1
|
Ng PC, Fung GPG. Spiritual and cultural influences on end-of-life care and decision-making in NICU. Semin Fetal Neonatal Med 2023; 28:101437. [PMID: 37105859 DOI: 10.1016/j.siny.2023.101437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Understanding and respecting the spiritual beliefs, ethnic roots, cultural norms and customs of individual families is essential for neonatologists to provide clinically appropriate and humane end-of-life care. This review describes the religious/philosophical principles, cultural-related practices/rituals, and traditions in end-of-life care in major spiritual groups of today's multi-cultural, multi-faith societies. The spiritual groups include Christians, Muslims, Jewish Judaism believers and Asian religious/philosophy followers such as Buddhists, Hindus, Taoists, Confucianism devotees and ancestral worshippers. It is vital to understand that substantial variation in views and practices may exist even within the same religion and culture in different geographic locations. Ethical views and cultural practices are not static elements in life but behave in a fluidic and dynamic manner that could change with time. Interestingly, an evolving pattern has been observed in some Asian and Middle East countries that more parents and/or religious groups are beginning to accept a form of redirection of care most compatible with their spiritual belief and culture. Thus, every family must be assessed and counseled individually for end-of-life decision-making. Also, every effort should be made to comply with parents' requests and to treat infants/parents of different religions and cultures with utmost dignity so that they have no regret for their irreversible decisions.
Collapse
Affiliation(s)
- Pak C Ng
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
| | - Genevieve P G Fung
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| |
Collapse
|
2
|
Chevallier M, Barrington KJ, Terrien Church P, Luu TM, Janvier A. Decision-making for extremely preterm infants with severe hemorrhages on head ultrasound: Science, values, and communication skills. Semin Fetal Neonatal Med 2023; 28:101444. [PMID: 37150640 DOI: 10.1016/j.siny.2023.101444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
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.
Collapse
Affiliation(s)
- M Chevallier
- Department of Neonatal Intensive Care Unit, CHU Grenoble, Grenoble, France; TIMC-IMAG Research Department; Grenoble Alps University; Grenoble, France
| | - K J Barrington
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - P Terrien Church
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - T M Luu
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada
| | - A Janvier
- Department of Pediatrics, Université de Montréal, Montréal, Canada; Division of Neonatology, CHU Sainte-Justine Research Center, CHU Sainte-Justine, Montréal, Canada; Centre de Recherche Du CHU Sainte-Justine, Montréal, Québec, Canada; Bureau de L'éthique Clinique, Université de Montréal, Canada; Unité D'éthique Clinique, Unité de Soins Palliatifs, Bureau Du Partenariat Patients-Familles-Soignants; CHU Sainte-Justine, Montréal, Canada.
| |
Collapse
|
3
|
Friedrich AB. Ethical Consequences of Technological Mediation on Parental Decision-Making Experiences in the Neonatal Intensive Care Unit. QUALITATIVE HEALTH RESEARCH 2023; 33:259-269. [PMID: 36704925 DOI: 10.1177/10497323231151816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The neonatal intensive care unit (NICU) is a morally charged space in which parents may be confronted with difficult decisions about the treatment of their newborns, decisions often complicated and created by the increasing use of technologies. This paper adopts a postphenomenological approach to explore the ethical consequences of technological mediation on parental treatment decision-making in the NICU. Semi-structured interviews were conducted with parents of children who received invasive technological support in the NICU to better understand how they made treatment decisions or decisions about specific interventions during their child's hospitalization. The findings suggest that technological mediation-or the various ways in which humans can interact with their world via technologies-contributes to experiences of ambiguity, ambivalence, and alienation in parental decision-making. The ambiguity of invasive NICU technologies can create uncertainty in a decision, which can then lead to internal ambivalence about which decision to make. Ultimately, this ambiguity and ambivalence may lead to alienation from one's child, as parents are disconnected physically and emotionally from the decision and thus their child. Articulating the effects of technological mediation on parental decision-making is a key step in addressing decisional conflict in neonatal intensive care settings and better supporting parents in their decision-making roles.
Collapse
Affiliation(s)
- Annie B Friedrich
- Center for Bioethics and Medical Humanities, Institute for Health & Equity, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
4
|
Theodoro MF, Hays J, DiBartolomeo M, Carter B. Ethics Roundtable: How Much is Too Much? Am J Hosp Palliat Care 2023; 40:106-110. [PMID: 35466683 DOI: 10.1177/10499091221088829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
How should the medical team approach care for a very preterm infant with a significant painful and life-limiting condition when the parents wish to pursue all life-sustaining therapies? Here, we discuss a case of an infant born at 28 weeks' gestation with a diagnosis of Carmi syndrome (junctional epidermolysis bullosa and pyloric atresia). While the medical team felt that a do-not-resuscitate order and redirection to comfort care were appropriate, the family held on to hope for recovery and wished to continue with full intensive care measures.
Collapse
Affiliation(s)
- Mariana F Theodoro
- Graduate Medical Education, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatrics, Division of Neonatology, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Jacinda Hays
- Department of Pediatrics, Division of Hospice and Palliative Medicine, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Mara DiBartolomeo
- Department of Pediatrics, Division of Neonatology, 7582Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Brian Carter
- Department of Pediatrics, Division of Neonatology and Bioethics Center, 4204Children's Mercy Hospital, Kansas City, MO, USA
| |
Collapse
|
5
|
How doctors manage conflicts with families of critically ill patients during conversations about end-of-life decisions in neonatal, pediatric, and adult intensive care. Intensive Care Med 2022; 48:910-922. [PMID: 35773499 PMCID: PMC9273549 DOI: 10.1007/s00134-022-06771-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/31/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Intensive care is a stressful environment in which team-family conflicts commonly occur. If managed poorly, conflicts can have negative effects on all parties involved. Previous studies mainly investigated these conflicts and their management in a retrospective way. This study aimed to prospectively explore team-family conflicts, including its main topics, complicating factors, doctors' conflict management strategies and the effect of these strategies. METHODS Conversations between doctors in the neonatal, pediatric, and adult intensive care unit of a large university-based hospital and families of critically ill patients were audio-recorded from the moment doubts arose whether treatment was still in patients' best interest. Transcripts were coded and analyzed using a qualitative deductive approach. RESULTS Team-family conflicts occurred in 29 out of 101 conversations (29%) concerning 20 out of 36 patients (56%). Conflicts mostly concerned more than one topic. We identified four complicating context- and/or family-related factors: diagnostic and prognostic uncertainty, families' strong negative emotions, limited health literacy, and burden of responsibility. Doctors used four overarching strategies to manage conflicts, namely content-oriented, process-oriented, moral and empathic strategies. Doctors mostly used content-oriented strategies, independent of the intensive care setting. They were able to effectively address conflicts in most conversations. Yet, if they did not acknowledge families' cues indicating the existence of one or more complicating factors, conflicts were likely to linger on during the conversation. CONCLUSION This study underlines the importance of doctors tailoring their communication strategies to the concrete conflict topic(s) and to the context- and family-related factors which complicate a specific conflict.
Collapse
|
6
|
Usuda H, Carter S, Takahashi T, Newnham JP, Fee EL, Jobe AH, Kemp MW. Perinatal care for the extremely preterm infant. Semin Fetal Neonatal Med 2022; 27:101334. [PMID: 35577715 DOI: 10.1016/j.siny.2022.101334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (200/7-256/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.
Collapse
Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Sean Carter
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, 6150, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan.
| |
Collapse
|
7
|
Yeoh M, Rafferty S, Saw C, Beedie J, Davis JW. Fifteen-minute consultation: Outcomes of the extremely preterm infant (<27 weeks): what to tell the parents. Arch Dis Child Educ Pract Ed 2022; 108:163-166. [PMID: 35045993 DOI: 10.1136/archdischild-2020-321178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 12/10/2021] [Indexed: 11/04/2022]
Abstract
An extremely preterm infant is one born at less than 27 weeks' gestation. Over time, survival rates in this population have improved. This cohort remains at high risk of mortality and life-long morbidity. The birth of extremely preterm infants is an important public health issue and one which concerns neonatologists, paediatricians, general practitioners and parents alike. This paper aims to provide guidance for the antenatal discussion between clinicians and expectant families and may serve as a template to facilitate open communication.
Collapse
Affiliation(s)
- Melanie Yeoh
- Neonatal Clinical Care Unit, King Edward Memorial Hospital Neonatal Clinical Care Unit, Subiaco, Western Australia, Australia
| | | | - Chia Saw
- Paediatrics, St John of God Midland Public Hospital, Perth, Western Australia, Australia
| | - Joanne Beedie
- Helping Little Hands (Parent Support Charity), Perth, Western Australia, Australia.,Parent Representative, King Edward Memorial Hospital Neonatal Clinical Care Unit, Subiaco, Western Australia, Australia
| | - Jonathan W Davis
- Neonatal Clinical Care Unit, King Edward Memorial Hospital Neonatal Clinical Care Unit, Subiaco, Western Australia, Australia .,School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia.,Newborn Emergency Transport Service Western Australia (NETS WA), Perth Children's Hospital, Perth, Western Australia, Australia
| |
Collapse
|
8
|
Cavolo A, Dierckx de Casterlé B, Naulaers G, Gastmans C. Neonatologists' Resuscitation Decisions at Birth for Extremely Premature Infants. A Belgian Qualitative Study. Front Pediatr 2022; 10:852073. [PMID: 35402353 PMCID: PMC8989134 DOI: 10.3389/fped.2022.852073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Deciding whether initiating or withholding resuscitation at birth for extremely preterm infants (EPIs) can be difficult due to uncertainty on outcomes. Clinical uncertainty generates ethical uncertainty. Thus, physicians' attitudes and perspectives on resuscitation of EPIs might influence resuscitation decisions. We aimed at understanding how neonatologists make clinical-ethical decisions for EPI resuscitation and how they perceive these decisions. METHODS We performed a qualitative study using a constructivist account of grounded theory. Face-to-face, semi-structured in-depth interviews with neonatologists comprised data collection. For data analysis, we used the Qualitative Analysis Guide of Leuven. RESULTS We interviewed 20 neonatologists working in 10 hospitals in Belgium. Participants' decision-making can be described as consensus-based, gestational age-based, contextualized, progressive, and shared. All participants agreed on the importance of using the consensus expressed in guidelines as a guidance for the decision-making, i.e., consensus-based. Consequently, all 20 participants use GA thresholds indicated in the guidelines, i.e., GA-based. However, they use these thresholds differently in their decisions. Few participants rigidly follow established thresholds. The vast majority reported using additional contextual factors as birthweight or parents' wishes in the decision-making, rather than only the EPIs' GA, i.e., contextualized. All participants agreed on the importance of involving the parents in the decision-making, i.e., shared, and indeed parents' wishes were among the most valued factors considered in the decision-making. However, the extent to which parents were involved in the decision-making depended on the infant's GA. Participants described a gray zone in which parents' were viewed as the main decision-makers due to the high clinical uncertainty. This mean that participants tend to follow parents' request even when they disagree with it. Outside the gray zone, physicians were viewed as the main decision-makers. This mean that, although parents' wishes were still considered, counseling was more directive and the final decision was made by the physician. CONCLUSION Although an EPI's GA remains the main factor guiding neonatologists' resuscitation decisions, other factors are seriously considered in the decision-making process. All neonatologist participants agreed on the importance of involving parents in the decision-making. However, they involve parents differently depending on the EPI's GA.
