 2024; 12:291. [PMID: 38790072 PMCID: PMC11127332 DOI: 10.1186/s40359-024-01793-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND The hospitalization of infants in the neonatal intensive care unit (NICU) is an ethically challenging situation. A limited number of studies have extended the concept of moral distress to parents of infants hospitalized in the NICU. This topic requires further investigation. METHODS The present prospective qualitative study was conducted from February 2023 to May 2023. Data were collected through semistructured in-depth interviews, which were conducted in-person with fifteen parents of infants who were hospitalized in the NICU at the time of the interviews. Purposive sampling was used. The data were classified and analyzed using thematic analysis. RESULTS Three themes emerged from the data analysis performed for this empirical study. One intrapersonal dimension featuring two aspects (one dynamic and one static) and another interpersonal dimension focusing on parental moral distress emerged from the data analysis. Furthermore, seven subthemes emerged across these themes: (1) self-directed negative feelings were experienced by parents due to their inability to fulfill their caregiving/parental roles; (2) intense internal conflict was experienced by parents in response to a moral dilemma that was difficult, which was perceived as irresolvable; (3) objectively unjustified, self-directed negative feelings of guilt or failure were experienced by parents; (4) parents experienced moral distress due to the poor image of the ill infants; (5) inadequate information may predispose parents to experience moral distress (6) neonatologists' caring behaviors were unduly perceived by parents as paternalistic behaviors; (7) reasonable or justified institutional rules were unduly perceived by parents as constraint. CONCLUSIONS In general, the results of this study support the integrated definition of parental moral distress proposed by Mooney-Doyle and Ulrich. Furthermore, the present study introduces new information. The study distinguishes between the dynamic and static aspects of the intrapersonal dimension of the phenomenon of parental moral distress. Moreover, participants experienced moral distress because they unduly perceived certain situations as causing moral distress. In addition, inadequate information may predispose parents to experience moral distress. The findings of this study may contribute promote family-centered care in the NICU context.
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Affiliation(s)
- Polychronis Voultsos
- Laboratory of Forensic Medicine & Toxicology (Medical law and Ethics), School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, GR, 54124, Greece.
| | - Maria Arabatzi
- Postgraduate Program on Bioethics, Laboratory of Bioethics, Laboratory of Experimental Surgery and Surgical Research, School of Medicine, Democritus University of Thrace, Dragana, Alexandroupolis, GR, 68100, Greece
| | - Maria Deligianni
- Laboratory of Forensic Medicine & Toxicology (Medical law and Ethics), School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, Thessaloniki, GR, 54124, Greece
| | - Alexandra K Tsaroucha
- Postgraduate Program on Bioethics, Laboratory of Bioethics, Laboratory of Experimental Surgery and Surgical Research, School of Medicine, Democritus University of Thrace, Dragana, Alexandroupolis, GR, 68100, Greece
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Lin M, Williams D, Vitcov G, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. Advance Care Planning and Parent-Reported End-of-Life Outcomes in the Neonatal Intensive Care Unit. Am J Perinatol 2024; 41:e1657-e1667. [PMID: 37116531 DOI: 10.1055/s-0043-1768488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
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..
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Affiliation(s)
- Matthew Lin
- Department of Pediatrics, Children's National Medical Center, Pediatric Palliative Care Program, Washington, District of Columbia
| | - David Williams
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Giselle Vitcov
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sadath Sayeed
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Christy Cummings
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts
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Quinn M, Gephart S, Crist J. Exploring Parent Experiences With Early Palliative Care Practices in the NICU. Adv Neonatal Care 2024; 24:98-109. [PMID: 38324727 DOI: 10.1097/anc.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND The anxiety and uncertain outcome of an admission of a seriously ill infant to the neonatal intensive care unit (NICU) can cause great stress for parents and contribute to poor mental health outcomes. Early implementation of family-centered palliative care (PC) may provide support for NICU parents. Key concepts of early PC in the NICU include shared decision-making, care planning, and support for coping with distress. PURPOSE The purpose of this study was to explore parent experiences during their child's NICU admission with the early PC practices of shared decision-making, care planning, and coping with distress. METHODS Qualitative descriptive methodology was used. Strategies of reflexive journaling, peer debriefing, and data audits were used to enhance trustworthiness. Parents (N = 16) were interviewed, and data were analyzed by conventional content analysis. Targeted recruitment of fathers occurred to ensure they comprised 25% of sample. RESULTS Parents' descriptions of decision-making were contextualized in gathering information to make a decision, the emotional impact of the decision, and influences on their decision-making. In experiences with care planning, parents described learning to advocate, having a spectator versus participant role, and experiencing care planning as communication. Key themes expressed regarding parental coping were exposure to trauma, survival mode, and a changing support network. IMPLICATIONS FOR PRACTICE AND RESEARCH These findings highlight key areas for practice improvement: providing more support and collaboration in decision-making, true engagement of parents in care planning, and encouraging peer support and interaction in the NICU and in online communities.
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Affiliation(s)
- Megan Quinn
- Author Affiliations: Oregon Health Sciences University, Portland (Dr Quinn); and University of Arizona, Tucson (Drs Gephart and Crist)
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Geurtzen R, Wilkinson DJC. Incorporating parental values in complex paediatric and perinatal decisions. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:225-235. [PMID: 38219752 DOI: 10.1016/s2352-4642(23)00267-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 01/16/2024]
Abstract
Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.
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Affiliation(s)
- Rosa Geurtzen
- Amalia Children's Hospital, Radboud Institute of Healthcare Sciences, Radboud University Medical Center, Nijmegen, Netherlands.
| | - Dominic J C Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; Oxford Newborn Care Unit, John Radcliffe Hospital, Oxford University, Oxford, UK; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore
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5
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Uveges MK, Hamilton JB, Pados BF, Thayer WM, Hinds PS, Nolan MT. Being a "Good Parent" to a NICU Infant With a Major Congenital Anomaly. Adv Neonatal Care 2024; 24:14-26. [PMID: 38232327 DOI: 10.1097/anc.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND In the United States, up to one-third of infants with a congenital anomaly require neonatal intensive care unit (NICU) hospitalization. Parents of these infants may have different decision-making priorities, which may be influenced by the timing of the infant's diagnosis. PURPOSE (1) To compare the ranked importance of decision-making beliefs for parents of infants who received a prenatal versus postnatal congenital diagnosis and (2) explore how parents describe their decision-making beliefs. METHODS A cross-sectional, sequential mixed-methods pilot design was applied to collect quantitative data using the Good Parent Ranking Exercise and further explore parents' decision-making beliefs through qualitative interviews. Maximum difference scaling/hierarchical Bayes estimation and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS Forty mothers completed the Good Parent Ranking Exercise and 20 mothers completed qualitative interviews. Four of the top 5 ranked parenting beliefs were shared by mothers in the prenatal and postnatal groups. Mothers in the postnatal group ranked "focusing on my child's quality of life" higher. Qualitative interviews revealed that previously identified decision-making beliefs were consistent in this NICU parent population, with 1 additional belief identified. Mixed-methods analysis revealed high concordance between the prenatal and postnatal groups. IMPLICATIONS FOR PRACTICE NICU nurses need to know that decision-making beliefs for parents who receive a prenatal versus postnatal congenital diagnosis, while largely similar, may have differences. IMPLICATIONS FOR RESEARCH Future research should explore decision-making beliefs in demographically diverse parent groups (ie, fathers, partnered vs nonpartnered couples) and effective strategies for promoting NICU parents' decision-making beliefs.
