Resilience Rather than Medical Factors: How Parents Predict Quality of Life of Their Sick Newborn

Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills

Severe intracranial hemorrhages are not rare in extremely preterm infants. They occur early, generally when babies require life-sustaining interventions. This may lead to ethical discussions and decision-making about levels of care. Prognosis is variable and depends on the extent, location, and laterality of the lesions, and, importantly also on the subsequent occurrence of other clinical complications or progressive ventricular dilatation. Decision-making should depend on prognosis and parental values. This article will review prognosis and the uncertainty of outcomes for different lesions and provide an outline of ways to conduct an ethically appropriate discussion on the decision of whether to continue life sustaining therapy. It is possible to communicate in a compassionate and honest way with parents and engage in decision-making, focussing on personalized information and decisions, and on function, as opposed to diagnosis.

Effect of Cognitive Behavioral Intervention Combined with the Resilience Model to Decrease Depression and Anxiety Symptoms and Increase the Quality of Life in ESRD Patients Treated with Hemodialysis

The aim of this study was to compare the effect of cognitive behavioral intervention (CBI) combined with the resilience model (CBI + R) vs CBI alone on depression symptoms, anxiety symptoms, and quality of life of end-stage renal disease (ESRD) patients undergoing hemodialysis replacement therapy.

METHOD

Fifty-three subjects were randomly assigned to one of two treatment groups. The control group (n = 25) was provided with treatment strategies based on a cognitive behavioral approach, while the experimental group (n = 28) were given the same techniques plus resilience model strategies. Five psychological instruments were applied: Beck Depression Inventory, Beck Anxiety Inventory, Mexican Resilience Scale, cognitive distortions scale, and the Kidney Disease related Quality of Life questionnaire. Participants were assessed at baseline (before treatment), eight weeks later (end of treatment), and four weeks after the end of treatment (follow up). The results were analyzed by ANOVA for repeated measures with a Bonferroni-adjusted test method, with p < 0.05 considered significant.

RESULTS

The experimental group had significant differences in total and somatic depression as well as differences in the dimensions of cognitive distortions and a significant increase in the dimensions of resilience. The control group had significant differences in all variables but showed lower scores in the evaluated times.

CONCLUSIONS

The resilience model strengthens and enhances the effectiveness of the cognitive behavioral approach to reduce symptoms of depression and anxiety in patients with ESRD.

Parental resilience and psychological distress in the neonatal intensive care unit

OBJECTIVE

To evaluate the associations between parental resilience and psychological distress during the neonatal intensive care unit (NICU) hospitalization.

STUDY DESIGN

Observational cohort study of parents of preterm infants (n = 45) admitted to a NICU between December 2017-October 2019. Data on resilience and psychological distress were collected using validated scales. Regression analysis was used to evaluate associations.

RESULT

One-third of NICU parents screened positive for depression or anxiety. There were no identified sociodemographic factors or parental engagement activities associated with resilience. Parents with higher resilience had lower scores on depression and anxiety screens. However, resilience alone was not a predictor for a positive depression or anxiety screen (aOR 0.93, CI 0.86-1.00; aOR 0.95, CI 0.89-1.02, respectively).

CONCLUSION

Resilience may be associated with lower scores on depression and anxiety screens but is not an independent predictor for a positive screen during the early NICU hospitalization.

Ethical considerations in the management of infants with severe intraventricular hemorrhage

Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.

The association between sense of coherence and quality of life: a cross-sectional study in a sample of patients on hemodialysis

Background

Patients on hemodialysis universally experience detriments in their general quality of life (QOL). Sense of coherence (SOC) is a long-standing factor that affects QOL. Nevertheless, the association between SOC and QOL in patients on hemodialysis was seldom investigated. Our research aims to study this association in a sample of Lebanese adult patients on hemodialysis.

Methods

In this cross-sectional study, SOC was measured using the short version of the “Orientation of Life" scale (SOC-13). QOL was assessed using the Kidney Disease Quality of Life- Short Form (KDQOL-SF). The association between SOC and QOL and its submodalities was first explored using Pearson Correlation and multivariate linear regression analyses, controlling for sociodemographic variables and medical variables.

Results

157 patients on hemodialysis (mean(SD) age: 62.1(13.81) years; 58.6% males) were included. Mean QOL score was 51.65 and that of SOC was 48.06. SOC was strongly corrected with the total QOL (r = 0.832; p value < 0.001), as well as its physical functioning (r = 0.767; p value < 0.001), emotional functioning (r = 0.757; p value < 0.001), cognitive functioning (r = 0.740; p value < 0.001), and social functioning (r = 0.773; p value < 0.001) submodailties. SOC was moderately correlated with professional functioning submodality of QOL (r = 0.618; p value < 0.001), but not correlated with the satisfaction with the quality of care (r = 0.052; p = 0.520). Within the regression models accounting for sociodemographic and medical variables, SOC was significantly associated with the total QOL (unstandardized B = 0.803; 95% CI 0.714, 0.893), physical functioning (unstandardized B = 0.761; standardized B = 0.763; 95% CI 0.661, 0.861), emotional functioning (unstandardized B = 1.205; standardized B = 0.757; 95% CI 1.037, 1.372), professional functioning (unstandardized B = 1.142; standardized B = 0.498; 95% CI 0.843, 1.442), cognitive functioning (unstandardized B = 1.239; standardized B = 0.739; 95% CI 1.058, 1.420), and social functioning (unstandardized B = 0.912; standardized B = 0.768; 95% CI 0.790, 1.034).