Collapse
Affiliation(s)
- Alice Cavolo
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | | | - Gunnar Naulaers
- Pregnancy, Fetus and Newborn, Department of Development and Regeneration, UZ Leuven, Leuven, Belgium
| | - Chris Gastmans
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| |
Collapse
|
9
|
Forth FA, Hammerle F, König J, Urschitz MS, Neuweiler P, Mildenberger E, Kidszun A. The COPE-Trial-Communicating prognosis to parents in the neonatal ICU: Optimistic vs. PEssimistic: study protocol for a randomized controlled crossover trial using two different scripted video vignettes to explore communication preferences of parents of preterm infants. Trials 2021; 22:884. [PMID: 34872601 PMCID: PMC8647439 DOI: 10.1186/s13063-021-05796-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One of the numerous challenges preterm birth poses for parents and physicians is prognostic disclosure. Prognoses are based on scientific evidence and medical experience. They are subject to individual assessment and will generally remain uncertain with regard to the individual. This can result in differences in prognostic framing and thus affect the recipients' perception. In neonatology, data on the effects of prognostic framing are scarce. In particular, it is unclear whether parents prefer a more optimistic or a more pessimistic prognostic framing. OBJECTIVE To explore parents' preferences concerning prognostic framing and its effects on parent-reported outcomes and experiences. To identify predictors (demographic, psychological) of parents' communication preferences. DESIGN, SETTING, PARTICIPANTS Unblinded, randomized controlled crossover trial (RCT) at the Division of Neonatology of the University Medical Center Mainz, Germany, including German-speaking parents or guardians of infants born preterm between 2010 and 2019 with a birth weight < 1500 g. Inclusion of up to 204 families is planned, with possible revision according to a blinded sample size reassessment. INTERVENTION Embedded in an online survey and in pre-specified order, participants will watch two video vignettes depicting a more optimistic vs. a more pessimistic framing in prognostic disclosure to parents of a preterm infant. Apart from prognostic framing, all other aspects of physician-parent communication are standardized in both videos. MAIN OUTCOMES AND MEASURES At baseline and after each video, participants complete a two-part online questionnaire (baseline and post-intervention). Primary outcome is the preference for either a more optimistic or a more pessimistic prognostic framing. Secondary outcomes include changes in state-anxiety (STAI-SKD), satisfaction with prognostic framing, evaluation of prognosis, future optimism and hope, preparedness for shared decision-making (each assessed using customized questions), and general impression (customized question), professionalism (adapted from GMC Patient Questionnaire) and compassion (Physician Compassion Questionnaire) of the consulting physician. DISCUSSION This RCT will explore parents' preferences concerning prognostic framing and its effects on physician-parent communication. Results may contribute to a better understanding of parental needs in prognostic disclosure and will be instrumental for a broad audience of clinicians, scientists, and ethicists. TRIAL REGISTRATION German Clinical Trials Register DRKS00024466 . Registered on April 16, 2021.
Collapse
Affiliation(s)
- Fiona A Forth
- Division of Neonatology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
- DFG-Research Training Group "Life Sciences - Life Writing", Institute for the History, Philosophy and Ethics of Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Am Pulverturm 13, 55131, Mainz, Germany.
| | - Florian Hammerle
- Department of Pediatric and Adolescent Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Jochem König
- Division of Pediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg-University Mainz, Obere Zahlbacher Strasse 69, 55131, Mainz, Germany
| | - Michael S Urschitz
- Division of Pediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg-University Mainz, Obere Zahlbacher Strasse 69, 55131, Mainz, Germany
| | - Philipp Neuweiler
- Journalistisches Seminar, Johannes Gutenberg-University Mainz, Alte Universitätsstrasse 17, 55116, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- DFG-Research Training Group "Life Sciences - Life Writing", Institute for the History, Philosophy and Ethics of Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Am Pulverturm 13, 55131, Mainz, Germany
| | - André Kidszun
- Division of Neonatology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
- Division of Neonatology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstraße, CH-3010, Bern, Switzerland
| |
Collapse
|
10
|
Soltys FC, Spilo K, Politi MC. The Content and Quality of Publicly Available Information About Congenital Diaphragmatic Hernia: Descriptive Study. JMIR Pediatr Parent 2021; 4:e30695. [PMID: 34665147 PMCID: PMC8564656 DOI: 10.2196/30695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/23/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) diagnosis in an infant is distressing for parents. Parents often feel unable to absorb the complexities of CDH during prenatal consultations and use the internet to supplement their knowledge and decision making. OBJECTIVE We aimed to examine the content and quality of publicly available, internet-based CDH information. METHODS We conducted internet searches across 2 popular search engines (Google and Bing). Websites were included if they contained CDH information and were publicly available. We developed a coding instrument to evaluate websites. Two coders (FS and KS) were trained, achieved interrater reliability, and rated remaining websites independently. Descriptive statistics were performed. RESULTS Searches yielded 520 websites; 91 met inclusion criteria and were analyzed. Most websites provided basic CDH information including describing the defect (86/91, 95%), need for neonatal intensive care (77/91, 85%), and surgical correction (79/91, 87%). Few mentioned palliative care, decisions about pregnancy termination (13/91, 14%), or support resources (21/91, 23%). CONCLUSIONS Findings highlight the variability of information about CDH on the internet. Clinicians should work to develop or identify reliable, comprehensive information about CDH to support parents.
Collapse
Affiliation(s)
- Frank Coyle Soltys
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Kimi Spilo
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| |
Collapse
|
11
|
Elternzentrierte ethische Entscheidungsfindung für Frühgeborene im Grenzbereich der Lebensfähigkeit – Reflexion über die Bedeutung probabilistischer Prognosen als Entscheidungsgrundlage. Ethik Med 2021. [DOI: 10.1007/s00481-021-00653-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungFrühgeborene im Grenzbereich der Lebensfähigkeit befinden sich in einer prognostischen Grauzone. Das bedeutet, dass deren Prognose zwar schlecht, aber nicht hoffnungslos ist, woraus folgt, dass nach Geburt lebenserhaltende Behandlungen nicht obligatorisch sind. Die Entscheidung für oder gegen lebenserhaltende Maßnahmen ist wertbeladen und für alle Beteiligten enorm herausfordernd. Sie sollte eine zwischen Eltern und Ärzt*innen geteilte Entscheidung sein, wobei sie unbedingt mit den Präferenzen der Eltern abgestimmt sein sollte. Bei der pränatalen Beratung der Eltern legen die behandelnden Ärzt*innen üblicherweise numerische Schätzungen der Prognose vor und nehmen in der Regel an, dass die Eltern ihre Behandlungspräferenzen davon ableiten. Inwieweit probabilistische Daten die Entscheidungen der Eltern in prognostischen Grauzonen tatsächlich beeinflussen, ist noch unzureichend untersucht. In der hier vorliegenden Arbeit wird eine Studie reflektiert, in welcher die Hypothese geprüft wurde, dass numerisch bessere oder schlechtere kindliche Prognosen die Präferenzen werdender Mütter für lebenserhaltende Maßnahmen nicht beeinflussen. In dieser Studie zeigte sich, dass die elterlichen Behandlungspräferenzen eher von individuellen Einstellungen und Werten als von Überlegungen zu numerischen Ergebnisschätzungen herzurühren scheinen. Unser Verständnis, welche Informationen werdende Eltern, die mit einer extremen Frühgeburt konfrontiert sind, wünschen und brauchen, ist noch immer unvollständig. Bedeutende medizinische Entscheidungen werden keineswegs nur rational und prognoseorientiert gefällt. In der vorliegenden Arbeit wird diskutiert, welchen Einfluss der Prozess der Entscheidungsfindung auf das Beratungsergebnis haben kann und welche Implikationen sich aus den bisher vorliegenden Studienergebnissen ergeben – klinisch-praktisch, ethisch und wissenschaftlich.
Collapse
|
12
|
Cavolo A, Dierckx de Casterlé B, Naulaers G, Gastmans C. Ethics of resuscitation for extremely premature infants: a systematic review of argument-based literature. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106102. [PMID: 32341186 DOI: 10.1136/medethics-2020-106102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/18/2020] [Accepted: 04/10/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To present (1) the ethical concepts related to the debate on resuscitation of extremely premature infants (EPIs) as they are described in the ethical literature; and (2) the ethical arguments based on these concepts. DESIGN We conducted a systematic review of the ethical literature. We selected articles based on the following predefined inclusion/exclusion criteria: (1) English language articles (2) presenting fully elaborated ethical arguments (3) on resuscitation (4) of EPIs, that is, infants born before 28 weeks of gestation. ANALYSIS After repeated reading of articles, we developed individual summaries, conceptual schemes and an overall conceptual scheme. Ethical arguments and concepts were identified and analysed. RESULTS Forty articles were included out of 4709 screened. Personhood, best interest, autonomy and justice were concepts grounding the various arguments. Regarding these concepts, included authors agreed that the best interest principle should guide resuscitation decisions, whereas justice seemed the least important concept. The arguments addressed two questions: Should we resuscitate EPIs? Who should decide? Included authors agreed that not all EPIs should be resuscitated but disagreed on what criteria should ground this decision. Overall, included authors agreed that both parents and physicians should contribute to the decision. CONCLUSIONS The included publications suggest that while the best interest is the main concept guiding resuscitation decisions, justice is the least important. The included authors also agree that both parents and physicians should be actively involved in resuscitation decisions for EPIs. However, our results suggest that parents' decision should be over-ridden when in contrast with the EPI's best interest.