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Affiliation(s)
- Melissa K Uveges
- William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts (Dr Uveges); Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia (Dr Hamilton); Infant Feeding Care, Wellesley Hills, Massachusetts (Dr Pados); School of Nursing, Johns Hopkins University, Baltimore, Maryland (Mr Thayer); Children's National Health System, Washington, District of Columbia (Dr Hinds); Department of Pediatrics, The George Washington University, Washington, District of Columbia (Dr Hinds); and Conway School of Nursing, The Catholic University of America, Washington, District of Columbia (Dr Nolan)
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Schneider K, Roll S, Tissen-Diabaté T, Bührer C, Garten L. Public Attitudes Toward Ethics and Practices in End-of-Life Decision-Making for Neonates. JAMA Netw Open 2024; 7:e2353264. [PMID: 38270948 PMCID: PMC10811557 DOI: 10.1001/jamanetworkopen.2023.53264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/05/2023] [Indexed: 01/26/2024] Open
Abstract
Importance Attitudes toward end-of-life decision-making in neonatology have been studied in physicians and other health care professionals and are mostly shaped by their clinical education and work experiences. In contrast, attitudes among the general public have not yet been investigated. Objective To assess (1) attitudes in the general public toward euthanasia and withdrawal of life-prolonging treatment in neonates with severe life-limiting conditions, (2) knowledge of current German recommendations, and (3) values in the German society regarding ethical issues and proxy decisions at the beginning of life. Design, Setting, and Participants This cross-sectional study was performed in Germany and used an exploratory design to analyze responses to an interview conducted by an independent, established commissioned polling institute in March and April 2022. Participants were 16 years or older, with German language fluency and comprehension and living in Germany. Main Outcomes and Measures Knowledge about recommendations for euthanasia and withdrawal of life-prolonging treatment as well as personal attitudes toward (1) euthanasia and withdrawal of life-prolonging treatment and (2) surrogate end-of-life decision-making for newborn infants were assessed. Results The study included 2116 participants (1077 females [50.9%]; mean [SD] age 52.1 [18.7] years). Of the participants, 16.8% (311 of 1851) reported knowing the German recommendations for euthanasia and withdrawal of life-prolonging treatment for neonates. Euthanasia and withdrawal of life-prolonging treatment were supported by 64.7% (1369 of 2116) and 77.9% (1649 of 2116) of respondents, respectively. Shared decision-making between parents and physicians for neonates in end-of-life situations was supported by 65.6% of participants (1388). In situations where shared decision-making was not possible, 73.4% of respondents (1019 of 1388) put the ultimate decision to the parents. The magnitude of the associations was low between sociodemographic factors and views on ethical issues and customary practices involved in end-of-life decisions for neonates. Conclusions and Relevance Results of this cross-sectional study suggested that most respondents were not aware of the national German recommendations for euthanasia and withdrawal of life-prolonging treatment for sick and extremely preterm newborns. When counseling parents of periviable newborns, clinicians may need to exert more effort in explaining the legal and ethical framework; a highly individualized approach is warranted.
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Affiliation(s)
- Katja Schneider
- Department of Neonatology, Gemeinnützige Gesellschaft der Franziskanerinnen zu Olpe, Marien-Hospital, Bonn, Germany
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Stephanie Roll
- Institute of Social Medicine, Epidemiology and Health Economics, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Tatjana Tissen-Diabaté
- Institute of Social Medicine, Epidemiology and Health Economics, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Garten
- Department of Neonatology, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Imai L, Gray MM, Kim BJH, Lyle ANJ, Bock A, Weiss EM. Clinician perception of care at the end of life in a quaternary neonatal intensive care unit. Front Pediatr 2023; 11:1197360. [PMID: 37384313 PMCID: PMC10293892 DOI: 10.3389/fped.2023.1197360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/16/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Care for neonates at the end of life (EOL) is often challenging for families and medical teams alike, performed suboptimally, and requires an experienced and compassionate clinician. Much literature exists on adult and pediatric EOL care, but limited studies examine the neonatal process. Methods We aimed to describe clinicians' experiences around EOL care in a single quaternary neonatal intensive care unit as we implemented a standard guideline using the Pediatric Intensive Care Unit-Quality of Dying and Death 20 tool. Results Surveys were completed by 205 multidisciplinary clinicians over three time periods and included 18 infants at EOL. While most responses were high, a meaningful minority were below goal (<8 on 0-10 scale) for troubling symptom management, conflict between parents and staff, family access to resources, and parent preparation of symptoms. Comparison between Epochs revealed improvement in one symptom management and four communication categories. Satisfaction scores related to education around EOL were better in later Epochs. Neonatal Pain, Agitation, and Sedation Scale scores were low, with few outliers. Discussion These findings can guide those aiming to improve processes around neonatal EOL by identifying areas with the greatest challenges (e.g., conflict management) and areas that need further study (e.g., pain management around death).
