A scoping review of parental values during prenatal decisions about treatment options after extremely premature birth

Barriers and facilitators to shared decision making: A qualitative study of families who delivered at the cusp of viability

OBJECTIVES

There is limited data regarding patients' experiences with periviable counseling. Exploring patient perspectives helps us improve provider communication and may aid in supporting high-quality decision-making. Our study explored patient-identified sources of support and conflict during discussions with their healthcare team when delivering during the periviable period with the goal of improving high-quality shared decision making (SDM).

METHODS

We conducted semi-structured interviews of birthing people who delivered between 20 0/7 and 25 6/7 weeks gestational age from 2010 to 2014. Interviews focused on shared decision making at the time of periviable birth with an emphasis on the three-talk model of SDM. Interviews were coded to perform thematic analysis.

RESULTS

We interviewed 20 patients who delivered during the periviable period and 6 important others. Participants valued providers aiding in their emotional processing. Conversely, participants identified lack of clarity during counseling and an emphasis on hopelessness as barriers to SDM.

CONCLUSION(S)

Participants highlighted the importance of using easy-to-understand language and focusing on hope. Finally, families emphasized the importance of explicitly eliciting values that might inform their choice and the positive impact of nursing staff.

PRACTICE IMPLICATIONS

Our findings underscore the importance of using a SDM model for periviability counseling and highlight areas for improvement.

Key factors in parental end-of-life decision making for surgical necrotizing enterocolitis: A Delphi study

BACKGROUND/OBJECTIVES

In severe cases of necrotizing enterocolitis (NEC) in preterm neonates, surgery may be the only option for survival. However, the consequences of active treatment are not always in the infant's best interest, urging parents and physicians to consider palliative care as an alternative. This study aims to identify key factors parents prioritize when making this decision, as a preliminary step towards developing a decision support tool.

METHODS

Three Dutch parent panels (without experience with NEC/preterm birth, with experience but without loss, and with loss due to NEC/preterm birth) were asked to rate 31 literature-based and self-suggested decision factors. Factors were rated on a scale of 1 to 9 in a two-round Delphi study. Factors that reached a median score of six or higher by one or more panels after the second Delphi round were discussed in a consensus meeting of the steering committee.

RESULTS

Sixty-six participants completed both Delphi rounds. Nine factors were excluded after the final round, including parental physical and mental health, finances, and religion. Of the other 22 factors, the steering committee decided upon 15 key factors to serve as a base for the decision support tool. Most important factors included chance of death, short- and long-term physical consequences, and future independence. Additionally, parents were influenced by doctors' opinions and feelings of responsibility and hope.

CONCLUSION

This study highlights fifteen decision factors for Dutch parents facing surgical NEC. These insights will inform the development of a decision support tool aiding parents in making informed end-of-life decisions.

Voices of experience: what Dutch parents teach us about values and intuition in periviable decisions

OBJECTIVE

When extremely premature birth at the limits of viability is imminent, shared decision-making with parents regarding the infant's treatment is widely recommended. Aligning decisions with parental values can be challenging. So, this study aims to get insight into (1) what values parents considered important in their decision, (2) whether their decision was based on intuition and/or rational analysis and (3) parental suggestions on how to help explore and articulate values during prenatal counselling.

DESIGN

A qualitative study was performed among Dutch parents who experienced (imminent) extremely premature birth. Diversity was aimed for through purposive sampling. Semistructured interviews were conducted until saturation was achieved. Transcripts were coded and themes were derived from the data.

RESULTS

Nineteen interviews were performed. Results show what parents considered important in their decision, such as the infants' future, family life and 'giving a chance'. Most parents made their decision more intuitively rather than rationally, for others both coexisted. Particularly fathers and parents who opted for palliative comfort care experienced the decision as rational. Parents would have liked to explore values, but found it challenging. They suggested strategies and conditions to help explore and articulate their values during counselling, such as a multidisciplinary approach.

CONCLUSIONS

Various considerations and underlying values were found to be important. Parents recognise the influence of emotions and intuition in decision-making and struggle to articulate their values, emphasising the need for guidance. Healthcare providers should engage in open, personalised discussions to facilitate value exploration, enabling informed decisions aligned with parental values.

Evaluating decision regret after extremely preterm birth

OBJECTIVES

Little is known about decision regret following extremely premature birth. We assessed decision regret in women who delivered an extremely premature infant, comparing decision regret scores based on resuscitation decision.

METHODS

Electronic survey assessment of decision regret using a validated tool included women who delivered at 22-25 completed weeks of gestation at two hospitals 2004-2019. Comparison of 'active care', 'comfort care' and 'other' groups was quantified and comments reviewed.