Collapse
Affiliation(s)
- Alice Cavolo
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Bernadette Dierckx de Casterlé
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| | - Gunnar Naulaers
- Pregnancy, Fetus and Newborn, Department of Development and Regeneration, KU Leuven UZ Leuven, Leuven, Belgium
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven Biomedical Sciences Group, Leuven, Belgium
| |
Collapse
|
13
|
Dombrecht L, Piette V, Deliens L, Cools F, Chambaere K, Goossens L, Naulaers G, Cornette L, Beernaert K, Cohen J. Barriers to and Facilitators of End-of-Life Decision Making by Neonatologists and Neonatal Nurses in Neonates: A Qualitative Study. J Pain Symptom Manage 2020; 59:599-608.e2. [PMID: 31639496 DOI: 10.1016/j.jpainsymman.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/09/2019] [Accepted: 10/09/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Making end-of-life decisions (ELDs) in neonates involves ethically difficult and distressing dilemmas for health care providers. Insight into which factors complicate or facilitate this decision-making process could be a necessary first step in formulating recommendations to aid future practice. OBJECTIVES This study aimed to identify barriers to and facilitators of the ELD-making process as perceived by neonatologists and nurses. METHODS We conducted semistructured face-to-face interviews with 15 neonatologists and 15 neonatal nurses, recruited through four neonatal intensive care units in Flanders, Belgium. They were asked what factors had facilitated and complicated previous ELD-making processes. Two researchers independently analyzed the data, using thematic content analysis to extract and summarize barriers and facilitators. RESULTS Barriers and facilitators were found at three distinct levels: the case-specific context (e.g., uncertainty of the diagnosis and specific characteristics of the child, parents, and health care providers, which make decision making more difficult), decision-making process (e.g., multidisciplinary consultations and advance care planning, which make decision making easier), and overarching structure (e.g., lack of privacy and complex legislation making decision making more challenging). CONCLUSION Barriers and facilitators found in this study can lead to recommendations, some simpler to implement than others, to aid the complex ELD-making process. Recommendations include establishing regular multidisciplinary meetings to include all health care providers and reduce unnecessary uncertainty, routinely implementing advance care planning in severely ill neonates to make important decisions beforehand, creating privacy for bad-news conversations with parents, and reviewing the complex legal framework of perinatal ELD making.
Collapse
Affiliation(s)
- Laure Dombrecht
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Veerle Piette
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Linde Goossens
- Department of Neonatology, Ghent University Hospital, Ghent, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Luc Cornette
- Department of Neonatology, AZ Sint-Jan Brugge-Oostende, Bruges, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium; Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
| | -
- Ghent University Hospital, Brussels University Hospital, Leuven University Hospital, Antwerp University Hospital, Hospital Oost-Limburg Genk, Hospital GZA St Augustinus, AZ St Jan Brugge, ZNA Middelheim, Belgium
| |
Collapse
|
14
|
Soltys F, Philpott-Streiff SE, Fuzzell L, Politi MC. The importance of shared decision-making in the neonatal intensive care unit. J Perinatol 2020; 40:504-509. [PMID: 31570796 DOI: 10.1038/s41372-019-0507-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/06/2019] [Accepted: 09/17/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Neonatal intensive care unit (NICU) admissions are common and rising. Parents with infants in the NICU face difficult decisions about their infants' care. Few studies have investigated parents' engagement in NICU decisions and its effects on decision regret. STUDY DESIGN We surveyed parents of children who had a NICU stay in the past 3 years. We explored whether sociodemographic characteristics affected preferred decision involvement, shared decision-making with NICU clinicians, or decision regret. Multivariable linear regression analyses examined the relationship between shared decision-making and decision regret. RESULTS Most parents preferred an active (212/405, 52.3%) or shared (139/405, 34.3%) approach to decision-making. No sociodemographic characteristics related to preferred decision involvement or shared decision-making (p's > 0.05). In multivariable analyses, shared decision-making, education and health literacy related to less decision regret (p's < 0.05). CONCLUSIONS These data suggest the importance of shared decision-making during NICU stays. Studies should identify ways to support parents through NICU decision-making.
Collapse
Affiliation(s)
- Frank Soltys
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis and St. Louis Children's Hospital, St. Louis, MO, USA.
| | - Sydney E Philpott-Streiff
- Division of Public Health Science, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Lindsay Fuzzell
- Division of Public Health Science, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Mary C Politi
- Division of Public Health Science, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| |
Collapse
|
15
|
Parham D, Reed D, Olicker A, Parrill F, Sharma J, Brunkhorst J, Noel-MacDonnell J, Voos K. Families as educators: a family-centered approach to teaching communication skills to neonatology fellows. J Perinatol 2019; 39:1392-1398. [PMID: 31371832 DOI: 10.1038/s41372-019-0441-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 06/10/2019] [Accepted: 06/17/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether the use of family members as educators in a structured educational intervention would increase neonatology fellows' confidence in performing core communication skills targeted to guide family decision-making. STUDY DESIGN Neonatology fellows at two centers participated in simulation-based training utilizing formally trained family members of former patients. Fellows completed self-assessment surveys before participating, immediately following participation, and 1-month following the training. Family members also evaluated fellow communication. RESULTS For each core competency assessed, there was a statistically significant increase in self-perceived preparedness from pre-course to post-course assessments. Fellows additionally endorsed using skills learned in the curriculum in daily clinical practice. Family educators rated fellow communication highest in empathetic listening and nonverbal communication. CONCLUSIONS Participation in a communication skills curriculum utilizing formally trained family members as educators for medical trainees successfully increased fellows' self-perceived preparedness in selected core competencies in communication. Family educators provided useful, generalizable feedback.
Collapse
Affiliation(s)
- Danielle Parham
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA. .,Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA. .,Division of Neonatology, University Hospitals Cleveland Medical Center Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
| | - Danielle Reed
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Arielle Olicker
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Neonatology, University Hospitals Cleveland Medical Center Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Fey Parrill
- Department of Cognitive Science, Case Western Reserve University, Cleveland, OH, USA
| | - Jotishna Sharma
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Jessica Brunkhorst
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Janelle Noel-MacDonnell
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO, USA
| | - Kristin Voos
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Neonatology, University Hospitals Cleveland Medical Center Rainbow Babies and Children's Hospital, Cleveland, OH, USA.,Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.,Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| |
Collapse
|
16
|
Levaillant C, Caeymaex L, Béhal H, Kaminski M, Diguisto C, Tosello B, Azria E, Claris O, Bétrémieux P, Foix L’Hélias L, Truffert P. Prenatal parental involvement in decision for delivery room management at 22-26 weeks of gestation in France - The EPIPAGE-2 Cohort Study. PLoS One 2019; 14:e0221859. [PMID: 31465428 PMCID: PMC6715208 DOI: 10.1371/journal.pone.0221859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 08/18/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Our main objective was to examine if parental prenatal preferences predict delivery-room management of extremely preterm periviable infants. The secondary objectives were to describe parental involvement and the content of prenatal counseling given to parents for this prenatal decision. DESIGN Prospective study of neonates liveborn between 22 and 26 weeks of gestation in France in 2011 among the neonates included in the EPIPAGE-2 study. SETTING 18 centers participating in the "Extreme Prematurity Group" substudy of the EPIPAGE-2 study. PATIENTS 302 neonates liveborn between 22-26 weeks among which 113 with known parental preferences while parental preferences were unknown or unavailable for 186 and delivery room management was missing for 3. RESULTS Data on prenatal counseling and parental preferences were collected by a questionnaire completed by professionals who cared for the baby at birth; delivery room (DR) management, classified as stabilization or initiation of resuscitation (SIR) vs comfort care (CC). The 113 neonates studied had a mean (SD) gestational age of 24 (0.1) weeks. Parents of neonates in the CC group preferred SIR less frequently than those with neonates in the SIR group (16% vs 88%, p < .001). After multivariate analysis, preference for SIR was an independent factor associated with this management. Professionals qualified decisions as shared (81%), exclusively medical (16%) or parental (3%). Information was described as medical with no personal opinion (71%), complete (75%) and generally pessimistic (54%). CONCLUSION Parental involvement in prenatal decision-making did not reach satisfying rates in the studied setting. When available, prenatal parental preference was a determining factor for DR management of extremely preterm neonates. Potential biases in the content of prenatal counselling given to parents need to be evaluated.
Collapse
Affiliation(s)
- Cerise Levaillant
- CHU Lille Neonatal unit, EA Epidemiology and Quality of Care, Lille, France
- * E-mail:
| | - Laurence Caeymaex
- Department of Neonatology, Centre Hospitalier Intercommunal de Creteil, Créteil, France
- CEDITEC, University Paris Est Creteil, France
| | - Hélène Béhal
- Department of biostatistics, Univ. Lille, CHU Lille, Lille, France
| | - Monique Kaminski
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | - Caroline Diguisto
- Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, France
| | - Barthélémy Tosello
- Department of Neonatology, Assistance Publique-Hôpitaux de Marseille, Nord Hospital, Marseille, France
- Aix-Marseille University, CNRS, EFS, ADES, Marseille, France
| | - Elie Azria
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
- Maternity Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Olivier Claris
- Department of Neonatology, Hospices Civils de Lyon, Hôpital Femme Mère Enfants
- Claude Bernard University, EAM, France
| | | | - Laurence Foix L’Hélias
- Inserm UMR, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
- Sorbonne Université Paris, France, Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Patrick Truffert
- CHU Lille Neonatal unit, EA Epidemiology and Quality of Care, Lille, France
| | | |
Collapse
|
17
|
Geurtzen R, van Heijst A, Draaisma J, Ouwerkerk L, Scheepers H, Hogeveen M, Hermens R. Prenatal counseling in extreme prematurity - Insight into preferences from experienced parents. PATIENT EDUCATION AND COUNSELING 2019; 102:1541-1549. [PMID: 30948203 DOI: 10.1016/j.pec.2019.03.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE In-depth analysis of parental preferences in prenatal counseling in extreme prematurity. METHODS A nationwide qualitative interview study among experienced parents of extremely premature babies born at 24+0/7 - 24+6/7 weeks of gestation. Semi-structured interviews were held until saturation, transcribed and qualitatively analyzed to search for parental counseling preferences. RESULTS Thirteen parents were included, most parents decided on active care. Organisation: Parents wanted counseling as soon as possible, and for various reasons they wanted more than one conversation. Supportive material to help visualize complex information was suggested to be helpful, preferably with adjustable levels of detail. An empathetic, honest style with commitment of the counselor was regarded important. CONTENT Understandable statistics should be used for those who want it. Parents needed different information with respect to the decision-making as opposed to being prepared for future situations. Decision-making: The preferred share of parents' and doctors' input in decision-making varied among parents and among situations. Parents expressed that their roles were to take responsibility for and protect their infant. CONCLUSIONS Various parental preferences for prenatal counseling were found. PRACTICE IMPLICATIONS Common parental preferences for the organisation, content and decision-making elements can provide a starting point for personalized prenatal counseling.