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Affiliation(s)
- Lauren Imai
- Division of Neonatology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Megan M. Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Brennan J. H. Kim
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Allison N. J. Lyle
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Amber Bock
- Department of Hospital Medicine, Seattle Children’s Hospital, Seattle, WA, United States
| | - Elliott Mark Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA, United States
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8
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Carlisle EM, Shinkunas LA, Lieberman MT, Hoffman RM, Reisinger HS. "Reading the room:" A qualitative analysis of pediatric surgeons' approach to clinical counseling. J Pediatr Surg 2023; 58:503-509. [PMID: 35973862 PMCID: PMC11108180 DOI: 10.1016/j.jpedsurg.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/30/2022] [Accepted: 08/03/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND In our prior analysis of parental preferences for discussions with pediatric surgeons, we identified that parents prefer more guidance from surgeons when discussing cancer surgery, emergency surgery, or surgery for infants, and they prefer to engage surgeons by asking questions. In this study, we investigate surgeon preferences for decision making discussions in pediatric surgery. METHODS We conducted a thematic content analysis of interviews of pediatric surgeons regarding their preferences for discussing surgery with parents. Board certified/board eligible pediatric surgeons who had been in practice for at least one year and spoke English were eligible. Fifteen surgeons were invited, and twelve 30-minute semi-structured interviews were completed (80%). Interviews were recorded and transcribed. Thematic content analysis was performed using deductive and inductive methods. RESULTS Data saturation was achieved after 12 interviews [6 women (50%), median years in practice 6.25, 10 in academic practice (83%), 8 from Midwest (67%)]. 5 themes emerged: (1) Collaboration to promote parental engagement; (2) "Cancer is distinct but not unique;" (3) "Read the room:" tailoring discussions to specific parental needs; (4) Perceived role of the surgeon; (5) Limited experience with decision support tools in pediatric surgery. CONCLUSIONS Pediatric surgeons prefer a collaborative approach to counseling that engages parents through education. They prioritize tailoring discussions to meet parental needs. Few have utilized decision support tools, however most expressed interest. Insight gained from our work will guide development of a decision support tool that empowers parental participation in counseling for pediatric surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Erica M Carlisle
- University of Iowa Hospitals and Clinics, Department of Surgery, Division of Pediatric Surgery, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, IA, USA.
| | - Laura A Shinkunas
- University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, IA, USA
| | | | - Richard M Hoffman
- University of Iowa Hospitals and Clinics, Iowa City, IA, Department of Internal Medicine, USA
| | - Heather Schacht Reisinger
- University of Iowa Carver College of Medicine, Program in Bioethics and Humanities, Iowa City, IA, USA; University of Iowa Hospitals and Clinics, Iowa City, IA, Department of Internal Medicine, USA; University of Original article Iowa, Institute for Clinical and Translational Science, Iowa City, IA, USA
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Mitra S, Hatfield T, Campbell-Yeo M, Dorling J, Johnston BC. Evaluation of Health-Related Values and Preferences of Adults Who Were Preterm Infants and Parents of Preterm Infants Concerning Use of Prophylactic Cyclooxygenase Inhibitor Drugs. JAMA Netw Open 2023; 6:e232273. [PMID: 36892840 PMCID: PMC9999240 DOI: 10.1001/jamanetworkopen.2023.2273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
IMPORTANCE There is wide variability in the use of prophylactic cyclooxygenase inhibitor (COX-I) drugs to prevent morbidity and mortality in preterm infants. Parents of preterm infants are rarely involved in this decision-making process. OBJECTIVE To explore the health-related values and preferences of adults who were preterm infants and families of preterm infants concerning the prophylactic use of indomethacin, ibuprofen, and acetaminophen initiated within the first 24 hours after birth. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used direct choice experiments conducted in 2 phases of virtual video-conferenced interviews between March 3, 2021, and February 10, 2022: (1) a pilot feasibility study and (2) a formal study of values and preferences, using a predefined convenience sample. Participants included adults born very preterm (gestational age <32 weeks) or parents of very preterm infants currently in the neonatal intensive care unit (NICU) or having graduated from the NICU in the last 5 years. MAIN OUTCOMES AND MEASURES Relative importance of clinical outcomes, willingness to use each of the COX-Is when presented as the only option, preference for using prophylactic hydrocortisone vs indomethacin, willingness to use any of the COX-Is when all 3 options are available, and relative importance of having family values and preferences included in decision-making. RESULTS Of 44 participants enrolled, 40 were included in the formal study (31 parents and 9 adults born preterm). The median gestational age of the participant or the participant's child at birth was 26.0 (IQR, 25.0-28.8) weeks. Death (median score, 100 [IQR, 100-100]) and severe intraventricular hemorrhage (IVH) (median score, 90.0 [IQR, 80.0-100]) were rated as the 2 most critical outcomes. Based on direct choice experiments, most participants were willing to consider prophylactic indomethacin (36 [90.0%]) or ibuprofen (34 [85.0%]), but not acetaminophen (4 [10.0%]) when offered as the only option. Among participants who initially chose indomethacin (n = 36), if prophylactic hydrocortisone was offered as a potential therapy with the caveat that both cannot be used simultaneously, only 12 of 36 (33.3%) preferred to remain with indomethacin. Variability in preference was noted when all 3 COX-I options were available, indomethacin (19 [47.5%]) being the most preferred option followed by ibuprofen (16 [40.0%]), while the remainder opted for no prophylaxis (5 [12.5%]). CONCLUSIONS AND RELEVANCE The findings of this cross-sectional study of former preterm infants and parents of preterm infants suggest that there was minimal variability in how participants valued the main outcomes, with death and severe IVH being rated as the 2 most important undesirable outcomes. While indomethacin was the most preferred form of prophylaxis, variability was noted in the choice of COX-I interventions when participants were presented with the benefits and harms of each drug.
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Affiliation(s)
- Souvik Mitra
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Neonatal-Perinatal Medicine, IWK Health, Halifax, Nova Scotia, Canada
| | - Tara Hatfield
- Division of Neonatal-Perinatal Medicine, IWK Health, Halifax, Nova Scotia, Canada
| | - Marsha Campbell-Yeo
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Neonatal-Perinatal Medicine, IWK Health, Halifax, Nova Scotia, Canada
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Neonatology, Southampton Children’s Hospital, Southampton, United Kingdom
| | - Bradley C. Johnston
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Nutrition, Texas A&M University, College Station
- Department of Epidemiology, Texas A&M University, College Station
- Department of Biostatistics, Texas A&M University, College Station
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Tadros HJ, Saidi A, Rawlinson AR, Cattier C, Black EW, Rackley J, Breault L, Pietra BA, Fricker FJ, Gupta D. Assessment of parental decision making in congenital heart disease, cardiomyopathy and heart transplantation: an observational study analysing decisional characteristics and preferences. Arch Dis Child 2023:archdischild-2022-324373. [PMID: 36732035 DOI: 10.1136/archdischild-2022-324373] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE We explore shared decision making (DM) in guardians of children with heart disease by assessing the desired weight of influence on DM and factors that may alter the relative weight of parent or medical team influence. METHODS Guardians of patients <21 years and admitted >1 week in the paediatric cardiac intensive care unit (PCICU) were recruited. Twelve vignettes were designed including technical (antibiotic selection, intubation, peripherally inserted central catheter placement, ventricular assist device placement, heart transplant, organ rejection, heart rhythm abnormalities and resuscitation effort) and non-technical vignettes (cessation of life-sustaining therapies, depression treatment, obesity and palliative care referral). Participants responded to questions on DM characteristics and one question querying preference for relative weight of parent or medical team influence on DM. RESULTS Of 209 participants approached, 183 were included. Most responded with equal desire of medical team and parental influence on DM in all vignettes (range 41.0%-66.7%). Technical scenarios formed one cluster based on DM characteristics, compared with non-technical scenarios. Factors that increase the relative weight of parental influence on DM include desired input and involvement in big-picture goals (OR 0.274, CI [0.217 to 0.346]; OR 0.794, CI [0.640 to 0.986]). Factors that increase the relative weight of medical team influence on DM include perception of medical expertise needed (OR 1.949 [1.630 to 2.330]), urgency (OR 1.373 [1.138 to 1.658]), benefit (OR 1.415 [1.172 to 1.710]), number of PCICU admissions (OR 1.134 [1.024 to 1.256]) and private insurance (OR 1.921 [1.144 to 3.226]). CONCLUSION Although factors may alter the weight of influence on DM, most parents desire equal parental and medical team influence on DM.