RESULTS

442 of 787 (56%) eligible women were contacted, 242 of 442 (55%) completed surveys, response rate 242 of 787 (31%). Women not contacted were younger (p=0.0001) and/or delivered in an earlier year (p=0.002). There was a higher percentage of white women who completed the survey (p=0.004). Decision regret was elevated in all groups, varied widely, but was lower in 'active care' compared with 'comfort care' (Decision Regret Score 14 vs 39, p<0.0001). Lower decision regret occurred in women who recalled a prenatal consult (p=0.014) or identified as the primary decision-maker compared with women who perceived the doctor had a major role (p=0.02) or made the decision (p<0.0001). Lower decision regret occurred in women whose infant was alive at survey completion compared with women whose infant died in the hospital (p<0.0001) or after discharge (p=0.01).

CONCLUSIONS

Decision regret was elevated in all groups. Women who recalled prenatal consultation, identified as the primary decision-maker, chose intensive care and/or whose infant survived had lower regret scores.

CLINICAL TRIAL REGISTRATION

NCT04074525.

Development of a parent decision support tool for surgical necrotising enterocolitis: a study protocol

INTRODUCTION

Necrotising enterocolitis is a devastating gastrointestinal disease predominantly affecting preterm infants. In 40% of cases, its rapid progression renders conservative treatment insufficient, necessitating laparotomy as the sole viable option for survival. However, high perioperative and postoperative mortality rates, along with severe future potential disabilities and suffering, can complicate the decision of whether surgery is still in the infant's best interest. In such cases, palliative care, aimed to minimise suffering, may be considered as an alternative to laparotomy, especially when the infant's expected quality of life and overall prognosis are concerning. Depending on the sociocultural context, parents are increasingly involved in this decision. However, weighing the risks, benefits and uncertainties can be challenging for them. Therefore, we aim to develop a decision support tool using a novel combination of the Delphi technique and Q-methodology. Ultimately, we anticipate that this approach will contribute to improved family-centred care and optimised outcomes.

METHODS AND ANALYSIS

The first phase of the study aims to identify key factors guiding Dutch parents' decisions between laparotomy and palliative care (decision factors). Using a Delphi process, parents with varying perspectives and experiences will evaluate decision factors found in the literature and those self-suggested. The pertinent set of decision factors is defined during a consensus meeting.During the second phase, parents are asked to compare statements about these decision factors using Q-methodology. A by-person factor analysis of these comparisons will identify different parental decision-making profiles, which allows for formulating advice tailored to those profiles.Ultimately, we will build an online decision support tool which facilitates the classification of parent perspectives. The tool will then provide the parents with the relevant advice. In the last phase of the study, the tool's effectiveness will be evaluated through an online questionnaire, asking parents to imagine using the tool in a real-world scenario.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Central Ethics Review Committee of The University Medical Center Groningen (METc 2023/577, CTc UMCG 153660). Participants will be asked to provide their informed consent for the parts of the study that involve non-anonymous data gathering. Findings will be disseminated through academic journals and conferences. Options for long-term data preservation are under consideration.

Attitudes and values towards decisions at the margin of viability among expectant mothers at risk for preterm birth

AIM

To explore how expectant mothers at risk for preterm birth would like to be involved in decision-making at the margin of viability and what they would base their decisions on.

METHODS

This cross-sectional observational study included a mixed-methods post-hoc analysis alongside a previously reported randomised clinical trial. Expectant mothers between 280/7 and 366/7 weeks' gestation who were hospitalised for risk of preterm birth responded to written case vignettes of an impending preterm birth at the margin of viability. Participants responded to closed and open-ended questions that were theoretically coded for attitudes and values towards shared decision-making.

RESULTS

Sixty-four expectant mothers were included in the analysis, 36 provided written perspectives. Decision-making was perceived as an enormous burden and a potential source of guilt and regret. Weighing personal values in terms of 'fighting for the baby' and 'quality of life' were used to inform the decision-making process. Explicitly stating that any decision is a good decision, empowerment through co-constructing shared decisions rather than simply presenting choices, sharing the clinicians' personal views, and honest, and empathetic counselling were perceived as supportive.

CONCLUSION

Mothers at risk for preterm birth provided specific insights into their decision-making patterns that may be helpful to clinicians.