Collapse
Affiliation(s)
- Rosa Geurtzen
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands.
| | - Arno van Heijst
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | - Jos Draaisma
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | - Laura Ouwerkerk
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | | | - Marije Hogeveen
- Amalia Children's Hospital, Radboud university medical center, Nijmegen, the Netherlands
| | - Rosella Hermens
- Scientific Institute for Quality of Care, Radboud university medical center, Nijmegen, the Netherlands
| |
Collapse
|
18
|
Guillén Ú, Mackley A, Laventhal N, Kukora S, Christ L, Derrick M, Batza J, Ghavam S, Kirpalani H. Evaluating the Use of a Decision Aid for Parents Facing Extremely Premature Delivery: A Randomized Trial. J Pediatr 2019; 209:52-60.e1. [PMID: 30952510 PMCID: PMC6625526 DOI: 10.1016/j.jpeds.2019.02.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/30/2019] [Accepted: 02/14/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To assess decisional conflict and knowledge about prematurity among mothers facing extreme premature delivery when the counseling clinicians were randomized to counsel using a validated decision aid compared with usual counseling. STUDY DESIGN In this randomized trial, clinicians at 5 level III neonatal intensive care units in the US were randomized to supplement counseling using the decision aid or to counsel mothers in their usual manner. We enrolled mothers with threatened premature delivery at 220/7 to 256/7 weeks of gestation within 7 days of their counseling. The primary outcome was the Decisional Conflict Scale (DCS) score. One hundred mothers per group were enrolled to detect a clinically relevant effect size of 0.4 in the Decisional Conflict Scale. Secondary outcomes included knowledge about prematurity; scores on the Preparedness for Decision Making scale; and acceptability. RESULTS Ninety-two clinicians were randomized and 316 mothers were counseled. Of these, 201 (64%) mothers were enrolled. The median gestational age was 24.1 weeks (IQR 23.7-24.9). In both groups, DCS scores were low (16.3 ± 18.2 vs 16.8 ± 17, P = .97) and Preparedness for Decision Making scores were high (73.4 ± 28.3 vs 70.5 ± 31.1, P = .33). There was a significantly greater knowledge score in the decision aid group (66.2 ± 18.5 vs 57.2 ± 18.8, P = .005). Most clinicians and parents found the decision aid useful. CONCLUSIONS For parents facing extremely premature delivery, use of a decision aid did not impact maternal decisional conflict, but it significantly improved knowledge of complex information. A structured decision aid may improve comprehension of complex information. TRIAL REGISTRATION Clinicaltrials.gov: NCT01713894.
Collapse
Affiliation(s)
- Úrsula Guillén
- Division of Neonatology, Christiana Care Health System, Newark, DE.
| | - Amy Mackley
- Division of Neonatology, Christiana Care Health System, Newark, DE
| | - Naomi Laventhal
- Division of Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, MI
| | - Stephanie Kukora
- Division of Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, MI
| | - Lori Christ
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Matthew Derrick
- Division of Neonatology, NorthShore University Health System, Evanston, IL
| | - Jennifer Batza
- Division of Neonatology, NorthShore University Health System, Evanston, IL
| | - Sarvin Ghavam
- Division of Neonatology, Virtua Voorhees Hospital, Voorhees Township, NJ
| | - Haresh Kirpalani
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
19
|
Drago MJ, Guillén U, Schiaratura M, Batza J, Zygmunt A, Mowes A, Munson D, Lorenz JM, Farkouh-Karoleski C, Kirpalani H. Constructing a Culturally Informed Spanish Decision-Aid to Counsel Latino Parents Facing Imminent Extreme Premature Delivery. Matern Child Health J 2019. [PMID: 29520727 DOI: 10.1007/s10995-018-2471-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective How Latino parents perceive and understand antenatal counseling for extreme prematurity, < 26 weeks of gestational age (GA), is not clear. We aim to characterize Latino parental perceptions of antenatal counseling in order to construct and validate a Spanish decision-aid (SDA) to improve parental knowledge of prematurity after antenatal consults. Methods This is a three-phased, prospective, multicenter study. First, interviews of 22 Latino parents with a history of birth < 26 weeks GA were conducted. Thematic analysis identified themes valued during antenatal counseling for decisions regarding neonatal resuscitation. Next, we incorporated these themes into the SDA. Finally, improvement in knowledge of prematurity in two Spanish-speaking groups, 'experienced' parents with a history of extremely premature birth and 'naïve' adult Latino volunteers, was measured using a multiple choice test before and after simulated counseling with the SDA. Result Twenty-two interviews generated seven unique themes. An SDA was constructed that preserved six themes paralleled by those found in a previously studied English population, and addressed a novel theme of "intercultural linguistic barriers" unique to our population. Knowledge scores rose in "naive" volunteers, 41 ± 12% to 71 ± 15% (P < 0.001), after simulated counseling with the SDA. 'Experienced' parents had a ceiling effect in knowledge scores, 62 ± 9% to 65 ± 11% (P = 0.22). The SDA was well received by participants. Conclusions for Practice Interviews of Latino parents with a history of premature birth generated similar themes to English-speaking parents, with intercultural linguistic barriers as a novel theme. An SDA for Latino parents facing extremely premature birth may improve comprehension of antenatal counseling.
Collapse
Affiliation(s)
- Matthew J Drago
- Columbia University, New York, NY, USA. .,Yale University School of Medicine, 333 Cedar Street, Neonatal-Perinatal Medicine, New Haven, CT, 06520, USA.
| | | | | | | | | | - Anja Mowes
- Drexel University, Philadelphia, PA, USA
| | - David Munson
- University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | |
Collapse
|
20
|
Gephart SM, Newnam KM. Closing the Gap Between Recommended and Actual Human Milk Use for Fragile Infants: What Will It Take to Overcome Disparities? Clin Perinatol 2019; 46:39-50. [PMID: 30771818 DOI: 10.1016/j.clp.2018.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
This article describes the components of human milk and their value to reduce risk for necrotizing enterocolitis, disparities in access to human milk, potential relationships to care practices within the neonatal intensive care unit, and ways to overcome the disparity.
Collapse
Affiliation(s)
- Sheila M Gephart
- Community and Health Systems Science Division, College of Nursing, The University of Arizona, PO Box 210203, Tucson, AZ 85721, USA.
| | - Katherine M Newnam
- College of Nursing, The University of Tennessee Knoxville, 1200 Volunteer Boulevard #361, Knoxville, TN 37996, USA
| |
Collapse
|
21
|
Ireland S, Larkins S, Ray R, Woodward L, Devine K. Adequacy of antenatal steroids, rather than place of birth, determines survival to discharge in extreme prematurity in North Queensland. J Paediatr Child Health 2019; 55:205-212. [PMID: 30151906 DOI: 10.1111/jpc.14184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/24/2018] [Accepted: 07/08/2018] [Indexed: 12/26/2022]
Abstract
AIM The Townsville Hospital cares for babies in a large geographical area, many of who are outborn, are of Aboriginal or Torres Strait Islander origin and have families who reside in areas of deprivation. This study examined the outcomes of babies born at all locations in North Queensland to assess the predictors of poor outcomes. METHODS A retrospective observational study examined the survival of 313 babies born from 22 completed weeks gestation to 27 + 6 weeks gestation in North Queensland between January 2010 and December 2016. Additional analyses were performed for the 300 non-syndromal babies whose mothers usually resided in North Queensland, studying demographics of gestation, gender, birthweight, Indigenous status, regionality of maternal residence and adequacy of antenatal steroids. Short-term morbidities of intraventricular haemorrhage/periventricular leukomalacia (IVH/PVL), surgical necrotizing enterocolitis, retinopathy of prematurity requiring treatment and chronic lung disease and death were studied in relation to demographic factors and clinical treatment. RESULTS Adequacy of steroids was significantly associated with a decreased mortality odds ratio of 2.872 (95% confidence interval 1.228-6.715), whilst no difference in outcome was seen by retrieval status or ethnic origin. Babies from remote locations were at increased risk for IVH/PVL, 2.334 (1.037-5.255). Male babies suffered more chronic lung disease, 1.608 (1.010-2.561), and IVH/PVL, 2.572 (1.215-5.445). Aboriginal and Torres Strait Islander babies were at lower risk of IVH/PVL. CONCLUSIONS Steroids should be administered wherever there is any possibility of the provision of intensive care for periviable babies. Place of birth and ethnicity of mother should not unduly influence antenatal counselling.
Collapse
Affiliation(s)
- Susan Ireland
- Neonatal Unit, The Townsville Hospital, Townsville, Queensland, Australia
| | - Sarah Larkins
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Robin Ray
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Lynn Woodward
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Kirsty Devine
- The Neonatal Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| |
Collapse
|
22
|
Geurtzen R, Draaisma J, Hermens R, Scheepers H, Woiski M, van Heijst A, Hogeveen M. Various experiences and preferences of Dutch parents in prenatal counseling in extreme prematurity. PATIENT EDUCATION AND COUNSELING 2018; 101:2179-2185. [PMID: 30029812 DOI: 10.1016/j.pec.2018.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/28/2018] [Accepted: 07/03/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate experienced and preferred prenatal counseling among parents of extremely premature babies. METHODS A Dutch nationwide, multicenter, cross-sectional study using an online survey. Surveys were sent to all parents of extremely premature babies born between 2010 and 2013 at 24+0/7-24+6/7 weeks of gestation. RESULTS Sixty-one out of 229 surveys were returned. A minority (14%) had no counseling conversation. Conversations were done more often by neonatologists (90%) than by obstetricians (39%) and in 37% by both these experts. Supportive material was rarely used (19%). Mortality (92%) and short-term morbidity (88%) were discussed the most, and more frequently than long-term morbidity (65%), practical items (63%) and delivery mode (52%). Most decisions on active care or palliative comfort care were perceived as decisions by doctor and parents together (61%). 80% felt they were involved in decision-making. The preferred way of involvement in decision-making varied among parents. CONCLUSION The vast majority of parents were counseled: mostly by neonatologists, and mainly about mortality and short-term morbidity. Parents wanted to be involved in the decision-making process but differed on the preferred extent of involvement. Practice implications Understanding of shared decision-making may contribute to meet the various preferences of parents.