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Affiliation(s)
- Hanna J Tadros
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Arwa Saidi
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Alana R Rawlinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Celine Cattier
- Department of Palliative Care, University of Florida, Gainesville, Florida, USA
| | - Erik W Black
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Jennifer Rackley
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Leah Breault
- Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Biagio A Pietra
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Fredrick J Fricker
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Dipankar Gupta
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA .,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
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11
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Lin M, Sayeed S, DeCourcey DD, Wolfe J, Cummings C. The Case for Advance Care Planning in the NICU. Pediatrics 2022; 150:189893. [PMID: 36321383 DOI: 10.1542/peds.2022-057824] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Matthew Lin
- Pediatric Palliative Care Program, Children's National Medical Center, Washington, District of Columbia
| | | | | | - Joanne Wolfe
- Departments of Psychosocial Oncology and Palliative Care and Pediatrics, Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
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12
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Kon NM, Kon AA. Informed Nondissent at the Limits of Viability. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:54-56. [PMID: 36332049 DOI: 10.1080/15265161.2022.2123974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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13
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Parish O, Williams D, Odd D, Joseph-Williams N. Barriers and facilitators to shared decision-making in neonatal medicine: A systematic review and thematic synthesis of parental perceptions. PATIENT EDUCATION AND COUNSELING 2022; 105:1101-1114. [PMID: 34503868 DOI: 10.1016/j.pec.2021.08.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 07/14/2021] [Accepted: 08/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Systematically review parental perceptions of shared decision-making (SDM) in neonatology, identifying barriers and facilitators to implementation. METHODS Electronic database (Medline, PsycINFO, CINAHL and Scopus) and follow-up searches were conducted to identify qualitative studies. Data were extracted, thematically analysed and synthesised. RESULTS Searches yielded 2445 papers, of which 25 were included. Thematic analysis identified six key themes. Key barriers included emotional crises experienced in the NICU setting, lack of medical information provided to parents to inform decision-making, inadequate communication of information, poor relationships with caregivers, lack of continuity in care, and perceived power imbalances between HCPs and parents. Key facilitators included clear, honest and compassionate communication of medical information, caring and empathetic caregivers, continuity in care, and tailored approaches that reflected parent's desired level of involvement. CONCLUSION The highly specialised environment, and the emotional crises experienced by parents impact significantly on their perceived capacity to engage in surrogate decision-making. PRACTICE IMPLICATIONS Complex and multi-factorial interventions that address the training needs of HCPs, and the emotional, informational and decision support needs of parents are needed. SDM skills training, improved information delivery, and integrated emotional and decisional support could help parents to become more involved in SDM for their infant.
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Affiliation(s)
- Olivia Parish
- Cardiff University, School of Medicine, Cardiff, UK.
| | - Denitza Williams
- Cardiff Metropolitan University, Cardiff School of Sport and Health Sciences, Cardiff, UK
| | - David Odd
- Cardiff University, School of Medicine, Cardiff, UK
| | - Natalie Joseph-Williams
- Cardiff University, School of Medicine, Cardiff, UK; PRIME Centre Wales, School of Medicine, Cardiff, UK
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14
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Jonas D, Scanlon C, Bogetz JF. Parental Decision-Making for Children With Medical Complexity: An Integrated Literature Review. J Pain Symptom Manage 2022; 63:e111-e123. [PMID: 34363953 DOI: 10.1016/j.jpainsymman.2021.07.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
CONTEXT Children with medical complexity (CMC) have multiple significant chronic health conditions that result in functional limitations and high health care utilization. The population of CMC is increasing and parent decision-making for this population is nuanced. OBJECTIVES To review the literature specifically related to the parent experience of medical decision-making for CMC from the parent perspective. METHODS A comprehensive, systematic approach was undertaken with the goal of identifying emergent themes in the existing literature as well as implications for clinical practice and future research. PubMed and PsycInfo databases were searched for English-language articles published between 1995-2020 that focused on parent experiences/perspectives using the search terms: children with medical complexity, children with serious illness, parent decision-making, parent experience, goals of care, parental priorities, advance care planning, and shared decision-making. RESULTS The search yielded 300 unique manuscripts; including 32 empirical articles incorporated in this review. The synthesized findings were broken down into three main sections: 1. types of decisions that parents of CMC face, 2. key factors that influence parental decision-making for CMC, and 3. reasons that the decision-making process for parents of CMC is unique. The findings suggest that parents should be considered experts in their child's care and should be incorporated in shared decision-making in a culturally appropriate manner. CMC should have their personhood valued and providers require specialized training in communication. CONCLUSIONS Parents of CMC have unique needs in their decision-making process and benefit from shared decision-making, continuity of care, collaborative communication and tailored, individualized care.
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Affiliation(s)
- Danielle Jonas
- Silver School of Social Work, New York University, New York, New York, USA.
| | - Caitlin Scanlon
- Pediatric Palliative Care Team, Riley Hospital For Children, Indiana University Health, Indianapolis, Indiana, USA
| | - Jori F Bogetz
- Division of Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Palliative Care and Resilience Lab, Center for Clinical and Translational Research, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
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15
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Soltys FC, Spilo K, Politi MC. The Content and Quality of Publicly Available Information About Congenital Diaphragmatic Hernia: Descriptive Study. JMIR Pediatr Parent 2021; 4:e30695. [PMID: 34665147 PMCID: PMC8564656 DOI: 10.2196/30695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/23/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) diagnosis in an infant is distressing for parents. Parents often feel unable to absorb the complexities of CDH during prenatal consultations and use the internet to supplement their knowledge and decision making. OBJECTIVE We aimed to examine the content and quality of publicly available, internet-based CDH information. METHODS We conducted internet searches across 2 popular search engines (Google and Bing). Websites were included if they contained CDH information and were publicly available. We developed a coding instrument to evaluate websites. Two coders (FS and KS) were trained, achieved interrater reliability, and rated remaining websites independently. Descriptive statistics were performed. RESULTS Searches yielded 520 websites; 91 met inclusion criteria and were analyzed. Most websites provided basic CDH information including describing the defect (86/91, 95%), need for neonatal intensive care (77/91, 85%), and surgical correction (79/91, 87%). Few mentioned palliative care, decisions about pregnancy termination (13/91, 14%), or support resources (21/91, 23%). CONCLUSIONS Findings highlight the variability of information about CDH on the internet. Clinicians should work to develop or identify reliable, comprehensive information about CDH to support parents.