Conclusions

In a sample of adult patients on hemodialysis, SOC was positively significantly associated with QOL and its submodalities, expect the satisfaction with the quality of care. The confirmation of the general hypothesis that relates the SOC with the QOL encourages more salutogenic research among this patient population.

Community, Hope, and Resilience: Parental Perspectives on Peer Support in Neonatology

OBJECTIVES

To describe the perspective of parents who participated in peer-to-peer support meetings with parents of children in a neonatal intensive care unit (NICU) and veteran resource parents with previous NICU experience.

STUDY DESIGN

During a longitudinal evaluation in a tertiary care NICU, participating parents were asked to evaluate meetings; with open-ended questions, they were asked about their perspectives. Results were analyzed using mixed methods.

RESULTS

Forty-five NICU parents participated over a 10-week study period. They were followed longitudinally after attending at least 1 of the 10 meetings offered; 95% of parents (43 of 45) reported that the meeting was useful to them and gave an overall evaluation of 8.7 out of 10 (average). For each meeting, all the subjects on the checklist of the moderators (veteran resource parents) were discussed with new parents. When describing why and how the meetings were useful to them in their answers to open-ended questions, NICU parents reported 3 major themes: (1) decreasing isolation and being a community (73%), (2) hope and resilience (63%), and (3) getting practical "parent" information (32%). Sharing stories with parents who also had experienced loss, sadness, and grief, NICU parents trusted that it was possible to adapt and thrive. The meetings normalized parents' emotions (92%), decreased negative emotions (eg, anger, sadness, guilt), empowered them in their parental role, and helped them communicate with loved ones and providers.

CONCLUSIONS

Peer support meetings are a unique and useful means to support parents. Future investigations will investigate whether and how this type of intervention can improve clinical outcomes.

Psychiatric Symptoms, Posttraumatic Growth, and Life Satisfaction Among Parents of Seriously Ill Infants: A Prospective Case-Controlled Study

We evaluated psychiatric symptoms, posttraumatic growth, and life satisfaction among the parents (n = 34) of newborns (n = 17) requiring therapeutic hypothermia or urgent surgery (interest group). Our control group included 60 parents of healthy newborns (n = 30). The first surveys were completed soon after diagnosis or delivery and the follow-up surveys 1 year later (participation rate 88% in the interest group and 70% in the control group). General stress was common in both groups but was more prevalent in the interest group as were depressive symptoms, too. Anxiety was more common in the interest group, although it showed a decrease from the baseline in both groups. Life satisfaction had an inverse correlation with all measures of psychiatric symptoms, and it was lower in the interest group in the early stage, but similar at 12 months due to the slight decline in the control group. Mothers in the interest group had more anxiety and depressive symptoms than fathers in the early stage. Mothers had more traumatic distress than fathers at both time points. Half of the parents experienced substantial posttraumatic growth at 12 months. In conclusion, the serious illness of an infant substantially affects the well-being of the parents in the early stages of illness and one year after the illness.

Ethical considerations in the care of encephalopathic neonates treated with therapeutic hypothermia

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.

Parental protective factors and stress in NICU mothers and fathers

OBJECTIVE

Evaluate the effect of parental protective factors on parental stress at time of NICU admission and prior to discharge.

STUDY DESIGN

Parents of infants born at <35 weeks gestation were approached at a single level III NICU. Consenting parents completed a questionnaire on admission and prior to infant's discharge of demographic information and three validated instruments: (1) parental stress (PSS:NICU), (2) Parents' Assessment of Protective Factors (PAPF), and (3) health literacy (PHLAT-8).

RESULTS

Mean PSS:NICU Total score was 2.8 ± 0.9 (Time 1) and 2.6 ± 1.1 (Time 2). Mean PAPF scores in all subcategories were high (means >3, ±0.3-0.5) (Time 1, Time 2). There was no clinically significant association between PSS:NICU scores and PAPF or any of the other measured variables.

CONCLUSION

PAPF and other commonly implicated factors were not associated with perceived self-reported parental stress at time of NICU admission and prior to discharge.

