[Implementing palliative care for newborns in various care settings. Part 3 of "Palliative care in the neonatal period"]

[Palliative care after neonatal intensive care: Contributions of Leonetti Law and remaining challenges]

The 2005 enactment of the "Patients' rights and end-of-life care" act, known as the Leonetti law, has been accompanied by practical changes in the processes of withdrawal and withholding of active life-sustaining treatments. This law has also promoted the implementation of palliative care in perinatal medicine to avoid unreasonable therapeutic interventions and to preserve the dying patient's quality of life and human dignity. Recently, a new law has been voted by the French National Assembly and new reflections on the ethical aspects of the end of life in neonatal medicine should resume again within the French Society of Neonatology in the working group on ethical issues in neonatology. This is why it appears important to discuss the perceived benefits and the persistent difficulties related to the implementation of the Leonetti law in neonatology. Collegiality in the decision-making processes as well as withdrawal and withholding of life-sustaining treatments that were already present in the practices of many centers has been stipulated within a legal framework and promoted in clinical practice. It has brought serenity within perinatal nursing and medical teams. It has helped them face the always-difficult end-of-life situations with parents and deal with decision-making processes in an intense emotional climate. However, new questions inherent to the law have appeared. The most important ones concern the withholding of artificial nutrition and hydration, the time pressure in the management of the decision-making process, and the management of the duration of palliative care. Challenges remain in addressing various persistent ethical dilemmas such as the possible survival of newborns with significant brain lesions detected after the period of life-sustaining treatments that have allowed their survival. The new law carried by Mr. Clayes and Mr. Léonetti should provide answers to some of these ethical issues, but it would probably not solve all of them.

[Palliative care for newborn infants with congenital malformations or genetic abnormalities]

The choice of palliative care can be made today in the perinatal period, as it can be made in children and adults. Palliative care, rather than curative treatment, may be considered in three clinical situations: babies born at the limits of viability, withholding/withdrawing treatments in the NICU, and babies with severe malformations of genetic abnormalities identified during pregnancy. Only the last situation is addressed hereafter. In newborn infants as in older patients, palliative care aims at taking care of the baby and at providing comfort and well-being. The presence of human beings by the newborn infant, most importantly the parents and family, is of utmost importance. The available time should not be used only for care and medical treatments. Sufficient time should be kept for the parents to interact with the baby and for human presence and warmth. The best interests of the newborn infant are the main element for guiding appropriate care. Before birth, the choice of palliative care for newborn infants requires successive steps: (1) establishing a diagnosis of malformation(s) or genetic abnormalities; (2) making a prognosis and ruling out intensive treatments at birth and thereafter; (3) giving the parents appropriate information; (4) assisting the pregnant woman in deciding to continue pregnancy while excluding intensive treatment of the newborn baby; (5) dialoguing with parents about the expected duration of the baby's life and the related uncertainty; (6) planning of palliative care to be implemented at birth; (7) preparing a plan with the parents for discharging the infant from the hospital and for taking care of him over a long time, when it is deemed possible that the baby may live for more than a few days.

[Neonatal palliative care at home: Contribution of the regional pediatric palliative care team]

The "patients' rights and end-of-life care" act, known as the Leonetti law, has allowed implementation of palliative care in neonatology as an alternative to unreasonable therapeutic interventions. A palliative care project can be offered to newborns suffering from intractable diseases. It must be focused on the newborn's quality of life and comfort and on family support. Palliative care for newborns can be provided in the delivery room, in the neonatal unit, and also at home. Going home is possible but requires medical support. Here we describe the potential benefits of the intervention of a regional team of pediatric palliative care for newborns, both in the hospital and at home. Two clinical situations of palliative care at home started in the neonatal period and the neonatal unit are presented. They are completed by a retrospective national survey focusing on the type of support to newborns in palliative care in 2014, which was conducted in 22 French regional pediatric palliative care teams. It shows that 26 newborns benefited from this support at home in 2014. Sixteen infants were born after a pregnancy with a palliative care birth plan and ten entered palliative care after a decision to limit life-sustaining treatments. Twelve of them returned home before the 20th day of life. Sixteen infants died, six of them at home. The regional pediatric palliative care team first receives in-hospital interventions: providing support for ethical reflection in the development of the infant's life project, meeting with the child and its family, helping organize the care pathway to return home. When the child is at home, the regional pediatric palliative care team can support the caregiver involved, provide home visits to continue the clinical monitoring of the infant, and accompany the family. The follow-up of the bereavement and the analysis of the practices with caregivers are also part of its tasks.

La famille face à l’enfant gravement malade : le point de vue du psychologue

La maladie grave atteint profondément et douloureusement l’enfant qui en souffre, mais aussi l’ensemble de sa famille. Celle-ci se retrouve précipitée dans une crise émotionnelle aiguë déclenchée par la menace de perdre l’enfant ainsi que par la remise en question des fantasmes d’immortalité de l’enfant et de l’ensemble des membres de sa famille. Cette situation induit des vécus et des sentiments variés (recherche de sens, sentiment d’échec, angoisse, agressivité, sentiment d’impuissance, de culpabilité, etc.) qui auront un impact inévitable sur l’enfant, sa famille et les relations aux soignants.

Notre expérience de plus de 15 ans en pédiatrie aiguë nous a appris que si la capacité à faire face à la maladie grave de l’enfant varie selon des facteurs personnels (la personnalité, l’âge de l’enfant, le tempérament de chacun), elle dépend aussi du couple parental et du système familial dans ses aspects d’adaptabilité, de communication, de cohésion et de développement.