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Affiliation(s)
- Frank Coyle Soltys
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Kimi Spilo
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
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16
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Lemmon ME, Wusthoff CJ, Boss RD, Rasmussen LA. Ethical considerations in the care of encephalopathic neonates treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101258. [PMID: 34176763 PMCID: PMC8627487 DOI: 10.1016/j.siny.2021.101258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Engaging with ethical issues is central to the management of neonatal encephalopathy (NE). As treatment for these neonates evolves, new ethical issues will arise and many existing challenges will remain. We highlight three key ethical issues that arise in the care of neonates with NE treated with therapeutic hypothermia: facilitating shared decision making, understanding futility, and defining the boundaries between standard of care and research. Awareness of these issues will help clinicians counsel families in light of evolving treatments and outcomes.
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Affiliation(s)
- Monica E. Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, DUMC 3936, Durham, NC, 27710, USA,Corresponding author. (M.E. Lemmon)
| | - Courtney J. Wusthoff
- Departments of Neurology and Pediatrics, Stanford University, Stanford, 750 Welch Road, Suite 317, Palo Alto, CA, 94304, USA
| | - Renee D. Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Berman Institute of Bioethics, 200 N. Wolfe St, Suite 2019, Baltimore, MD, 21287, United States
| | - Lisa Anne Rasmussen
- Division of Palliative Care, Department of Family Medicine, Department of Neurology, Department of Pediatrics, Larner College of Medicine, University of Vermont, UVM Medical Center Palliative Care, 111 Colchester Avenue, Main Campus, Smith 262, Burlington, VT, 05401-1473, USA.
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17
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Labrie NHM, van Veenendaal NR, Ludolph RA, Ket JCF, van der Schoor SRD, van Kempen AAMW. Effects of parent-provider communication during infant hospitalization in the NICU on parents: A systematic review with meta-synthesis and narrative synthesis. PATIENT EDUCATION AND COUNSELING 2021; 104:1526-1552. [PMID: 33994019 DOI: 10.1016/j.pec.2021.04.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To synthesize and analyse the literature on the effects of parent-provider communication during infant hospitalization in the neonatal (intensive) care unit (NICU) on parent-related outcomes. METHODS Systematic review with meta-synthesis and narrative synthesis. Databases (PubMed, PsycINFO, Cochrane Library, CINAHL, Web of Science, Scopus) were searched in October/November 2019. Studies reporting, observing, or measuring parent-related effects of parent-provider communication in the NICU were included. Study quality was assessed using the Quality Assessment Tool for Studies with Diverse Designs. Qualitative studies were meta-synthesized using deductive and inductive thematic analysis. Quantitative studies were analysed using narrative synthesis. RESULTS 5586 records were identified; 77 were included, reporting on N = 6960 parents, N = 693 providers, and N = 300 NICUs. Analyses revealed five main (positive and negative) effects of parent-provider interaction on parents' (1) coping, (2) knowledge, (3) participation, (4) parenting, and (5) satisfaction. Communication interventions appeared impactful, particularly in reducing parental stress and anxiety. Findings confirm and refine the NICU Communication Framework. CONCLUSIONS Parent-provider communication is a crucial determinant for parental well-being and satisfaction with care, during and following infant hospitalization in the NICU. R. Practice Implications: Providers should particularly consider the impact on parents of their day-to-day interaction - the most occurring form of communication of all.
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Affiliation(s)
- Nanon H M Labrie
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Department of Pediatrics and Neonatology, OLVG, Amsterdam, The Netherlands.
| | - Nicole R van Veenendaal
- Department of Pediatrics and Neonatology, OLVG, Amsterdam, The Netherlands; Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
| | | | - Johannes C F Ket
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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18
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Bogetz JF, Weiss EM, Opel DJ. Use of Cognitive Shortcuts in Decision-making for Children With Severe Neurologic Impairment. Pediatrics 2021; 147:peds.2020-0930. [PMID: 33574161 DOI: 10.1542/peds.2020-0930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jori F Bogetz
- Divisions of Bioethics and Palliative Care, .,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - Elliott Mark Weiss
- Divisions of Bioethics and Palliative Care.,Neonatology, and.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | - Douglas J Opel
- Divisions of Bioethics and Palliative Care.,General Pediatrics, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
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19
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Weiss EM, Olszewski AE, Guttmann KF, Magnus BE, Li S, Shah AR, Juul SE, Wu YW, Ahmad KA, Bendel-Stenzel E, Isaza NA, Lampland AL, Mathur AM, Rao R, Riley D, Russell DG, Salih ZNI, Torr CB, Weitkamp JH, Anani UE, Chang T, Dudley J, Flibotte J, Havrilla EM, Kathen CM, O'Kane AC, Perez K, Stanley BJ, Wilfond BS, Shah SK. Parental Factors Associated With the Decision to Participate in a Neonatal Clinical Trial. JAMA Netw Open 2021; 4:e2032106. [PMID: 33433595 PMCID: PMC7804922 DOI: 10.1001/jamanetworkopen.2020.32106] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE It remains poorly understood how parents decide whether to enroll a child in a neonatal clinical trial. This is particularly true for parents from racial or ethnic minority populations. Understanding factors associated with enrollment decisions may improve recruitment processes for families, increase enrollment rates, and decrease disparities in research participation. OBJECTIVE To assess differences in parental factors between parents who enrolled their infant and those who declined enrollment for a neonatal randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS This survey study conducted from July 2017 to October 2019 in 12 US level 3 and 4 neonatal intensive care units included parents of infants who enrolled in the High-dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial or who were eligible but declined enrollment. Data were analyzed October 2019 through July 2020. EXPOSURE Parental choice of enrollment in neonatal clinical trial. MAIN OUTCOMES AND MEASURES Percentages and odds ratios (ORs) of parent participation as categorized by demographic characteristics, self-assessment of child's medical condition, study comprehension, and trust in medical researchers. Survey questions were based on the hypothesis that parents who enrolled their infant in HEAL differ from those who declined enrollment across 4 categories: (1) infant characteristics and parental demographic characteristics, (2) perception of infant's illness, (3) study comprehension, and (4) trust in clinicians and researchers. RESULTS Of a total 387 eligible parents, 269 (69.5%) completed the survey and were included in analysis. This included 183 of 242 (75.6%) of HEAL-enrolled and 86 of 145 (59.3%) of HEAL-declined parents. Parents who enrolled their infant had lower rates of Medicaid participation (74 [41.1%] vs 47 [55.3%]; P = .04) and higher rates of annual income greater than $55 000 (94 [52.8%] vs 30 [37.5%]; P = .03) compared with those who declined. Black parents had lower enrollment rates compared with White parents (OR, 0.35; 95% CI, 0.17-0.73). Parents who reported their infant's medical condition as more serious had higher enrollment rates (OR, 5.7; 95% CI, 2.0-16.3). Parents who enrolled their infant reported higher trust in medical researchers compared with parents who declined (mean [SD] difference, 5.3 [0.3-10.3]). There was no association between study comprehension and enrollment. CONCLUSIONS AND RELEVANCE In this study, the following factors were associated with neonatal clinical trial enrollment: demographic characteristics (ie, race/ethnicity, Medicaid status, and reported income), perception of illness, and trust in medical researchers. Future work to confirm these findings and explore the reasons behind them may lead to strategies for better engaging underrepresented groups in neonatal clinical research to reduce enrollment disparities.