Conventional revolution: the ethical implications of the natural progress of neonatal intensive care to artificial wombs

Research teams have used extra-uterine systems (Biobags) to support premature fetal lambs and to bring them to maturation in a way not previously possible. The researchers have called attention to possible implications of these systems for sustaining premature human fetuses in a similar way. Some commentators have pointed out that perfecting these systems for human fetuses might alter a standard expectation in abortion practices: that the termination of a pregnancy also (inevitably) entails the death of the fetus. With Biobags, it might be possible, some argue, that no woman has the right to expect that outcome if the technology is able to sustain fetal life after an abortion. In order to protect the expectation that the termination of a pregnancy always entails the death of the fetus, Elizabeth Romanis has argued that fetuses sustained in Biobags have a status different than otherwise 'born' children. In support of that view, she argues that these 'gestatelings' are incapable of independent life. This argument involves a misunderstanding of the gestational support involved, as well as a misapprehension of neonatology practice. Here, we argue that any human fetus sustained in a Biobag would be as 'independent' as any other premature infant, and just as 'born'. Neonatologists would seem to have certain presumptive moral responsibilities toward any human fetus gestating in a Biobag. It remains a separate question whether the perfection and widespread application of Biobags for premature human beings would or should alter the expectation that ending a pregnancy also entails fetal death.

A Prospective Study of Parent Health-Related Quality of Life before and after Discharge from the Neonatal Intensive Care Unit

OBJECTIVE

To determine how infant illness and parent demographics are associated with parent health-related quality of life (HRQL) during and 3 months after hospitalization in the neonatal intensive care unit (NICU). We hypothesized that parents of extremely preterm infants would report lower NICU HRQL than other parents, and that all parents would report improved HRQL after discharge.

STUDY DESIGN

This prospective study of parent-infant dyads admitted to a level IV NICU for ≥14 days from 2016 to 2017 measured parent HRQL before and 3 months after discharge using the Pediatric Quality of Life Inventory Family Impact Module. Multivariable regression was used to identify risk factors associated with HRQL differences during hospitalization and after discharge.

RESULTS

Of the 194 dyads, 167 (86%) completed the study (24% extremely preterm; 53% moderate to late preterm; 22% term). During the NICU hospitalization, parents of extremely preterm infants reported lower adjusted HRQL (-7 points; P = .013) than other parents. After discharge, parents of extremely preterm infants reported higher HRQL compared with their NICU score (+10 points; P = .001). Tracheostomy (-13; P = .006), home oxygen (-6; P = .022), and readmission (-5; P = .037) were associated with lower parent HRQL 3 months after discharge, adjusted for NICU HRQL score.

CONCLUSIONS

Parents of extremely preterm infants experienced a greater negative impact on HRQL during the NICU hospitalization and more improvement after discharge than parents of other infants hospitalized in the NICU. Complex home care was associated with lower parent HRQL after discharge. The potential benefit of home discharge should be balanced against the potential negative impact of complex home care.

From congenial paralysis to post-early brain injury developmental condition: Where does cerebral palsy actually stand?

Cerebral palsy (CP), an umbrella term for a developmental motor disorder caused by early brain injury (EBI)/interference, remains debated. In this essay, we present a narrative, beginning with the original anatomical-clinical description of the so-called paralysie congéniale (congenial paralysis) by the French psychiatrist Jean-Baptiste Cazauvieilh. We then discuss how the concept has evolved over the last 2 centuries. We aim to illustrate these ideas with the biopsychosocial model of health, especially in light of the current neuroscientific and sociological knowledge of human development. We endeavour to integrate 3 connected but distinct entities: (1) the EBI as a seminal turning point of the individual's story; (2) the clinical findings we call CP, when motor impairment and activity limitation related to post-EBI (or other early non-progressive brain interference) appears, and; (3) a post-EBI developmental condition that encompasses the overall consequences of an EBI. This framework should guide individual, familial and collective care discussions and research strategies beyond the scope of CP.

The complexity of physicians' understanding and management of prognostic uncertainty in neonatal hypoxic-ischemic encephalopathy

OBJECTIVE

Prognosis of Hypoxic-Ischemic Encephalopathy (HIE) remains challenging and uncertain. This paper investigates how physicians understand and address the ethical challenges of prognostic uncertainty in the case of neonatal HIE, contextualized within the social science literature.

STUDY DESIGN

Semi-structured interviews were conducted with 12 Canadian neurologists and neonatologists, addressing their perspectives and clinical experiences concerning neonatal HIE prognostication. Interviews were analyzed using thematic content analysis.

RESULTS

Participants unanimously recognized uncertainty in their prognostication. They identified several sources contributing to uncertainty in HIE prognostication, including etiology and underlying pathophysiologic mechanisms, statistical limitations, variable clinical data, the dynamic process of neurodevelopment, or the impact of hypothermia treatment. Unlike in some other literature, some physicians in this study talked about ways to render uncertainty explicit rather than hide it.

CONCLUSION

Results from this study support the call for recognition of the ubiquitous uncertainty surrounding this act in medical education and training.