Collapse
Affiliation(s)
- Rosa Geurtzen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands.
| | - Jos Draaisma
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| | - Rosella Hermens
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of IQ Healthcare, Nijmegen, The Netherlands
| | | | - Mallory Woiski
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Gynecology, Nijmegen, The Netherlands
| | - Arno van Heijst
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| |
Collapse
|
23
|
Nimbalkar SM, Raval H, Bansal SC, Pandya U, Pathak A. Non-verbal Communication in a Neonatal Intensive Care Unit: A Video Audit Using Non-verbal Immediacy Scale (NIS-O). Indian J Pediatr 2018; 85:1025-1027. [PMID: 29721670 DOI: 10.1007/s12098-018-2680-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/05/2018] [Indexed: 10/17/2022]
Abstract
Effective communication with parents is a very important skill for pediatricians especially in a neonatal setup. The authors analyzed non-verbal communication of medical caregivers during counseling sessions. Recorded videos of counseling sessions from the months of March-April 2016 were audited. Counseling episodes were scored using Non-verbal Immediacy Scale Observer Report (NIS-O). A total of 150 videos of counseling sessions were audited. The mean (SD) total score on (NIS-O) was 78.96(7.07). Female counseled sessions had significantly higher proportion of low scores (p < 0.001). No video revealed high score. Overall 67(44.67%) sessions revealed low total score. This reflects an urgent need to develop strategies to improve communication skills in a neonatal unit. This study lays down a template on which other Neonatal intensive care units (NICUs) can carry out gap defining audits.
Collapse
Affiliation(s)
- Somashekhar Marutirao Nimbalkar
- Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, 388325, India.,Central Research Services, Charutar Arogya Mandal, Karamsad, Gujarat, 388325, India
| | - Himalaya Raval
- Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, 388325, India
| | | | - Utkarsh Pandya
- Department of Pediatrics, Pramukhswami Medical College, Karamsad, Gujarat, 388325, India
| | - Ajay Pathak
- Central Research Services, Charutar Arogya Mandal, Karamsad, Gujarat, 388325, India
| |
Collapse
|
24
|
Schrijvers NM, Geurtzen R, Draaisma JM, Halamek LP, Yamada NK, Hogeveen M. Perspectives on periviability counselling and decision-making differed between neonatologists in the United States and the Netherlands. Acta Paediatr 2018; 107:1710-1715. [PMID: 29603788 DOI: 10.1111/apa.14347] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 12/27/2017] [Accepted: 03/23/2018] [Indexed: 11/28/2022]
Abstract
AIM American guidelines suggest that neonatal resuscitation be considered at 23 weeks of gestation, one week earlier than in the Netherlands, but how counselling practices differ at the threshold of viability is unknown. This pilot study compared prenatal periviability counselling in the two countries. METHODS In 2013, a cross-sectional survey was sent to 121 Dutch neonatologists as part of a nationwide evaluation of prenatal counselling. In this pilot study, the same survey was sent to a convenience sample of 31 American neonatologists in 2014. The results were used to compare the organisation, content and decision-making processes in prenatal counselling at 24 weeks of gestation between the two countries. RESULTS The survey was completed by 17 (55%) American and 77 (64%) Dutch neonatologists. American neonatologists preferred to meet with parents more frequently, for longer periods of time, and to discuss more intensive care topics, including long-term complications, than Dutch neonatologists. Neonatologists from both countries preferred shared decision-making when deciding whether to initiate intensive care. CONCLUSION Neonatologists in the United States and the Netherlands differed in their approach to prenatal counselling at 24 weeks of gestation. Cross-cultural differences may play a role.
Collapse
Affiliation(s)
| | - Rosa Geurtzen
- Radboudumc Amalia Children's Hospital; Nijmegen the Netherlands
| | | | - Louis P. Halamek
- Center for Advanced Pediatric and Perinatal Education; Stanford University; Palo Alto CA USA
| | - Nicole K. Yamada
- Center for Advanced Pediatric and Perinatal Education; Stanford University; Palo Alto CA USA
| | - Marije Hogeveen
- Radboudumc Amalia Children's Hospital; Nijmegen the Netherlands
| |
Collapse
|
25
|
Exploring parent expectations of neonatal therapeutic hypothermia. J Perinatol 2018; 38:857-864. [PMID: 29740186 PMCID: PMC6486821 DOI: 10.1038/s41372-018-0117-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 03/26/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We aimed to assess the parent experience of therapeutic hypothermia (TH), specifically focusing on unmet expectations. STUDY DESIGN Open-ended questions were used in a focus group setting. We employed an inductive approach to develop thematic content from the transcribed recordings. RESULTS 30 parents of infants treated with TH participated. Within the principal theme of managing expectations, four sub-themes emerged. These included parental concerns about morphine use; specifically the association of morphine with end-of-life care and addiction. Parents perceived their role as key in the decision to implement TH and were emotionally burdened by this during and after TH. Parents recall intense fear for the infant's immediate survival and were not sufficiently reassured regarding survival. Parents also experience ongoing uncertainties about the long-term prognosis after TH. CONCLUSION The identification of these four areas in which parents have unmet expectations is important in order to improve the delivery of care.
Collapse
|
26
|
Eneriz-Wiemer M, Liu SD, Chu MC, Uribe-Leitz T, Rajani K, Sankar M, Robbins SL, Lee HC, Woodard C, Wang CJ. Parents' Knowledge and Education of Retinopathy of Prematurity in Four California Neonatal Intensive Care Units. Am J Ophthalmol 2018; 191:7-13. [PMID: 29621506 DOI: 10.1016/j.ajo.2018.03.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 03/24/2018] [Accepted: 03/25/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Retinopathy of prematurity (ROP) may cause visual impairment in infants with very low birth weight. Lack of parent knowledge may contribute to gaps in screening and treatment. We studied parents' knowledge and education of ROP. DESIGN Cross-sectional study. METHODS Setting: Four high-acuity neonatal intensive care units in California (40-84 beds). PARTICIPANTS Total of 194 English- and Spanish-speaking parents of very low birth weight (<1500 grams) infants recruited from September 2013 to April 2015. MAIN OUTCOME MEASURES We asked parents what they knew about ROP, how they were educated about ROP, and their experiences obtaining outpatient eye care. We used multivariate analysis to assess whether parent knowledge was associated with level of English proficiency and literacy, education modality (verbal, written, online, video), and hospital transfer status. RESULTS Of the 194 participants, 131 (68%) completed surveys: 18% had both limited English proficiency and low literacy while overall 26% had limited English proficiency and 37% had low literacy; 17% did not know that ROP is an eye disease, and 38% did not know that very low birth weight and prematurity are both risk factors for ROP. Parents reported receiving verbal (62%) or written (56%) information; few used online resources (12%) or videos (3%). Half reported receiving information about infants' retinopathy status at discharge. No education modality was associated with higher knowledge. Limited English proficiency and low literacy were associated with lower knowledge (vs English-proficient, literate). CONCLUSIONS Parents of infants with very low birth weight, particularly those with limited English proficiency and low health literacy, lack knowledge about ROP.
Collapse
|
27
|
Motz P, Gray M, Sawyer T, Kett J, Danforth D, Maicher K, Umoren R. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): Pilot Study. JMIR Serious Games 2018; 6:e8. [PMID: 29752249 PMCID: PMC5970284 DOI: 10.2196/games.9611] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 11/13/2022] Open
Abstract
Background Prenatal counseling at the limits of newborn viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in times of high stress. Decision aids may help improve provider communication but have not been universally adopted. Virtual standardized patients are increasingly recognized as a modality for education, but prenatal counseling simulations have not been described. To be valuable as a tool, a virtual patient would need to accurately portray emotions and elicit a realistic response from the provider. Objective To determine if neonatal providers can accurately identify a standardized virtual prenatal patient’s emotional states and examine the frequency of empathic responses to statements made by the patient. Methods A panel of Neonatologists, Simulation Specialists, and Ethicists developed a dialogue and identified empathic responses. Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA), a screen-based simulation of a woman at 23 weeks gestation, was capable of displaying anger, fear, sadness, and happiness through animations. Twenty-four neonatal providers, including a subgroup with an ethics interest, were asked to identify VANESSA’s emotions 28 times, respond to statements, and answer open-ended questions. The emotions were displayed in different formats: without dialogue, with text dialogue, and with audio dialogue. Participants completed a post-encounter survey describing demographics and experience. Data were reported using descriptive statistics. Qualitative data from open ended questions (eg, “What would you do?”) were examined using thematic analysis. Results Half of our participants had over 10 years of clinical experience. Most participants reported using medical research (18/23, 78%) and mortality calculators (17/23, 74%). Only the ethics-interested subgroup (10/23, 43%) listed counseling literature (7/10, 70%). Of 672 attempts, participants accurately identified VANESSA’s emotions 77.8% (523/672) of the time, and most (14/23, 61%) reported that they were confident in identifying these emotions. The ethics interest group was more likely to choose empathic responses (P=.002). Participants rated VANESSA as easy to use (22/23, 96%) and reported that she had realistic dialogue (15/23, 65%). Conclusions This pilot study shows that a prenatal counseling simulation is feasible and can yield useful data on prenatal counseling communication. Our participants showed a high rate of emotion recognition and empathy in their responses.
Collapse
Affiliation(s)
- Patrick Motz
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Megan Gray
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Taylor Sawyer
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Jennifer Kett
- Division of Neonatology, Department of Pediatrics, Mary Bridge Children's Hospital, Tacoma, WA, United States
| | - Douglas Danforth
- Medical Simulation, Obstetrics and Gynocology, Ohio State University, Columbus, OH, United States
| | - Kellen Maicher
- Medical Simulation, Obstetrics and Gynocology, Ohio State University, Columbus, OH, United States
| | - Rachel Umoren
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
| |
Collapse
|
28
|
Synnot A, Bragge P, Lowe D, Nunn JS, O'Sullivan M, Horvat L, Tong A, Kay D, Ghersi D, McDonald S, Poole N, Bourke N, Lannin N, Vadasz D, Oliver S, Carey K, Hill SJ. Research priorities in health communication and participation: international survey of consumers and other stakeholders. BMJ Open 2018; 8:e019481. [PMID: 29739780 PMCID: PMC5942413 DOI: 10.1136/bmjopen-2017-019481] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To identify research priorities of consumers and other stakeholders to inform Cochrane Reviews in 'health communication and participation' (including such concepts as patient experience, shared decision-making and health literacy). SETTING International. PARTICIPANTS We included anyone with an interest in health communication and participation. Up to 151 participants (18-80 years; 117 female) across 12 countries took part, including 48 consumers (patients, carers, consumer representatives) and 75 professionals (health professionals, policymakers, researchers) (plus 25 people who identified as both). DESIGN Survey. METHODS We invited people to submit their research ideas via an online survey open for 4 weeks. Using inductive thematic analysis, we generated priority research topics, then classified these into broader themes. RESULTS Participants submitted 200 research ideas, which we grouped into 21 priority topics. Key research priorities included: insufficient consumer involvement in research (19 responses), 'official' health information is contradictory and hard to understand (18 responses), communication/coordination breakdowns in health services (15 responses), health information provision a low priority for health professionals (15 responses), insufficient eliciting of patient preferences (14 responses), health services poorly understand/implement patient-centred care (14 responses), lack of holistic care impacting healthcare quality and safety (13 responses) and inadequate consumer involvement in service design (11 responses). These priorities encompassed acute and community health settings, with implications for policy and research. Priority populations of interest included people from diverse cultural and linguistic backgrounds, carers, and people with low educational attainment, or mental illness. Most frequently suggested interventions focused on training and cultural change activities for health services and health professionals. CONCLUSIONS Consumers and other stakeholders want research addressing structural and cultural challenges in health services (eg, lack of holistic, patient-centred, culturally safe care) and building health professionals' communication skills. Solutions should be devised in partnership with consumers, and focus on the needs of vulnerable groups.
