Neurologic uncertainty in newborn intensive care

Emerging trends and patterns of self-reported morbidity in India: Evidence from three rounds of national sample survey

BACKGROUND

India is rapidly undergoing an epidemiological transition with a sudden change in the disease profile of its population. It is important to understand the changing nature of the burden of disease across the states of India for adequate policy intervention.

METHODS

We analyzed the trend and pattern of self-reported morbidity across states of India using three rounds of (52nd, 60th and 71st) National Sample Survey Organization (NSSO) data. Descriptive analysis was carried out to understand the prevalence of self-reported morbidity variation over a period of two decades (1995-2014) and multivariate analysis was performed to identify the significant determinants of various types of self-reported morbidities.

RESULTS

The results indicated an increasing trend of infectious disease, Cardio Vascular Diseases (CVDs) and Non-Communicable Diseases (NCDs) over the last two decades (1995-2014). CVDs increased by a whopping eight-fold and the NCDs increased by three times during this period. A higher prevalence of self-reported morbidity was observed among the elderly and female, particularly in the urban locality. The growing incidence of CVDs and NCDs, especially among the elderly were reported from Kerala, Tamil Nadu, Punjab and West Bengal.

CONCLUSIONS

The already constrained public health system in India is likely to face serious challenges with a double burden of communicable and non-communicable diseases. An effective and responsive public health system needs to be in place to make health care services available for NCDs and CVDs at the primary level. In order to ameliorate caregiving, the involvement of family will be critical. Informing the people inculcate healthy habits may be an effective health promotion measure.

Integrating neurocritical care approaches into neonatology: should all infants be treated equitably?

To improve the neurologic outcomes for infants with brain injury, neonatal providers are increasingly implementing neurocritical care approaches into clinical practice. Term infants with brain injury have been principal beneficiaries of neurologically-integrated care models to date, as evidenced by the widespread adoption of therapeutic hypothermia protocols for hypoxic-ischemic encephalopathy. Innovative therapeutic and diagnostic support for very low birth weight infants with brain injury has lagged behind. Given that concern for significant future neurodevelopmental impairment can lead to decisions to withdraw life supportive care at any gestational age, providing families with accurate prognostic information is essential for all infants. Current variable application of multidisciplinary neurocritical care approaches to infants at different gestational ages may be ethically problematic and reflect distinct perceptions of brain injury for infants born extremely premature.

Beyond Baby Doe: does infant transplantation justify euthanasia?

Recent advances in medical technology have made it possible to transplant organs into infants with severe heart and kidney disease, but the need for these organs exceeds the presently available supply. Some have suggested that infants born with the severe neurological defect of anencephaly might be used as organ donors, even if these infants do not meet the criteria for brain death. Current criteria for brain death are reviewed and it is concluded that this proposal represents active euthanasia or medical killing of infants with anencephaly. Justification of active euthanasia is discussed in medical, ethical, and historical terms. Recently developed protocols to obtain organs for transplantation from infants with anencephaly after brain death has been determined are described and their ethical implications are discussed. It is argued that active euthanasia of infants with anencephaly is undesirable and should be prohibited in order to safeguard the rights of all persons with severe neurological disabilities.

Neonatal neurologic prognostication: the asphyxiated term newborn

The pediatric neurologist is often requested to predict the neurologic outcome in an uncertain situation. A common and problematic clinical setting in which this occurs is the asphyxiated term newborn. This report reviews the predictive tools available for prognostication in this situation and formulates a practical paradigm that the authors hope will improve predictive accuracy and lessen uncertainty in this setting.

[Ethical decisions making in neonatal intensive care. Survey among nursing staff in 2 French centers]

A European Concerted Action, Euronic, has been set up to study the attitudes and self-reported practices of the staff working in neonatal intensive care units about parent's information and ethical decisionmaking. This paper presents the results of a preliminary qualitative survey conducted in two French units and including 23 physicians and nurses. The answers indicate that withdrawal of treatments are part of their practices. Parents are never directly involved in the decision-making process. The decision to withdraw life sustaining treatments generate psychological distress among the caregivers. Nurses consider that they are more emotionally involved with the baby and the parents. They express concerns about painful treatments and life-prolonging therapies. Most respondents believe that an ethical committee would be of little help in the decision-making process and that the actual legislation should not be modified as it gives obligation for more in-depth consideration of each case.