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Affiliation(s)
- Elliott Mark Weiss
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Aleksandra E Olszewski
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Katherine F Guttmann
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brooke E Magnus
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, Massachusetts
| | - Sijia Li
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Anita R Shah
- Division of Neonatology, Children's Hospital of Orange County, Orange, California
| | - Sandra E Juul
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Yvonne W Wu
- Departments of Neurology and Pediatrics, University of California San Francisco School of Medicine, San Francisco
| | - Kaashif A Ahmad
- Department of Pediatrics, Baylor College of Medicine, San Antonio, Texas
| | | | - Natalia A Isaza
- Division of Neonatology, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Andrea L Lampland
- Department of Neonatology, Children's Minnesota Hospital, Minneapolis
| | - Amit M Mathur
- Department of Pediatrics, St Louis University School of Medicine, St Louis, Missouri
| | - Rakesh Rao
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - David Riley
- Department of Pediatrics, Cook Children's Medical Center, Fort Worth, Texas
| | - David G Russell
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Zeynep N I Salih
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Carrie B Torr
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | | | - Uchenna E Anani
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Juanita Dudley
- Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John Flibotte
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erin M Havrilla
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Alexandra C O'Kane
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Krystle Perez
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | | | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Seema K Shah
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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20
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Guttmann KF, Wu YW, Juul SE, Weiss EM. Consent Related Challenges for Neonatal Clinical Trials. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:38-40. [PMID: 32364480 DOI: 10.1080/15265161.2020.1745940] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
| | - Yvonne W Wu
- University of California San Francisco School of Medicine
| | | | - Elliott M Weiss
- University of Washington School of Medicine
- Seattle Children's Research Institute
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21
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Abstract
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.
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Affiliation(s)
- Anne Sullivan
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Christy Cummings
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
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22
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Early for Everyone: Reconceptualizing Palliative Care in the Neonatal Intensive Care Unit. Adv Neonatal Care 2020; 20:109-117. [PMID: 31990696 DOI: 10.1097/anc.0000000000000707] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Palliative care (PC) in the neonatal intensive care unit (NICU) is often provided exclusively to infants expected to die. Standards of care support providing PC early after diagnosis with any condition likely to impact quality of life. PURPOSE To determine the state of early PC practice across populations to derive elements of early PC applicable to neonates and their families and demonstrate their application in practice. SEARCH STRATEGY Multiple literature searches were conducted from 2016 to 2019. Common keywords used were: palliative care; early PC; end of life, neonate; NICU; perinatal PC; pediatric PC; family-centered care; advanced care planning; palliative care consultant; and shared decision-making. FINDINGS Early PC is an emerging practice in adult, pediatric, and perinatal populations that has been shown to be helpful for and recommended by families. Three key elements of early PC in the NICU are shared decision-making, care planning, and coping with distress. A hypothetical case of a 24-week infant is presented to illustrate how findings may be applied. Evidence supports expansion of neonatal PC to include infants and families without terminal diagnoses and initiation earlier in care. IMPLICATIONS FOR PRACTICE Involving parents more fully in care planning activities and decision-making and providing structured support for them to cope with distress despite their child's prognosis are essential to early PC. IMPLICATIONS FOR RESEARCH As early PC is incorporated into practice, strategies should be evaluated for feasibility and efficacy to improve parental and neonatal outcomes. Researchers should consider engaging NICU parent stakeholders in leading early PC program development and research.
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23
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Soltys F, Philpott-Streiff SE, Fuzzell L, Politi MC. The importance of shared decision-making in the neonatal intensive care unit. J Perinatol 2020; 40:504-509. [PMID: 31570796 DOI: 10.1038/s41372-019-0507-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/06/2019] [Accepted: 09/17/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Neonatal intensive care unit (NICU) admissions are common and rising. Parents with infants in the NICU face difficult decisions about their infants' care. Few studies have investigated parents' engagement in NICU decisions and its effects on decision regret. STUDY DESIGN We surveyed parents of children who had a NICU stay in the past 3 years. We explored whether sociodemographic characteristics affected preferred decision involvement, shared decision-making with NICU clinicians, or decision regret. Multivariable linear regression analyses examined the relationship between shared decision-making and decision regret. RESULTS Most parents preferred an active (212/405, 52.3%) or shared (139/405, 34.3%) approach to decision-making. No sociodemographic characteristics related to preferred decision involvement or shared decision-making (p's > 0.05). In multivariable analyses, shared decision-making, education and health literacy related to less decision regret (p's < 0.05). CONCLUSIONS These data suggest the importance of shared decision-making during NICU stays. Studies should identify ways to support parents through NICU decision-making.
