1
|
Tiao MM, Chang YC, Ou LS, Hung CF, Khwepeya M. An Exploration of Pediatricians' Professional Identities: A Q-Methodology Study. Healthcare (Basel) 2024; 12:144. [PMID: 38255033 PMCID: PMC10815713 DOI: 10.3390/healthcare12020144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
Professional identities may influence a wide range of attitudes, ethical standards, professional commitments and patient safety. This study aimed to explore the important elements that comprise pediatricians' professional identities. A Q-methodology was used to identify the similarities and differences in professional identity. Forty pediatricians were recruited from two tertiary referral hospitals in Taiwan. A list of statements was developed by five attending physicians and three residents. R software was used to analyze the Q-sorts to load the viewpoints and formulate the viewpoint arrays. Additional qualitative data-one-to-one personal interviews-were analyzed. Twenty-eight of forty pediatricians, 11 males and 17 females, with an average age of 39.9 (27-62) years, were associated with four viewpoints. We labeled the four viewpoints identified for professional identity as (1) professional recognition, (2) patient communication, (3) empathy and (4) insight. The professional recognition viewpoint comprised of youngest participants-28-36 years-with the majority as residents (77.8%), while the empathy viewpoint comprised the oldest participants-38-62 years-with all as attending physicians. All participants in the empathy and insight viewpoints were married. This study found professional identity to be a multifaceted concept for pediatricians, especially in the areas of professional recognition, patient communication, empathy and insight into patient care.
Collapse
Affiliation(s)
- Mao-Meng Tiao
- Department of Pediatrics, Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Yu-Che Chang
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
- Chang Gung Medical Education Research Centre, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan;
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan
| | - Liang-Shiou Ou
- Chang Gung Medical Education Research Centre, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan;
| | - Chi-Fa Hung
- Department of Psychology, Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
| | - Madalitso Khwepeya
- Chang Gung Medical Education Research Centre, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan;
| |
Collapse
|
2
|
Lin M, Deming R, Wolfe J, Cummings C. Infant mode of death in the neonatal intensive care unit: A systematic scoping review. J Perinatol 2022; 42:551-568. [PMID: 35058594 DOI: 10.1038/s41372-022-01319-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To characterize literature that describes infant mode of death and to clarify how limitation of life-sustaining treatment (LST) is defined and rationalized. STUDY DESIGN Eligible studies were peer-reviewed, English-language, and included number of infant deaths by mode out of all infant deaths in the NICU and/or delivery room. RESULT 58 included studies were primarily published in the last two decades from North American and European centers. There was variation in rates of infant mode of death by study, with some showing an increase in deaths following limitation of LST over time. Limitation of LST was defined by the intervention withheld/withdrawn, the relationship between the two practices, and prior frameworks. Themes for limiting LST included diagnoses, low predicted survival and/or quality of life, futility, and suffering. CONCLUSION Limitation of LST is a common infant mode of death, although rates, study definitions, and clinical rationale for this practice are variable.
Collapse
Affiliation(s)
- Matthew Lin
- Boston Children's Hospital, Division of Newborn Medicine, Boston, MA, USA.
| | - Rachel Deming
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Boston Children's Hospital, Boston, USA
| | - Joanne Wolfe
- Dana-Farber Cancer Institute, Department of Psychosocial Oncology and Palliative Care and Department of Pediatrics, Boston Children's Hospital, Boston, USA
| | - Christy Cummings
- Boston Children's Hospital, Division of Newborn Medicine, Boston, MA, USA
| |
Collapse
|
3
|
Abstract
This article explores the ethical concept of "the equivalence thesis" (ET), or the idea that withdrawing and withholding life sustaining treatments are morally equivalent practices, within neonatology. We review the historical origins, theory, and clinical rationale behind ET, and provide an analysis of how ET relates to literature that describes neonatal mode of death and healthcare professional and parent attitudes towards end-of-life care. While ET may serve as an ethical tool to optimize resource allocation in theory, its clinical utility is limited given the complexity of end-of-life care decisions.