Your child is brain dead

One to two per cent of admissions to Paediatric Intensive Care Units eventually fulfil the criteria for brain death, implying the need for very difficult decisions. Brain death is defined as irreversible loss of function of the whole brain. The diagnostic criteria caused a great deal of anxiety but are now the subject of a consensus approach. When the situation can be anticipated it is of immense value for the professional staff to develop a good working relationship with the parents to help and support them through the phase of impending disaster and facing the issue when the time actually comes. However, it is vital to help parents to make their own decision regarding continuation or otherwise of life support and they should be supported in whichever decision they take. They must be absolutely convinced that the child is brain dead and this territory may have to be covered again and again in discussion, questions must be answered factually, and time allowed for reflection. Stage management of the process of 'switching off' is vital and the parents' wishes may vary widely from one family to another. They must be warned what is likely to happen and provided with appropriate privacy and support for expression of their grief. The question of asking for post-mortem permission has to be handled sensitively and long-term support for the parents must be offered. Education of undergraduate and postgraduate doctors in this area is now receiving more attention with skills being increased by video teaching and role play. It should not be overlooked that the professional staff attending such patients sometimes require counselling and support themselves.

Forgoing medically provided nutrition and hydration in pediatric patients

Discussion of the ethics of forgoing medically provided nutrition and hydration tends to focus on adults rather than infants and children. Many appellate court decisions address the legal propriety of forgoing medically provided nutritional support of adults, but only a few have ruled on pediatric cases that pose the same issue.

The cessation of nutritional support is implemented most commonly for patients in apermanent vegetative state(often referred to aspersistent vegetative state(hereinafter “PVS”)). An estimated 4,000 to 10,000 American children are in the permanent vegetative state, compared to 10,000 to 25,000 adults. Yet the dearth of literature, case reports, and court decisions suggests that physicians and families of pediatric patients stop medically provided nutrition or seek court orders much less frequently.

Medical aspects of the persistent vegetative state (1)

This consensus statement of the Multi-Society Task Force summarizes current knowledge of the medical aspects of the persistent vegetative state in adults and children. The vegetative state is a clinical condition of complete unawareness of the self and the environment, accompanied by sleep-wake cycles, with either complete or partial preservation of hypothalamic and brain-stem autonomic functions. In addition, patients in a vegetative state show no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli; show no evidence of language comprehension or expression; have bowel and bladder incontinence; and have variably preserved cranial-nerve and spinal reflexes. We define persistent vegetative state as a vegetative state present one month after acute traumatic or nontraumatic brain injury or lasting for at least one month in patients with degenerative or metabolic disorders or developmental malformations. The clinical course and outcome of a persistent vegetative state depend on its cause. Three categories of disorder can cause such a state: acute traumatic and non-traumatic brain injuries; degenerative and metabolic brain disorders, and severe congenital malformations of the nervous system. Recovery of consciousness from a posttraumatic persistent vegetative state is unlikely after 12 months in adults and children. Recovery from a nontraumatic persistent vegetative state after three months is exceedingly rare in both adults and children. Patients with degenerative or metabolic disorders or congenital malformations who remain in a persistent vegetative state for several months are unlikely to recover consciousness. The life span of adults and children in such a state is substantially reduced. For most such patients, life expectancy ranges from 2 to 5 years; survival beyond 10 years is unusual.

PET of infant in persistent vegetative state

This is the first report of cranial positron emission tomography findings of an infant in a persistent vegetative state. Serial positron emission tomography/2-deoxy-2[18F]fluoro-D-glucose studies demonstrated persistent global reduction of cerebral glucose metabolism, results similar to those found in adults in persistent vegetative states. Positron emission tomography may be useful in confirming this clinical diagnosis in infants.

The ethics of cardiopulmonary resuscitation. II. Medical logistics and the potential for good response

Mismatches between provision of paediatric cardiopulmonary resuscitation (CPR) and potential to benefit are examined. Deficiencies are most likely to occur in peripheral maternity units but futile CPR is more common in emergency departments where the child is unknown. Decision making in individual cases is best retained by the medical profession for the sake of the child and family. American style intervention by the legislature is likely to dissipate scarce resources and perhaps harm infants not capable of benefiting.