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Affiliation(s)
- Frank Soltys
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis and St. Louis Children's Hospital, St. Louis, MO, USA.
| | - Sydney E Philpott-Streiff
- Division of Public Health Science, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Lindsay Fuzzell
- Division of Public Health Science, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Mary C Politi
- Division of Public Health Science, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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24
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Neu M, Klawetter S, Greenfield JC, Roybal K, Scott JL, Hwang SS. Mothers' Experiences in the NICU Before Family-Centered Care and in NICUs Where It Is the Standard of Care. Adv Neonatal Care 2020; 20:68-79. [PMID: 31567314 PMCID: PMC10029125 DOI: 10.1097/anc.0000000000000671] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Family-centered care (FCC) in neonatal intensive care units (NICUs) was initiated in 1992 to promote a respectful response to individual family needs and support parental participation in care and decision-making for their infants. Although benefits of FCC have been reported, changes in the maternal experience in the NICU are unknown. PURPOSE The purpose of this study was to compare mothers' experiences in NICUs where FCC is the standard of care and to compare these with the experiences of mothers 2 decades ago. METHODS In this qualitative descriptive design, mothers of infants born under 32 weeks postconceptional age were asked to describe their experiences with their infant's birth and hospitalization. Open-ended probing questions clarified maternal responses. Saturation was reached after 14 interviews. Iterative coding and thematic grouping was used for analysis. RESULTS Common themes that emerged were: (1) visiting; (2) general caregiving; (3) holding; (4) feeding; and (5) maternal ideas for improvement. Findings indicated important improvements in privacy, mother-nurse relationship, ease of visiting, and maternal knowledge and participation in infant caregiving. IMPLICATIONS FOR PRACTICE Mothers suggested improvements such as additional comforts in private rooms, areas in the NICU where they can meet other mothers, and early information on back-transport. Better recognition and response for mothers without adequate social support would provide much needed emotional assistance. IMPLICATIONS FOR RESEARCH Future research addressing benefits of webcams, wireless monitors, back-transport, maternity leave, and accommodations for extended visiting for siblings would address other needs mentioned by mothers.
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Affiliation(s)
- Madalynn Neu
- College of Nursing, University of Colorado, and Children's Hospital Colorado, Aurora (Dr Neu); Portland State University, Oregon (Dr Klawetter); University of Denver, Colorado (Dr Greenfield and Ms Roybal); Department of Pediatrics/Neonatology, University of Colorado, Aurora (Ms Scott and Dr Hwang); and Children's Hospital Colorado, Aurora (Dr Hwang)
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25
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Cummings BM, Mercurio MR, Paris JJ. A review of approaches for resolving disputes between physicians and families on end-of-life care for newborns. J Perinatol 2020; 40:1441-1445. [PMID: 32393828 PMCID: PMC7223960 DOI: 10.1038/s41372-020-0675-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/27/2020] [Accepted: 04/24/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Brian M. Cummings
- grid.32224.350000 0004 0386 9924Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 USA
| | - Mark R. Mercurio
- grid.47100.320000000419368710Yale School of Medicine, New Haven, CT 06504 USA
| | - John J. Paris
- grid.208226.c0000 0004 0444 7053Boston College, Chestnut Hill, MA 02167 USA ,grid.262952.80000 0001 0699 5924Present Address: St. Joseph’s University, Philadelphia, PA USA
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Fayed N, Guttmann A, Chiu A, Gardecki M, Orkin J, Hamid JS, Major N, Lim A, Cohen E. Family-provider consensus outcomes for children with medical complexity. Dev Med Child Neurol 2019; 61:1093-1100. [PMID: 30536803 DOI: 10.1111/dmcn.14110] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2018] [Indexed: 12/13/2022]
Abstract
AIM To describe the process of obtaining consensus of outcome priorities between families of children with medical complexity (CMC) and their healthcare providers (HCPs) for the purpose of evaluating changes to service delivery. METHOD The consensus of outcomes involved surveying families of CMC and HCPs and an in-person consensus meeting. Priorities were obtained from the survey using a stratified ranking approach ensuring equal representation among unequally sized subgroups. An in-person meeting was held using the survey results to inform Delphi voting. RESULTS Families of CMC (n=40) and HCPs (n=74) responded to the survey. Consensus generated three main target areas (child health, family health, experience of care) covered by 15 specific outcomes needed to evaluate care. Differences between family and HCP perceptions of importance were found for child self-care, play, social skills, and recreation as well as emotional health (for both parent and child) outcomes. INTERPRETATION Families of CMC and HCPs identified common priorities for outcome evaluation of CMC initiatives. Outcomes that differ in importance between families of CMC and HCPs should be studied further. WHAT THIS PAPER ADDS Families of children with medical complexity and their providers can reach consensus on important outcomes. Stratifying subgroups ensures diverse representation, which is important to outcome prioritization.
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Affiliation(s)
- Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Astrid Guttmann
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Allison Chiu
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Meghan Gardecki
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Julia Orkin
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Jemila S Hamid
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nathalie Major
- Department of Paediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Audrey Lim
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.,McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Eyal Cohen
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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27
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Klawetter S, Greenfield JC, Speer SR, Brown K, Hwang SS. An integrative review: maternal engagement in the neonatal intensive care unit and health outcomes for U.S.-born preterm infants and their parents. AIMS Public Health 2019; 6:160-183. [PMID: 31297402 PMCID: PMC6606523 DOI: 10.3934/publichealth.2019.2.160] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/21/2019] [Indexed: 11/18/2022] Open
Abstract
Hospitals and perinatal organizations recognize the importance of family engagement in the neonatal intensive care unit (NICU). The Agency for Healthcare Research and Quality (AHRQ) defines family engagement as "A set of behaviors by patients, family members, and health professionals and a set of organizational policies and procedures that foster both the inclusion of patients and family members as active members of the health care team and collaborative partnerships with providers and provider organizations." In-unit barriers and facilitators to enhance family engagement are well studied; however, less is known specifically about maternal engagement's influence in the NICU on the health of infants and mothers, particularly within U.S. social and healthcare contexts. In this integrative review, we examine the relationship between maternal engagement in the NICU and preterm infant and maternal health outcomes within the U.S. Results from the 33 articles that met inclusion criteria indicate that maternal engagement in the NICU is associated with infant outcomes, maternal health-behavior outcomes, maternal mental health outcomes, maternal-child bonding outcomes, and breastfeeding outcomes. Skin-to-skin holding is the most studied maternal engagement activity in the U.S. preterm NICU population. Further research is needed to understand what types of engagement are most salient, how they should be measured, and which immediate outcomes are the best predictors of long-term health and well-being.