Collapse
Affiliation(s)
- Anneliese Synnot
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Dianne Lowe
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Jack S Nunn
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Molly O'Sullivan
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Lidia Horvat
- Safer Care Victoria, Melbourne, Victoria, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Debra Kay
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Davina Ghersi
- NHMRC Clinical Trials Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- National Health and Medical Research Council, Canberra, New South Wales, Australia
| | - Steve McDonald
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Naomi Poole
- Australian Commission on Safety and Quality in Healthcare, Sydney, New South Wales, Australia
| | - Noni Bourke
- Bass Coast Health, Wonthaggi, Victoria, Australia
| | - Natasha Lannin
- Alfred Health, Melbourne, Victoria, Australia
- School of Allied Health (Occupational Therapy), La Trobe University, Melbourne, Victoria, Australia
| | - Danny Vadasz
- Health Issues Centre, Melbourne, Victoria, Australia
| | - Sandy Oliver
- University College London, London, UK
- Universityof Johannesburg, Johannesburg, South Africa
| | - Karen Carey
- Formerly of Consumers Health Forum, Canberra, Australia
| | - Sophie J Hill
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| |
Collapse
|
29
|
Antenatal Consultations at Extreme Prematurity: A Systematic Review of Parent Communication Needs. J Pediatr 2018; 196:109-115.e7. [PMID: 29223461 DOI: 10.1016/j.jpeds.2017.10.067] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/28/2017] [Accepted: 10/26/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To synthesize and describe parental expectations on how healthcare professionals should interact with them during a peripartum, antenatal consultation for extremely preterm infants. STUDY DESIGN For this systematic literature review with textual narrative synthesis, we included studies that explored parental perspectives regarding the antenatal consultation for an extremely preterm infant. Electronic searches of Medline, CINAHL, PsycInfo, and Embase were conducted, along with a search of the grey literature. Quality appraisal was conducted using the guide by Walsh and Downe. Two independent reviewers reviewed 783 titles, of which 130 abstracts then 40 full-text articles were reviewed. Final data abstraction includes 19 studies. We predetermined 6 topics of interest (setting, timing, preferred healthcare professional, information, resources, and parents-physician interaction) to facilitate thematic analysis. RESULTS In consideration of the variability of parents' specific desires, six predetermined topics and additional overarching themes such as perception of support, degree of understanding, hope, spirituality, and decision-making influences emerged. Studies suggest the quality of the antenatal consultation is not purely about information content, but also the manner in which it is provided. Limitations include thematic analysis that can potentially lead to the exclusion of important nuances. Relevant studies may have been missed if published outside the healthcare literature. CONCLUSIONS The findings may inform clinical practice guidelines. This paper includes suggested strategies related to parents' perspectives that may facilitate communication during antenatal consultation for an extremely preterm infant. These strategies may also support parental engagement and satisfaction.
Collapse
|
30
|
Geurtzen R, Van Heijst A, Hermens R, Scheepers H, Woiski M, Draaisma J, Hogeveen M. Preferred prenatal counselling at the limits of viability: a survey among Dutch perinatal professionals. BMC Pregnancy Childbirth 2018; 18:7. [PMID: 29298669 PMCID: PMC5751814 DOI: 10.1186/s12884-017-1644-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 12/21/2017] [Indexed: 01/10/2023] Open
Abstract
Background Since 2010, intensive care can be offered in the Netherlands at 24+0 weeks gestation (with parental consent) but the Dutch guideline lacks recommendations on organization, content and preferred decision-making of the counselling. Our aim is to explore preferred prenatal counselling at the limits of viability by Dutch perinatal professionals and compare this to current care. Methods Online nationwide survey as part of the PreCo study (2013) amongst obstetricians and neonatologists in all Dutch level III perinatal care centers (n = 205).The survey regarded prenatal counselling at the limits of viability and focused on the domains of organization, content and decision-making in both current and preferred practice. Results One hundred twenty-two surveys were returned out of 205 eligible professionals (response rate 60%). Organization-wise: more than 80% of all professionals preferred (but currently missed) having protocols for several aspects of counselling, joint counselling by both neonatologist and obstetrician, and the use of supportive materials. Most professionals preferred using national or local data (70%) on outcome statistics for the counselling content, in contrast to the international statistics currently used (74%). Current decisions on initiation care were mostly made together (in 99% parents and doctor). This shared decision model was preferred by 95% of the professionals. Conclusions Dutch perinatal professionals would prefer more protocolized counselling, joint counselling, supportive material and local outcome statistics. Further studies on both barriers to perform adequate counselling, as well as on Dutch outcome statistics and parents’ opinions are needed in order to develop a national framework. Trial registration Clinicaltrials.gov, NCT02782650, retrospectively registered May 2016. Electronic supplementary material The online version of this article (10.1186/s12884-017-1644-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- R Geurtzen
- Amalia Children's Hospital, Department of Pediatrics, Radboud university Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands.
| | - Arno Van Heijst
- Amalia Children's Hospital, Department of Pediatrics, Radboud university Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Rosella Hermens
- Scientific Institute for Quality of Care, Radboud university medical center, Nijmegen, The Netherlands
| | | | - Mallory Woiski
- Amalia Children's Hospital, Department of Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jos Draaisma
- Amalia Children's Hospital, Department of Pediatrics, Radboud university Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Amalia Children's Hospital, Department of Pediatrics, Radboud university Medical Center, PO Box 9101, 6500HB, Nijmegen, The Netherlands
| |
Collapse
|
31
|
Balan S, Hassali M, Mak V. Non-regulatory related factors leading to off-label prescribing in children: A concept map. Res Social Adm Pharm 2017; 13:1219-1221. [DOI: 10.1016/j.sapharm.2017.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 05/23/2017] [Indexed: 11/16/2022]
|
32
|
Boss RD, Lemmon ME, Arnold RM, Donohue PK. Communicating prognosis with parents of critically ill infants: direct observation of clinician behaviors. J Perinatol 2017; 37:1224-1229. [PMID: 28749479 PMCID: PMC5688012 DOI: 10.1038/jp.2017.118] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/27/2017] [Accepted: 06/26/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Delivering prognostic information to families requires clinicians to forecast an infant's illness course and future. We lack robust empirical data about how prognosis is shared and how that affects clinician-family concordance regarding infant outcomes. STUDY DESIGN Prospective audiorecording of neonatal intensive care unit family conferences, immediately followed by parent/clinician surveys. Existing qualitative analysis frameworks were applied. RESULTS We analyzed 19 conferences. Most prognostic discussion targeted predicted infant functional needs, for example, medications or feeding. There was little discussion of how infant prognosis would affect infant/family quality of life. Prognostic framing was typically optimistic. Most parents left the conference believing their infant's prognosis to be more optimistic than did clinicians. CONCLUSIONS Clinician approach to prognostic disclosure in these audiotaped family conferences tended to be broad and optimistic, without detail regarding implications of infant health for infant/family quality of life. Families and clinicians left these conversations with little consensus about infant prognosis.
Collapse
Affiliation(s)
- Renee D. Boss
- Johns Hopkins University School of Medicine,Berman Institute of Bioethics
| | - Monica E. Lemmon
- Johns Hopkins University School of Medicine,Duke University Medical Center
| | | | - Pamela K. Donohue
- Johns Hopkins University School of Medicine,Johns Hopkins Bloomberg School of Public Health
| |
Collapse
|
33
|
Tom DM, Aquino C, Arredondo AR, Foster BA. Parent Preferences for Shared Decision-making in Acute Versus Chronic Illness. Hosp Pediatr 2017; 7:602-609. [PMID: 28951430 PMCID: PMC5613816 DOI: 10.1542/hpeds.2017-0049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The goal of this study was to examine preferences for shared decision-making (SDM) in parents of acutely ill versus chronically ill children in the inpatient setting. Additionally, we explored the effect of parental perception of illness severity and uncertainty in illness on decision-making preference. METHODS In this cross-sectional study, we surveyed parents of children admitted to pediatric inpatient units at an academic, tertiary-care hospital. Surveys were administered in person and used validated tools to assess SDM preferences and uncertainty in illness. Descriptive statistics evaluated associations stratified by acute versus chronic illness, and multivariable analyses were performed. RESULTS Of the 200 parents who participated, the majority were women (78%), Hispanic (81.5%), English speaking (73%), between 30 and 39 years old (37.5%), and had an education achievement of less than a college degree (77%). The mean age of hospitalized children was 8.1 years, and half reported a chronic illness. Most parents preferred an active (43%) or collaborative (40%) role in SDM. There was no association with SDM preference by demographics, number of previous hospitalizations, perception of illness severity, or uncertainty. However, parents of chronically ill children significantly preferred a passive role in SDM when they perceived a high level of uncertainty in illness. CONCLUSIONS Most parents of hospitalized children prefer to take an active or collaborative role in SDM. However, parents of chronically ill children who perceive high levels of uncertainty surrounding their children's illness prefer a passive role, thus illustrating the complexity in decision-making among this parent population.