Spinning the wheels: a CAPS survey of ethical issues in pediatric surgery

To evaluate decision-making factors of pediatric surgeons when faced with ethical dilemmas in a clinical setting, questionnaires were mailed to members of the Canadian Association of Paediatric Surgeons. The surgeons were asked to respond to scenarios regarding ethical dilemmas in the treatment of children. Fifty-one responses (57%) were computer analyzed based on chosen responses to the clinical dilemma and demographic factors such as age, sex, marital status, country of citizenship, religion, and "religiousness," a determination of religious conviction as viewed by the respondent. In addition, ethical convictions were sought regarding abortion, fetal research, AIDS, HIV testing, denial of medical care due to religious beliefs (Jehovah's Witness), and limitations in health care access for indigents. In general, respondents found it difficult to separate ethical guidelines for determining aggressive treatment--absolute value of life; best interests of the child; parental authority; and ability of the child to engage in social, intellectual, or emotional attachments (quality of life)--in the face of actual patient care issues. In fact, results of this survey indicate that the operating surgeon applies his/her medical knowledge and surgical "experience" to each individual case, incorporating his or her own ethical beliefs (in a respondent's words: "In the operating room, the surgeon must satisfy his own conscience in making decisions") while cognizant of legal guidelines for "standard care" ("Decisions would be based on personal experience, and what the local society believes to be right").(ABSTRACT TRUNCATED AT 250 WORDS)

Brain-death criteria currently used by pediatric intensivists

A survey was done to identify how pediatric intensivists determine brain death in children. Forty-nine pediatric intensive-care units (PICUs) were surveyed. The questionnaire explored the following areas: 1) clinical and confirmatory studies performed, 2) types of physicians involved, and 3) reevaluation intervals. Thirty-four centers responded to the questionnaire. Sixty-nine percent were children's hospitals, and 94% were university affiliates. The mean number of PICU beds was 17, with a mean admission rate of 890 patients per year, and the mean mortality rate for these units was 6%. There was general agreement on the sufficiency of clinical examination to determine cortical and brain-stem function. All the pediatric intensivists noted that a positive apnea test, absent cephalic reflexes, fixed and dilated pupils, and no motor response to pain were reliable signs of brain death. Radionuclide cerebral-flow scan and EEG were the confirmatory tests routinely used. Most physicians (77%) felt a second clinical examination was required within 12 to 24 hours. The opinion of more than one physician, one of whom was a neurospecialist, was required in 80% of the surveyed institutions.

[Diagnosis of brain death in the newborn and the child]

The purpose of this article was to sum up the problems raised by diagnosis of brain death in the child through a review of the literature. The clinical and paraclinical criteria of the diagnosis are considered in terms of the respective value and complementarity of different examinations. The fact that organ removal has become increasingly frequent in the child requires a rapid and reliable determination of the irreversibility of brain damage. The guidelines set up after conferences in which American authors participated to reach a consensus opinion relate to the child's age, the etiology, of the coma and the results of various paraclinical examinations. The diagnostic value of these examinations is assessed and the limitations of the various approaches are considered, particularly as regards certain etiologies in the newborn. It is suggested that it would be useful to inquire into the different diagnostic means used in France with respect to this difficult problem. Finally, the ethical and moral problems raised by some recent practices such as organ removal in anencephalic patients are discussed.

Neocortical death and human death

Proposals to make neocortical death, sometimes called cerebral death, a medical and legal indication of human death are becoming more common. Increased sensitivity to the futility and costs of providing life support for patients long after they could be considered dead guarantees that interest in the proposals will continue for some time. Neocortical death would be an acceptable indication of human death if 1) it is consistent with our concepts of human death, 2) it can be diagnosed with certainty and 3) it is sufficiently understood by the general public to be accepted as public policy.

In this paper the phrase “neocortical death” will refer to permanent loss of consciousness due to the irreversible cessation of whatever chemical and biological functions of the brain are needed to support consciousness. By consciousness is meant “the state of awareness of the self and the environment.”

Neonatologists judge the "Baby Doe" regulations

The federal regulations now in effect governing the treatment of severely handicapped infants--the so-called Baby Doe regulations--are based on the 1984 amendments to the Child Abuse Prevention and Treatment Act; these regulations require that, except under certain specified conditions, all newborns receive maximal life-prolonging treatment. We sent questionnaires to the 1007 members of the Perinatal Pediatrics Section of the American Academy of Pediatrics to determine their views on the Baby Doe regulations and on whether the regulations had affected their practices; 494 of the members (49 percent) responded. Of the respondents, 76 percent believed that the current regulations were not necessary to protect the rights of handicapped infants; 66 percent believed that the regulations interfered with parents' right to determine what course of action was in the best interest of their children; and 60 percent believed that the regulations did not allow adequate consideration of infants' suffering. In responding to the three hypothetical cases of severely handicapped newborns, up to 32 percent of the respondents said that maximal life-prolonging treatment was not in the best interests of the infants described but that the Baby Doe regulations required such treatment. The responding neonatologists' concerns about the current Baby Doe regulations were similar to those expressed by the United States Supreme Court in rejecting an earlier set of Baby Doe regulations. This similarity suggests that the current Baby Doe regulations should be reevaluated.