Collapse
Affiliation(s)
- Matthew Lin
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
| | | | - Christy L Cummings
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA; Center for Bioethics, Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
4
|
Yotani N, Nabetani M, Feudtner C, Honda J, Kizawa Y, Iijima K. Withholding and withdrawal of life-sustaining treatments for neonate in Japan: Are hospital practices associated with physicians' beliefs, practices, or perceived barriers? Early Hum Dev 2020; 141:104931. [PMID: 31810052 DOI: 10.1016/j.earlhumdev.2019.104931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the current status of withholding or withdrawal of life-sustaining interventions (LSI) for neonates in Japan and to identify physician- and institutional-related factors that may affect advance care planning (ACP) practices with parents. STUDY DESIGN A self-reported questionnaire was administered to assess frequency of withholding and withdrawing intensive care at the respondent's facility, the physician's degree of affirming various beliefs about end-of-life care that was compared to 7 European countries, their self-reported ACP practices and perceived barriers to ACP. Three neonatologists at all 298 facilities accredited by the Japan Society for Neonatal Health and Development were surveyed, with 572 neonatologists at 217 facilities responding. RESULTS At 76% of facilities, withdrawing intensive care treatments was "never" done, while withholding intensive care had been done "sometimes" or more frequently at 82% of facilities. Japanese neonatologists differed from European neonatologists regarding their degree of affirmation of 3 out of 7 queried beliefs about end-of-life care. In hospitals that were more likely to "sometimes" (or more often) withdraw treatments, respondents were less likely to affirm beliefs about doing "everything possible" or providing the "maximum of intensive care". Self-reported ACP practices did not vary between neonatologists based on their hospital's overall pattern of withholding or withdrawing treatments. CONCLUSION Among NICU facilities in Japan, 21% had been sometimes withdrawing LSI and 82% had been "sometimes" withholding LSI. Institutional treatment practices may have a strong association with physicians' beliefs that then affect end-of-life discussions, but not with self-reported ACP practices.
Collapse
Affiliation(s)
- Nobuyuki Yotani
- Department of Palliative Medicine, National Centre for Child Health and Development, Tokyo, Japan.
| | | | - Chris Feudtner
- Department Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Junko Honda
- College of Nursing Art and Science, University of Hyogo, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| |
Collapse
|
5
|
Lam V, Kain N, Joynt C, van Manen MA. A descriptive report of end-of-life care practices occurring in two neonatal intensive care units. Palliat Med 2016; 30:971-978. [PMID: 26934947 DOI: 10.1177/0269216316634246] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND In Canada and other developed countries, the majority of neonatal deaths occur in tertiary neonatal intensive care units. Most deaths occur following the withdrawal of life-sustaining treatments. AIM To explore neonatal death events and end-of-life care practices in two tertiary neonatal intensive care settings. DESIGN A structured, retrospective, cohort study. SETTING/PARTICIPANTS All infants who died under tertiary neonatal intensive care from January 2009 to December 2013 in a regional Canadian neonatal program. Deaths occurring outside the neonatal intensive care unit in delivery rooms, hospital wards, or family homes were not included. Overall, 227 infant deaths were identified. RESULTS The most common reasons for admission included prematurity (53.7%), prematurity with congenital anomaly/syndrome (20.3%), term congenital anomaly (11.5%), and hypoxic ischemic encephalopathy (12.3%). The median age at death was 7 days. Death tended to follow a decision to withdraw life-sustaining treatment with anticipated poor developmental outcome or perceived quality of life, or in the context of a moribund dying infant. Time to death after withdrawal of life-sustaining treatment was uncommonly a protracted event but did vary widely. Most dying infants were held by family members in the neonatal intensive care unit or in a parent room off cardiorespiratory monitors. Analgesic and sedative medications were variably given and not associated with a hastening of death. CONCLUSION Variability exists in end-of-life care practices such as provision of analgesic and sedative medications. Other practices such as discontinuation of cardiorespiratory monitors and use of parent rooms are more uniform. More research is needed to understand variation in neonatal end-of-life care.
Collapse
Affiliation(s)
| | - Nicole Kain
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Chloe Joynt
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Michael A van Manen
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada .,John Dossetor Health Ethics Centre, University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
6
|
Finn D, Collins A, Murphy BP, Dempsey EM. Mode of neonatal death in an Irish maternity centre. Eur J Pediatr 2014; 173:1505-9. [PMID: 24916041 DOI: 10.1007/s00431-014-2356-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 05/27/2014] [Accepted: 05/29/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED Modes of neonatal dying vary among maternity centres, both within and between countries. There have been few reports concerning mode of dying from countries with low rates of termination of pregnancy, such as Ireland. We conducted a retrospective chart review of all neonatal deaths, between January 2010 and January 2013, within a single Irish maternity centre. The mode of dying was classified as one of (1) withholding life-sustaining treatment (LST), (2) withdrawal of LST in moribund infants, (3) withdrawal of LST for quality of life reasons or (4) death despite maximal intensive care treatment. There were a total of 64 deaths during the study period. Congenital abnormalities accounted for 47 % of deaths and prematurity for 41 % of deaths. Withholding LST was the most frequent mode of dying, occurring in 38 % of all deaths. A total of 12 % of neonatal deaths occurred despite maximal intensive care treatment. CONCLUSIONS Congenital abnormalities were the most common cause of neonatal deaths. A high proportion followed LST being withheld, most likely a reflection of the low rates of medical termination in Ireland. Modes of dying in the neonatal period vary between maternity centres with culturally different backgrounds.