En passant par la retranscription du discours de quelques familles, nous abordons quelques réactions parentales et familiales face à l’enfant gravement malade, en s’attardant sur certaines situations complexes (bébé malformé, enfant de parents séparés, besoins des parents dont l’enfant est en soins palliatifs) et sur quelques pistes de réflexion autour de leur accompagnement. Nous terminerons en évoquant brièvement la question du deuil et de son suivi.

Perinatal palliative care: barriers and attitudes of neonatologists and nurses in Poland

Objective. To identify barriers and personnel attitudes towards realization of palliative care principles in neonatological units. Study Design. An anonymous questionnaire was posted to all heads of departments and head nurses of all the 27 neonatological units in the Lodz area. Results. We received 46 (85%) questionnaires. Final analysis comprised 42 properly filled-in questionnaires (by 22 doctors and 20 nurses). In case of prenatal diagnosis of a lethal defect, 77.27% of doctors and 65% of nurses opted for informing the mother also about the possibility of pregnancy continuation and organization of palliative care after delivery. Most of respondents accepted conditions for abortion pointed by the Polish law. The most common barriers pointed out by both groups were insufficient knowledge of the personnel on palliative medicine and family preference for life sustaining treatment. Conclusions. Understanding attitudes of personnel towards palliative care and identification of barriers are a starting point for future efforts to improve the system of neonatological care.

[Very preterm births (22-26 WG): from the decision to the implement of palliative care in the delivery room. Experience of Rennes University Hospital (France)]

OBJECTIVES

After the establishment of a palliative care protocol (PC) in the delivery room, study how the postnatal management decision was taken and in particular how PC was developed.

MATERIAL AND METHODS

Retrospective analysis of births between 22 and 25+6 WG, in Rennes University Hospital, during 21 months.

RESULTS

Twenty-seven women meeting the criteria gave birth to 32 live children. Decision making (intensive care or PC) was fast but shared with the parents, mainly on the criterion of the term. The delivery was vaginal for 24 children. Thirteen children were resuscitated. Nineteen children received comfort care, their life was less than 3 hours, 18/19 were supported by their parents.

CONCLUSION

The management of these births is consistent with current recommendations, decisions are individualized but often informally. The secondary prognostic criteria could be better taken into account. Obstetrical and pediatric management is consistent. The PC protocol is fairly well used but the collective decisions should be more formally organized and transcribed more accurately in the records, the requirements for analgesics should be based on clinical assessments.

Rights of the newborn and end-of-life decisions

Advances in perinatal medicine have dramatically improved neonatal survival. End-of-life decision making for newborns with adverse prognosis is an ethical challenge and the ethical issues are controversial. The newborn is a person with specific rights which he cannot claim, due to his physical and mental immaturity. These rights impose to the society obligations and responsibilities, which health professionals and institutions of all countries must enforce. Every newborn has the right to life with dignity. Providing compassionate family-centered end-of-life care to infants and their families in the NICU should be a mandatory component of an optimally neonatal palliative care.

Ethics in neonatology: a look over Europe

Advances in perinatal medicine have dramatically improved neonatal survival. End-of-life decision making for newborns with adverse prognosis is an ethical challenge, the ethical issues are controversial and little evidence exists on attitudes and values in Europe.

OBJECTIVE

to assess the attitudes of the neonatal departments in perinatal clinical practice in the hospitals of European countries.

METHODS

a questionnaire was send to 55 NICUs from 19 European countries.

RESULTS

Forty five (81.8%) NICUs were Level III. Religion was Christian in 90.7% and we observed that in north countries the religion is more influent on clinical decisions (p = 0.032). Gestational age was considered with no significant difference for clinical investment. North countries consider birth weight (p = 0.011) and birth weight plus gestational age (p = 0.024) important for clinical investment. In north countries ethical questions should not prevail when the decision is made (p = 0.049) and from an ethical point of view, there is no difference between withdraw a treatment and do not initiate the treatment (p = 0.029). More hospitals in south countries administer any analgesia (p = 0.007). When the resuscitation is not successful 96.2% provide comfort care.

CONCLUSION

Our study reveals that cultural and religious differences influenced ethical attitudes in NICUs of the European countries.

[Palliative care in delivery room for preterm infants less than 24 weeks of gestation. Analysis of two different behaviors]

AIMS OF THE STUDY

To describe the management of extremely preterm newborns at the threshold of viability before 24 weeks of gestation in the delivery room when the decision has been made not to provide intensive care; to assess the role of palliative care (PC); to report the problems encountered.

METHOD

A prospective qualitative study was conducted using semi-structured interviews from November 2009 to June 2010 in two level III French maternity hospitals (A and B). In each center, four midwives, two obstetricians, two pediatricians, two anesthetists, and one chief midwife were interviewed.

RESULTS

In maternity hospital A, a protocol was in place that proposed PC derived from developmental care (noise limitation, drying, warming) provided by parents or staff. The problems reported were related to former euthanasia practices rather than new procedures. In maternity hospital B, no palliative care protocol had been set up. Euthanasia was practiced and accepted fatalistically because the only currently existing alternative (letting the infant die) was considered inhumane. Few problems were reported. The reluctance to carry out PC is conceptual and organizational (the ratio of births per midwife in maternity hospital B was twice that of maternity hospital A). Lexical analysis showed preferential use of the words "fetus" and "expulsion" versus "child" and "delivery" in maternity hospital B (p<0.05) when speaking of the delivery of the extremely preterm infant. Our explanatory hypothesis is that the concept of "fetus ex utero" legitimates euthanasia by assimilating it to feticide.

CONCLUSION

At the time of this study, two very different approaches to the death of extremely preterm, non-resuscitated newborns in the delivery room coexisted in France. Palliative care is obviously possible, after group reflection, if a true motivation to change, a better understanding of the law, and a clear identification of the respective status of the fetus and the newborn exist in the maternity hospital.