Perspectives of extremely prematurely born adults on what to consider in prenatal decision-making: a qualitative focus group study

OBJECTIVE

A shared decision-making (SDM) approach is recommended for prenatal decisions at the limit of viability, with a guiding role for parental values. People born extremely premature experience the consequences of the decision made, but information about their perspectives on prenatal decisions is lacking. Therefore, this study aims to describe their perspectives on what is important in decision-making at the limit of viability.

DESIGN

Semi-structured focus group discussions were conducted, recorded and transcribed verbatim. The data were independently analysed by two researchers in Atlas.ti.

RESULTS

Four focus groups were conducted in the Netherlands, with five to six participants each, born between 240/7 and 300/7 weeks gestation in the period between 1965 and 2002. Considering their personal life experiences and how their extremely premature birth affected their families, the participants reflected on decision-making at the limit of viability. Various considerations were discussed and summarised into the following themes: anticipated parental regret, the wish to look at the baby directly after birth, to give the infant a chance at survival, quality of life, long-term outcomes for the infant and the family, and religious or spiritual considerations.

CONCLUSIONS

Insights into the perspectives of adults born extremely premature deepened our understanding of values considered in decision-making at the limit of viability. Results point out the need for a more individualised prediction of the prognosis and more extensive information on the lifelong impact of an extremely premature birth on both the infant and the family. This could help future parents and healthcare professionals in value-laden decision-making.

Increasing Realism and Variety of Virtual Patient Dialogues for Prenatal Counseling Education Through a Novel Application of ChatGPT: Exploratory Observational Study

BACKGROUND

Using virtual patients, facilitated by natural language processing, provides a valuable educational experience for learners. Generating a large, varied sample of realistic and appropriate responses for virtual patients is challenging. Artificial intelligence (AI) programs can be a viable source for these responses, but their utility for this purpose has not been explored.

OBJECTIVE

In this study, we explored the effectiveness of generative AI (ChatGPT) in developing realistic virtual standardized patient dialogues to teach prenatal counseling skills.

METHODS

ChatGPT was prompted to generate a list of common areas of concern and questions that families expecting preterm delivery at 24 weeks gestation might ask during prenatal counseling. ChatGPT was then prompted to generate 2 role-plays with dialogues between a parent expecting a potential preterm delivery at 24 weeks and their counseling physician using each of the example questions. The prompt was repeated for 2 unique role-plays: one parent was characterized as anxious and the other as having low trust in the medical system. Role-play scripts were exported verbatim and independently reviewed by 2 neonatologists with experience in prenatal counseling, using a scale of 1-5 on realism, appropriateness, and utility for virtual standardized patient responses.

RESULTS

ChatGPT generated 7 areas of concern, with 35 example questions used to generate role-plays. The 35 role-play transcripts generated 176 unique parent responses (median 5, IQR 4-6, per role-play) with 268 unique sentences. Expert review identified 117 (65%) of the 176 responses as indicating an emotion, either directly or indirectly. Approximately half (98/176, 56%) of the responses had 2 or more sentences, and half (88/176, 50%) included at least 1 question. More than half (104/176, 58%) of the responses from role-played parent characters described a feeling, such as being scared, worried, or concerned. The role-plays of parents with low trust in the medical system generated many unique sentences (n=50). Most of the sentences in the responses were found to be reasonably realistic (214/268, 80%), appropriate for variable prenatal counseling conversation paths (233/268, 87%), and usable without more than a minimal modification in a virtual patient program (169/268, 63%).

CONCLUSIONS

Generative AI programs, such as ChatGPT, may provide a viable source of training materials to expand virtual patient programs, with careful attention to the concerns and questions of patients and families. Given the potential for unrealistic or inappropriate statements and questions, an expert should review AI chat outputs before deploying them in an educational program.

Opportunities and Challenges of Prognostic Models for Extremely Preterm Infants

Predicting the short- and long-term outcomes of extremely preterm infants remains a challenge. Multivariable prognostic models might be valuable tools for clinicians, parents, and policymakers for providing accurate outcome estimates. In this perspective, we discuss the opportunities and challenges of using prognostic models in extremely preterm infants at population and individual levels. At a population level, these models could support the development of guidelines for decisions about treatment limits and may support policy processes such as benchmarking and resource allocation. At an individual level, these models may enhance prenatal counselling conversations by considering multiple variables and improving transparency about expected outcomes. Furthermore, they may improve consistency in projections shared with parents. For the development of prognostic models, we discuss important considerations such as predictor and outcome measure selection, clinical impact assessment, and generalizability. Lastly, future recommendations for developing and using prognostic models are suggested. Importantly, the purpose of a prognostic model should be clearly defined, and integrating these models into prenatal counselling requires thoughtful consideration.