Collapse
Affiliation(s)
- Daragh Finn
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland,
| | | | | | | |
Collapse
|
7
|
Saha S, Kent AL. Length of time from extubation to cardiorespiratory death in neonatal intensive care patients and assessment of suitability for organ donation. Arch Dis Child Fetal Neonatal Ed 2014; 99:F59-63. [PMID: 24105623 DOI: 10.1136/archdischild-2013-304704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE A common concern for parents when end of life decisions are made is the length of time their baby may take to die. Postcardiac death organ donation is now becoming more common, along with neonatal organ donation. The aim was to determine the length of time from extubation until cardiorespiratory death (CRD) in neonatal intensive care patients and consideration of potential organ donation. DESIGN Retrospective review of medical records of neonates who died in a neonatal intensive care unit between 2000 and 2009. PATIENTS Data collected included gestation at birth, age at death, birth weight, reason for cessation of intensive care, inotrope and ventilation requirements, sedation and muscle relaxation prior to death, time from extubation to documented CRD. An assessment was made for potential suitability for consideration of organ donation with a gestation at birth ≥ 34 weeks and birth weight >2.0 kg. RESULTS 117 neonates were included, median gestation 29 weeks and median birth weight 1220 grams. The median age at death was 4 days of age. The median time from discussing prognosis to death was 137 min. The median time from extubation to CRD was 30 min. Seven (6%) neonates were considered suitable for organ donation, and for these infants the median time from extubation to CRD was 120 min. Two neonates donated heart valves. CONCLUSIONS This provides a guide for grieving parents on time frames for the interval between extubation and CRD. More accurate postextubation CRD times are required to determine likely potential for postcardiac death organ donation.
Collapse
Affiliation(s)
- S Saha
- Department of Obstetrics and Gynaecology, Canberra Hospital, , Canberra, Australian Capital Territory, Australia
| | | |
Collapse
|
8
|
Fajardo CA, González S, Zambosco G, Cancela MJ, Forero LV, Venegas M, Baquero H, Lemus-Varela L, Kattan J, Wormald F, Sola A, Lantos J. End of life, death and dying in neonatal intensive care units in Latin America. Acta Paediatr 2012; 101:609-13. [PMID: 22536812 DOI: 10.1111/j.1651-2227.2012.02596.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Most analyses of end of life decisions in Neonatal Intensive Care Units (NICUs) have come from Europe/English-speaking countries. Would decisions be different in Latin American NICUs? Therefore, we aim to evaluate the approach to dying infants/families in NICUs in Latin America. METHODS Multinational descriptive study of all deaths in babies born at >22 weeks in eight NICUs in five Latin American countries. Deaths were categorized as: (i) no Cardiopulmonary Resuscitation (CPR) or life support offered; (ii) life support initiated but do not resuscitate (DNR) orders written or no CPR provided; (iii) full life support and CPR; and (iv) unclassifiable. RESULTS There were 100 deaths, 81% in >27 weeks. Seventeen infants received no CPR/life support at birth, 10 died in DR and seven in NICU. There were 27 infants in group 2, 54 in group three and two in group 4. No baby had care withdrawn or care withdrawn/CPR withheld. Thirty-two infants had 'do not resuscitate' order. Decisions without parents' involvement in 15%, both parents present at death 24% and sedatives/narcotics documented 14%. CONCLUSIONS Latin American NICUs differ from those in Northern Europe/English-speaking countries. More deaths are accompanied by full life support and CPR. DNR orders are rare. Withdrawal of life support is virtually non-existent. Latin American's doctors are more likely to make decisions without the objections of family about withholding life-sustaining treatment.