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Affiliation(s)
| | | | | | - Kyria Brown
- Graduate School of Social Work, University of Denver, Denver, CO USA; School of Public Health, University of Colorado, Aurora, CO, USA
| | - Sunah S Hwang
- School of Medicine, University of Colorado; Department of Pediatrics, Children's Hospital Colorado, Aurora, CO, USA
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28
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Weiss EM, Magnus BE, Coughlin K. Factors associated with decision-making preferences among parents of infants in neonatal intensive care. Acta Paediatr 2019; 108:967-968. [PMID: 30715746 DOI: 10.1111/apa.14735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Elliott Mark Weiss
- Division of Neonatology Department of Pediatrics University of Washington School of Medicine Seattle WA USA
- Treuman Katz Center for Pediatric Bioethics Seattle Children's Hospital & Research Institute Seattle WA USA
| | | | - Katherine Coughlin
- Division of Neonatology Department of Pediatrics The Children's Hospital of Philadelphia Philadelphia PA USA
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29
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Aija A, Toome L, Axelin A, Raiskila S, Lehtonen L. Parents' presence and participation in medical rounds in 11 European neonatal units. Early Hum Dev 2019; 130:10-16. [PMID: 30639968 DOI: 10.1016/j.earlhumdev.2019.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 01/02/2019] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Parents' involvement during hospital care is beneficial for preterm infants and their parents. Although parents are encouraged to be present in many neonatal intensive care units (NICUs), little is known about their role during medical rounds. AIMS To study parents' presence in the NICU, the degree of parents' participation during medical rounds, and to identify underlying factors for participation. STUDY DESIGN AND SUBJECTS A prospective study was performed in 11 neonatal units in six European countries including parents of preterm infants born before 35 gestational weeks. OUTCOME MEASURES Parents' presence and the degree of participation (7-point Likert scale) during medical rounds were asked using a text-message question sent to the mobile phone of each parent separately. RESULTS A total of 241 families were included in the study; mothers responded to 630 and fathers to 474 text-message questions, respectively. In studied units, mothers were present during medical rounds on 62.5% to 91% and fathers 30.8% to 77.8% of the days. The degree of mothers' and fathers' participation also varied between units (p < 0.001 and p = 0.022, respectively). In multivariate analysis, parents' presence increased by increasing gestational age (p = 0.010), fathers' education (p = 0.009), and by the policy in the unit to invite parents to medical rounds (p = 0.036). The background characteristics did not explain the degree of participation. CONCLUSION There is significant variation between neonatal units in how they include parents in medical rounds. Only few background characteristics explained the differences suggesting that unit culture plays a major role in welcoming parents to participate.
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Affiliation(s)
- Anette Aija
- University of Turku, Turku, Finland; Clinic of Paediatrics, Tallinn Children's Hospital, Tallinn, Estonia.
| | - Liis Toome
- Clinic of Paediatrics, Tallinn Children's Hospital, Tallinn, Estonia; Department of Paediatrics, University of Tartu, Tartu, Estonia
| | - Anna Axelin
- Department of Nursing Science, University of Turku, Turku, Finland
| | | | - Liisa Lehtonen
- University of Turku, Turku, Finland; Department of Paediatrics, Turku University Hospital, University of Turku, Turku, Finland
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30
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Weiss EM, Clark JD, Heike CL, Rosenberg AR, Shah SK, Wilfond BS, Opel DJ. Gaps in the Implementation of Shared Decision-making: Illustrative Cases. Pediatrics 2019; 143:peds.2018-3055. [PMID: 30824603 DOI: 10.1542/peds.2018-3055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2018] [Indexed: 11/24/2022] Open
Abstract
Shared decision-making (SDM) has emerged as the preferred decision-making model in the clinician-patient relationship. Through collaboration, SDM helps to facilitate evidence-based medical decisions that are closely aligned with patient or surrogate preferences, values, and goals. How to implement SDM in clinical pediatric practice, however, remains elusive, in part because SDM in pediatrics is complicated by the involvement of parents as a special class of surrogate decision-maker. A provisional framework for the process of SDM in pediatrics was recently proposed by Opel to help facilitate its implementation. To identify aspects of the framework that require refinement, we applied it across a diverse range of clinical cases from multiple pediatric specialties. In doing so, several questions surfaced that deserve further scrutiny: (1) For which medical decisions is consideration of SDM required? (2) What is considered medically reasonable when there is variability in standard practice? (3) Can an option that is not consistent with standard practice still be medically reasonable? (4) How should public health implications be factored into SDM? (5) How should variability in preference sensitivity be approached? (6) How should the developing autonomy of adolescents be integrated into SDM?; and (7) How should SDM address parental decisional burden for emotionally charged decisions? We conduct a brief analysis of each question raised to illustrate key areas for future research.
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Affiliation(s)
- Elliott Mark Weiss
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington; .,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Jonna D Clark
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Carrie L Heike
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Abby R Rosenberg
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Seema K Shah
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
| | - Douglas J Opel
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, Washington.,Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington; and
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31
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Sisk BA, Kang TI, Goldstein R, DuBois JM, Mack JW. Decisional burden among parents of children with cancer. Cancer 2019; 125:1365-1372. [DOI: 10.1002/cncr.31939] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/19/2018] [Accepted: 11/26/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Bryan A. Sisk
- Division of Hematology/Oncology, Department of Pediatrics Washington University School of Medicine St. Louis Missour
| | - Tammy I. Kang
- Section of Pediatric Palliative Care Texas Children’s Hospital Houston Texas
- Department of Pediatrics Baylor College of Medicine Houston Texas
| | - Richard Goldstein
- Division of General Pediatrics, Department of Medicine Boston Children’s Hospital Boston Massachusetts
| | - James M. DuBois
- Department of Medicine Washington University School of Medicine St. Louis Missouri
| | - Jennifer W. Mack
- Pediatric Oncology, Dana‐Farber Cancer Institute Boston Massachusetts
- Division of Population Sciences Dana‐Farber Cancer Institute Boston Massachusetts
- Division of Pediatric Hematology/Oncology Boston Children’s Hospital Boston Massachusetts
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32
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Morrison W, Clark JD, Lewis-Newby M, Kon AA. Titrating Clinician Directiveness in Serious Pediatric Illness. Pediatrics 2018; 142:S178-S186. [PMID: 30385625 DOI: 10.1542/peds.2018-0516i] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 11/24/2022] Open
Abstract
Shared decision-making in pediatrics is based on a trusting partnership between parents, clinicians, and sometimes patients, wherein all stakeholders explore values and weigh options. Within that framework, clinicians often have an obligation to provide guidance. We describe a range of ethically justifiable clinician directiveness that could be appropriate in helping families navigate serious pediatric illness. The presentation of "default" options and informed nondissent as potential strategies are discussed. The degree of clinician directiveness may vary even for decisions that are equally "shared." A myriad of factors affect how directive a clinician can or should be. Some of the most important factors are the degree of prognostic certainty and the family's desire for guidance, but others are important as well, such as the urgency of the decision; the relationship between the clinician, patient, and family; the degree of team consensus; and the burdens and benefits of therapy. Directiveness should be considered an important tool in a clinician's armamentarium and is one that can be used to support families in stressful and emotionally difficult situations.
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Affiliation(s)
- Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Jonna D Clark
- Divisions of Pediatric Critical Care Medicine and Pediatric Bioethics, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Mithya Lewis-Newby
- Divisions of Pediatric Critical Care Medicine and Pediatric Bioethics, University of Washington, Seattle, Washington.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, Washington; and
| | - Alexander A Kon
- Department of Pediatrics, University of California, San Diego, San Diego, California
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