Collapse
Affiliation(s)
- Dina M Tom
- Division of Inpatient Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
- University Hospital, San Antonio, Texas
| | - Christian Aquino
- Division of Inpatient Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
- University Hospital, San Antonio, Texas
| | - Anthony R Arredondo
- Division of Inpatient Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
- University Hospital, San Antonio, Texas
| | - Byron A Foster
- Division of Inpatient Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
- University Hospital, San Antonio, Texas
| |
Collapse
|
34
|
Garfield CF, Karbownik K, Murthy K, Falciglia G, Guryan J, Figlio DN, Roth J. Educational Performance of Children Born Prematurely. JAMA Pediatr 2017; 171:764-770. [PMID: 28604933 PMCID: PMC5710633 DOI: 10.1001/jamapediatrics.2017.1020] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Survivors of preterm birth often present with medical morbidities; however, variation in their long-term educational performance has not been well described. OBJECTIVE To estimate the association between gestational age and 4 outcomes in school-aged children: readiness to enter kindergarten, scores on standardized tests in elementary and middle school, gifted status, and low performance. DESIGN, SETTING, AND PARTICIPANTS In a retrospective cohort study, children born in Florida between 1992 and 2002 at 23 to 41 weeks' gestation who entered Florida's public schools between 1995 and 2012 were assessed for kindergarten readiness and tested in mathematics and reading in grades 3 through 8. Data analysis was performed from January 12, 2016, to March 1, 2017. EXPOSURES Gestational age at birth. MAIN OUTCOMES AND MEASURES Kindergarten readiness, scores on the Florida Comprehensive Achievement Test (FCAT), classified as gifted, and classified as low performance. RESULTS A total of 1 527 113 singleton infants with gestational ages of 23 to 41 weeks born between 1992 and 2002 were matched to Florida public school records. Of these, 1 301 497 children were included in the analysis; 641 479 (49.3%) were girls. A total of 301 (65.0%) Florida children born at 23 to 24 weeks' gestation were designated as ready to start kindergarten. When the FCAT test scores were adjusted for potentially confounding maternal and infant variables, children born at 23 to 24 weeks' gestation performed 0.66 SD (95% CI, -0.73 to -0.59) lower compared with those born at full term. A total of 123 554 (9.5%) of all Florida-born public school students were considered gifted, including 17 (1.8%) of those born at 23 to 24 weeks' gestation. In comparison, 75 458 (5.8%) of all Florida-born public school students were low performing; 310 (33.5%) of these children had been born at 23 to 24 weeks' gestation. Kindergarten readiness, FCAT scores, and gifted status were positively related to gestational age, whereas low performance was inversely related to gestational age. CONCLUSIONS AND RELEVANCE Although gestational age has long been associated with poor educational performance, a sufficient proportion of children born near the limits of viability performed within expected school norms, warranting further investigation into how and why certain children are able to overcome the educational burdens that may follow preterm birth.
Collapse
Affiliation(s)
- Craig F. Garfield
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Institute for Policy Research, Northwestern University, Evanston, Illinois
| | | | - Karna Murthy
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gustave Falciglia
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan Guryan
- Institute for Policy Research, Northwestern University, Evanston, Illinois,Human Development and Social Policy, Northwestern University School of Education and Social Policy, Evanston, Illinois
| | - David N. Figlio
- Institute for Policy Research, Northwestern University, Evanston, Illinois,Human Development and Social Policy, Northwestern University School of Education and Social Policy, Evanston, Illinois
| | - Jeffrey Roth
- Department of Pediatrics, University of Florida, Gainesville
| |
Collapse
|
35
|
Zaal-Schuller IH, Willems DL, Ewals FVPM, van Goudoever JB, de Vos MA. How parents and physicians experience end-of-life decision-making for children with profound intellectual and multiple disabilities. RESEARCH IN DEVELOPMENTAL DISABILITIES 2016; 59:283-293. [PMID: 27665411 DOI: 10.1016/j.ridd.2016.09.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/28/2016] [Accepted: 09/15/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND End-of-life decisions (EoLD) often concern children with profound intellectual and multiple disabilities (PIMD). Yet, little is known about how parents and physicians discuss and make these decisions. AIMS The objective of this research was to investigate the experiences of the parents and the involved physician during the end-of-life decision-making (EoLDM) process for children with PIMD. METHODS In a retrospective, qualitative study, we conducted semi-structured interviews with the physicians and parents of 14 children with PIMD for whom an EoLD was made within the past two years. RESULTS A long-lasting relationship appeared to facilitate the EoLDM process, although previous negative healthcare encounters could also lead to distrust. Parents and physicians encountered disagreements during the EoLDM process, but these disagreements could also improve the decision-making process. Most parents, as well as most physicians, considered the parents to be the experts on their child. In making an EoLD, both parents and physicians preferred a shared decision-making approach, although they differed in what they actually meant by this concept. CONCLUSION The EoLDM process for children with PIMD can be improved if physicians are more aware of the specific situation and of the roles and expectations of the parents of children with PIMD.
Collapse
Affiliation(s)
- I H Zaal-Schuller
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - D L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - F V P M Ewals
- Intellectual Disability Medicine, Department of General Practice, Erasmus Medical Centre Rotterdam, The Netherlands.
| | - J B van Goudoever
- Department of Paediatrics, Emma Children's Hospital - Academic Medical Centre, Amsterdam & Department of Paediatrics, VU University Medical Centre, Amsterdam, The Netherlands.
| | - M A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| |
Collapse
|
36
|
Daboval T, Shidler S, Thomas D. Shared Decision Making at the Limit of Viability: A Blueprint for Physician Action. PLoS One 2016; 11:e0166151. [PMID: 27893823 PMCID: PMC5125593 DOI: 10.1371/journal.pone.0166151] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 10/23/2016] [Indexed: 12/05/2022] Open
Abstract
Objective To document interactions during the antenatal consultation between parents and neonatologist that parents linked to their satisfaction with their participation in shared decision making for their infant at risk of being born at the limit of viability. Methods This multiple-case ethnomethodological qualitative research study, included mothers admitted for a threatened premature delivery between 200/7 and 266/7 weeks gestation, the father, and the staff neonatologist conducting the clinical antenatal consultation. Content analysis of an audiotaped post-antenatal consultation interview with parents obtained their satisfaction scores as well as their comments on physician actions that facilitated their desired participation. Results Five cases, each called a “system—infant at risk”, included 10 parents and 6 neonatologists. From the interviews emerged a blueprint for action by physicians, including communication strategies that parents say facilitated their participation in decision making; such as building trustworthy physician-parent relationships, providing "balanced" information, offering choices, and allowing time to think. Conclusion Parent descriptions indicate that the opportunity to participate to their satisfaction in the clinical antenatal consultation depends on how the physician interacts with them. Practice implications The parent-identified communication strategies facilitate shared decision making regarding treatment in the best interest of the infant at risk to be born at the limit of viability.
Collapse
Affiliation(s)
- Thierry Daboval
- Children’s hospital of Eastern Ontario. Department Pediatrics. The Ottawa Hospital, Department of Obstetrics and Gynecology. University of Ottawa, Ottawa, Canada
- * E-mail:
| | - Sarah Shidler
- Department of Health Science Sciences, University of Quebec in Abitibi-Temiscamingue, Rouyn-Noranda, Québec, Canada
| | - Daniel Thomas
- Department of Human Sciences, University of Quebec in Abitibi-Temiscamingue, Rouyn-Noranda, Québec, Canada
| |
Collapse
|
37
|
Doronjski A, Stojanović V. Ethical issues in the treatment of extremely low birth weight neonates. Croat Med J 2016; 57:395-7. [PMID: 27586555 PMCID: PMC5048224 DOI: 10.3325/cmj.2016.57.395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Vesna Stojanović
- Vesna Stojanović, Institute for Child and Youth Health Care of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia,
| |
Collapse
|
38
|
Xafis V, Watkins A, Wilkinson D. Death talk: Basic linguistic rules and communication in perinatal and paediatric end-of-life discussions. PATIENT EDUCATION AND COUNSELING 2016; 99:555-561. [PMID: 26561310 DOI: 10.1016/j.pec.2015.10.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 10/22/2015] [Accepted: 10/28/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE This paper considers clinician/parent communication difficulties noted by parents involved in end-of-life decision-making in the light of linguistic theory. METHODS Grice's Cooperative Principle and associated maxims, which enable effective communication, are examined in relation to communication deficiencies that parents have identified when making end-of-life decisions for the child. Examples from the literature are provided to clarify the impact of failing to observe the maxims on parents and on clinician/parent communication. RESULTS Linguistic theory applied to the literature on parental concerns about clinician/parent communication shows that the violation of the maxims of quantity, quality, relation, and manner as well as the stance that some clinicians adopt during discussions with parents impact on clinician/parent communication and lead to distrust, anger, sadness, and long-term difficulties coping with the experience of losing one's child. CONCLUSION Parents have identified communication deficiencies in end-of-life discussions. Relating these communication deficiencies to linguistic theory provides insight into communication difficulties but also solutions. PRACTICE IMPLICATIONS Gaining an understanding of basic linguistic theory that underlies human interactions, gaining insight into the communication deficiencies that parents have identified, and modifying some communication behaviours in light of these with the suggestions made in this article may lead to improved clinician/parent communication.
Collapse
Affiliation(s)
- Vicki Xafis
- Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia.
| | | | - Dominic Wilkinson
- Discipline of Obstetrics and Gynaecology, Women's and Children's Hospital, The University of Adelaide, Adelaide, Australia; Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.
| |
Collapse
|
39
|
Geurtzen R, van Heijst AFJ, Babarao S, Molloy E, Draaisma JMT, Hogeveen M. Practices in antenatal counseling for extremely premature infants amongst European trainees. J Matern Fetal Neonatal Med 2016; 29:3956-9. [DOI: 10.3109/14767058.2016.1152245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Rosa Geurtzen
- Radboudumc Amalia Children’s Hospital, Nijmegen, The Netherlands,
| | | | | | - Eleanor Molloy
- Royal College of Surgeons, Dublin, Ireland, and
- National Maternity Hospital, Dublin, Ireland
| | - Jos MT Draaisma
- Radboudumc Amalia Children’s Hospital, Nijmegen, The Netherlands,
| | - Marije Hogeveen
- Radboudumc Amalia Children’s Hospital, Nijmegen, The Netherlands,
| |
Collapse
|
40
|
Boss RD, Donohue PK, Larson SM, Arnold RM, Roter DL. Family Conferences in the Neonatal ICU: Observation of Communication Dynamics and Contributions. Pediatr Crit Care Med 2016; 17:223-30. [PMID: 26684988 PMCID: PMC4779670 DOI: 10.1097/pcc.0000000000000617] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Clinicians in the neonatal ICU must engage in clear and compassionate communication with families. Empirical, observational studies of neonatal ICU family conferences are needed to develop counseling best practices and to train clinicians in key communication skills. We devised a pilot study to record and analyze how interdisciplinary neonatal ICU clinicians and parents navigate difficult conversations during neonatal ICU family conferences. DESIGN We prospectively identified and audiotaped a convenience sample of neonatal ICU family conferences about "difficult news." Conversations were analyzed using the Roter interaction analysis system, a quantitative tool for assessing content and quality of patient-provider communication. SETTING An urban academic children's medical center with a 45-bed level IV neonatal ICU. SUBJECTS Neonatal ICU parents and clinicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 19 family conferences that included 31 family members and 23 clinicians. The child's mother was included in all conferences, and a second parent, usually the father, was present in 13 conferences. All but one conference included multiple medical team members. On average, physicians contributed 65% of all dialogue, regardless of who else was present. Over half (56%) of this dialogue involved giving medical information; under 5% of clinician dialogue involved asking questions of the family, and families rarely (5% of dialogue) asked questions. Conversations were longer with the presence of nonphysician clinicians, but this did not increase the amount of dialogue about psychosocial information or increase parent dialogue. CONCLUSIONS We collected a novel repository of audio-recorded neonatal ICU family meetings that offers insights into discussion content and process. These meetings were heavily focused on biomedical information even when interdisciplinary clinicians were present. Clinicians always talked more than parents, and no one asked many questions. Maximizing the participation of interdisciplinary clinicians in neonatal ICU family meetings may require explicit strategies. Methods to increase family engagement should be targeted.