Collapse
|
9
|
Verhagen AAE, Janvier A, Leuthner SR, Andrews B, Lagatta J, Bos AF, Meadow W. Categorizing neonatal deaths: a cross-cultural study in the United States, Canada, and The Netherlands. J Pediatr 2010; 156:33-7. [PMID: 19772968 DOI: 10.1016/j.jpeds.2009.07.019] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 06/02/2009] [Accepted: 07/06/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To clarify the process of end-of-life decision-making in culturally different neonatal intensive care units (NICUs). STUDY DESIGN Review of medical files of newborns >22 weeks gestation who died in the delivery room (DR) or the NICU during 12 months in 4 NICUs (Chicago, Milwaukee, Montreal, and Groningen). We categorized deaths using a 2-by-2 matrix and determined whether mechanical ventilation was withdrawn/withheld and whether the child was dying despite ventilation or physiologically stable but extubated for neurological prognosis. RESULTS Most unstable patients in all units died in their parents' arms after mechanical ventilation was withdrawn. In Milwaukee, Montreal, and Groningen, 4% to 12% of patients died while receiving cardiopulmonary resuscitation. This proportion was higher in Chicago (31%). Elective extubation for quality-of-life reasons never occurred in Chicago and occurred in 19% to 35% of deaths in the other units. The proportion of DR deaths in Milwaukee, Montreal, and Groningen was 16% to 22%. No DR deaths occurred in Chicago. CONCLUSIONS Death in the NICU occurred differently within and between countries. Distinctive end-of-life decisions can be categorized separately by using a model with uniform definitions of withholding/withdrawing mechanical ventilation correlated with the patient's physiological condition. Cross-cultural comparison of end-of-life practice is feasible and important when comparing NICU outcomes.
Collapse
Affiliation(s)
- A A Eduard Verhagen
- Department of Pediatrics, University Medical Center Groningen, Groningen, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
10
|
Miljeteig I, Sayeed SA, Jesani A, Johansson KA, Norheim OF. Impact of ethics and economics on end-of-life decisions in an Indian neonatal unit. Pediatrics 2009; 124:e322-8. [PMID: 19651570 DOI: 10.1542/peds.2008-3227] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of this article was to describe how providers in an Indian NICU reach life-or-death treatment decisions. METHODS Qualitative in-depth interviews, field observations, and document analysis were conducted at an Indian nonprofit private tertiary institution that provided advanced neonatal care under conditions of resource scarcity. RESULTS Compared with American and European units with similar technical capabilities, the unit studied maintained a much higher threshold for treatment initiation and continuation (range: 28-32 completed gestational weeks). We observed that complex, interrelated socioeconomic reasons influenced specific treatment decisions. Providers desired to protect families and avoid a broad range of perceived harms: they were reluctant to risk outcomes with chronic disability; they openly factored scarcity of institutional resources; they were sensitive to local, culturally entrenched intrafamilial dynamics; they placed higher regard for "precious" infants; and they felt relatively powerless to prevent gender discrimination. Formal or regulatory guidelines were either lacking or not controlling. CONCLUSIONS In a tertiary-level academic Indian NICU, multiple factors external to predicted clinical survival of a preterm newborn influence treatment decisions. Providers adjust their decisions about withdrawing or withholding treatment on the basis of pragmatic considerations. Numerous issues related to resource scarcity are relevant, and providers prioritize outcomes that affect stakeholders other than the newborn. These findings may have implications for initiatives that seek to improve global neonatal health.
Collapse
Affiliation(s)
- Ingrid Miljeteig
- Division of Medical Ethics, Department of Public Health and Primary Health Care and Global Health: Ethics, Economics and Culture, Centre for International Health, University of Bergen, Bergen, Norway.
| | | | | | | | | |
Collapse
|
11
|
Verhagen AAE, de Vos M, Dorscheidt JHHM, Engels B, Hubben JH, Sauer PJ. Conflicts about end-of-life decisions in NICUs in the Netherlands. Pediatrics 2009; 124:e112-9. [PMID: 19564256 DOI: 10.1542/peds.2008-1839] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the frequency and background of conflicts about neonatal end-of-life (EoL) decisions. METHODS We reviewed the medical files of 359 newborns who had died during 1 year in the 10 Dutch NICUs and identified 150 deaths that were preceded by an EoL decision on the basis of the child's poor prognosis. The attending neonatologists of 147 of the 150 newborns were interviewed to obtain details about the decision-making process. RESULTS EoL decisions about infants with a poor prognosis were initiated mainly by the physician, who subsequently involved the parents. Conflicts between parents and the medical team occurred in 18 of 147 cases and were mostly about the child's poor neurologic prognosis. Conflicts within the team occurred in 6 of 147 cases and concerned the uncertainty of the prognosis. In the event of conflict, the EoL decision was postponed. Consensus was reached by calling additional meetings, performing additional diagnostic tests, or obtaining a second opinion. The chief causes of conflict encountered by the physicians were religious convictions that forbade withdrawal of life-sustaining treatment and poor communication between the parents and the team. CONCLUSIONS The parents were involved in all EoL decision-making processes, and consensus was ultimately reached in all cases. Conflicts within the team occurred in 4% of the cases and between the team and the parents in 12% of the cases. The conflicts were resolved by postponing the EoL decision until consensus was achieved.
Collapse
Affiliation(s)
- A A Eduard Verhagen
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, Netherlands.
| | | | | | | | | | | |
Collapse
|