Collapse
Affiliation(s)
- Renee D. Boss
- Johns Hopkins University School of Medicine,Berman Institute of Bioethics
| | - Pamela K. Donohue
- Johns Hopkins University School of Medicine,Johns Hopkins Bloomberg School of Public Health
| | - Susan M. Larson
- Johns Hopkins University School of Medicine,Johns Hopkins Bloomberg School of Public Health
| | | | - Debra L. Roter
- Johns Hopkins University School of Medicine,Johns Hopkins Bloomberg School of Public Health
| |
Collapse
|
41
|
Perinatal practice in extreme premature delivery: variation in Dutch physicians' preferences despite guideline. Eur J Pediatr 2016; 175:1039-46. [PMID: 27251669 PMCID: PMC4930484 DOI: 10.1007/s00431-016-2741-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/19/2016] [Accepted: 05/25/2016] [Indexed: 11/04/2022]
Abstract
UNLABELLED Decisions at the limits of viability about initiating care are challenging. We aimed to investigate physicians' preferences on treatment decisions, against the background of the 2010 Dutch guideline offering active care from 24(+0/7) weeks of gestational age (GA). Obstetricians' and neonatologists' opinions were compared. An online survey was conducted amongst all perinatal professionals (n = 205) of the 10 Dutch level III perinatal care centers. Response rate was 60 % (n = 122). Comfort care was mostly recommended below 24(+0/7) weeks and intensive care over 26(+0/7) weeks. The professional views varied most at 24 and 25 weeks, with intensive care recommended but comfort care at parental request optional being the median. There was a wide range in perceived lowest limits of GA for interventions as a caesarian section and a neonatologist present at birth. Obstetricians and neonatologists disagreed on the lowest limit providing chest compressions and administering epinephrine for resuscitation. The main factors restricting active treatment were presence of congenital disorders, "small for gestational age" fetus, and incomplete course of corticosteroids. CONCLUSION There was a wide variety in individually preferred treatment decisions, especially when aspects were not covered in the Dutch guideline on perinatal practice in extreme prematurity. Furthermore, obstetricians and neonatologists did not always agree. WHAT IS KNOWN • Cross-cultural differences exists in the preferred treatment at the limits of viability • In the Netherlands since 2010, intensive care can be offered starting at 24 (+0/7) weeks gestation What is new: • There was a wide variety in preferred treatment decisions at the limits of viability especially when aspects were not covered in the Dutch national guideline on perinatal practice in extreme prematurity.
Collapse
|
42
|
Ireland S, Ray R, Larkins S, Woodward L. Factors influencing the care provided for periviable babies in Australia: a narrative review. Reprod Health 2015; 12:108. [PMID: 26608822 PMCID: PMC4660795 DOI: 10.1186/s12978-015-0094-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 10/31/2015] [Indexed: 11/15/2022] Open
Abstract
Survival at extreme prematurity is becoming increasingly common. Neurodisability is an increasing risk with decreasing gestation. This review outlines the risks of extreme prematurity and the attitudes of health care providers and families in Australia of periviable babies. High quality data is difficult to find due to differing definitions and methods of assessment of disability. Meta-analyses of outcomes of prematurity published from 2008 to 2013, including babies born from 1990 onwards, suggest a severe disability rate of around 20 % at 22 to 26 weeks completed gestation, with moderate disability decreasing with increasing gestation. Studies show that Australian health care providers underestimate the survival and positive outcomes of these babies. The majority of Australian health care providers state that parental preference would determine the decision to offer care to babies at 23 weeks gestation, however, all had a threshold above which parental preference would be ignored in favour of resuscitation .This ranged from 22 to 27 completed weeks gestation. The few studies examining Australian parental involvement in resuscitation decisions, showed that the majority of parents felt that health professionals alone had made the decision to resuscitate their extremely preterm babies and the parents themselves did not wish to be the primary decision makers in withholding care. The babies progressed better than parents had expected following antenatal counselling. The attitudes of health care providers, experiences and opinions of parents seem to be at odds with the current move to increase parental decision making at the most extremes of gestation. Current Australian guidelines suggest parental decision making below 25 weeks gestation, and primarily clinician decision making over this gestation. The increased risks of prematurity and adverse outcomes for the North Queensland population is also explored. This population has a high proportion of Aboriginal and Torres Strait Islanders who have increased risks which are primarily linked to poor socioeconomic factors and are highest for the most remote residents. Attitudes towards delivery of care to these highest risk babies from health professionals and in the populations themselves have not been studied.
Collapse
Affiliation(s)
- Susan Ireland
- The neonatal unit, The Townsville Hospital, 100 Angus Smith Dve, Douglas, Queensland, 4814, Australia.
| | - Robin Ray
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, 4814, Australia.
| | - Sarah Larkins
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, 4814, Australia.
| | - Lynn Woodward
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, 4814, Australia.
| |
Collapse
|
43
|
Xafis V, Gillam L, Hynson J, Sullivan J, Cossich M, Wilkinson D. Caring Decisions: The Development of a Written Resource for Parents Facing End-of-Life Decisions. J Palliat Med 2015; 18:945-55. [PMID: 26418215 PMCID: PMC4638203 DOI: 10.1089/jpm.2015.0048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Written resources in adult intensive care have been shown to benefit families facing end of life (EoL) decisions. There are few resources for parents making EoL decisions for their child and no existing resources addressing ethical issues. The Caring Decisions handbook and website were developed to fill these gaps. Aim: We discuss the development of the resources, modification after reviewer feedback and findings from initial pilot implementation. Design: A targeted literature review-to identify resources and factors that impact on parental EoL decision-making; development phase-guided by the literature and the researchers' expertise; consultation process-comprised a multi-disciplinary panel of experts and parents; pilot evaluation study-hard-copy handbook was distributed as part of routine care at an Australian Children's Hospital. Setting/Participants: Twelve experts and parents formed the consultation panel. Eight parents of children with life-limiting conditions and clinicians were interviewed in the pilot study. Results: Numerous factors supporting/impeding EoL decisions were identified. Caring Decisions addressed issues identified in the literature and by the multidisciplinary research team. The consultation panel provided overwhelmingly positive feedback. Pilot study parents found the resources helpful and comforting. Most clinicians viewed the resources as very beneficial to parents and identified them as ideal for training purposes. Conclusions: The development of the resources addressed many of the gaps in existing resources. The consultation process and the pilot study suggest these resources could be of significant benefit to parents and clinicians.
Collapse
Affiliation(s)
- Vicki Xafis
- 1 Discipline of Obstetrics and Gynaecology, Women's and Children's Hospital, The University of Adelaide , Adelaide, Australia .,2 The Sydney Children's Hospitals Network , Westmead, New South Wales, Australia
| | - Lynn Gillam
- 3 Children's Bioethics Centre, The Royal Children's Hospital , Melbourne, Australia .,5 Centre for Health Equity, University of Melbourne , Melbourne, Australia
| | - Jenny Hynson
- 4 Victorian Paediatric Palliative Care Program, The Royal Children's Hospital , Melbourne, Australia
| | - Jane Sullivan
- 3 Children's Bioethics Centre, The Royal Children's Hospital , Melbourne, Australia .,5 Centre for Health Equity, University of Melbourne , Melbourne, Australia
| | - Mary Cossich
- 6 Disciplines of Palliative Medicine and General Paediatrics, Women's and Children's Health Network , Adelaide, Australia
| | - Dominic Wilkinson
- 1 Discipline of Obstetrics and Gynaecology, Women's and Children's Hospital, The University of Adelaide , Adelaide, Australia .,7 Medical Ethics Department, Oxford Uehiro Centre for Practical Ethics, Oxford University , Oxford, United Kingdom .,8 John Radcliffe Hospital , Oxford, United Kingdom
| |
Collapse
|
44
|
Xafis V, Wilkinson D, Sullivan J. What information do parents need when facing end-of-life decisions for their child? A meta-synthesis of parental feedback. BMC Palliat Care 2015; 14:19. [PMID: 25924893 PMCID: PMC4424961 DOI: 10.1186/s12904-015-0024-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 04/23/2015] [Indexed: 11/17/2022] Open
Abstract
Background The information needs of parents facing end-of-life decisions for their child are complex due to the wide-ranging dimensions within which such significant events unfold. While parents acknowledge that healthcare professionals are their main source of information, they also turn to a variety of additional sources of written information in an attempt to source facts, discover solutions, and find hope. Much has been written about the needs of parents faced with end-of-life decisions for their child but little is known about the written information needs such parents have. Research in the adult intensive care context has shown that written resources impact positively on the understanding of medical facts, including diagnoses and prognoses, communication between families and healthcare professionals, and the emotional wellbeing of families after their relative’s death. Methods A meta-synthesis of predominantly empirical research pertaining to features which assist or impede parental end-of-life decisions was undertaken to provide insight and guidance in our development of written resources (short print and online comprehensive version) for parents. Results The most prominently cited needs in the literature related to numerous aspects of information provision; the quantity, quality, delivery, and timing of information and its provision impacted not only on parents’ ability to make end-of-life decisions but also on their emotional wellbeing. The meta-synthesis supports the value of written materials, as these provide guidance for both parents and healthcare professionals in pertinent content areas. Conclusions Further research is required to determine the impact that written resources have on parental end-of-life decision-making and on parents’ wellbeing during and after their experience and time in the hospital environment. Electronic supplementary material The online version of this article (doi:10.1186/s12904-015-0024-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Vicki Xafis
- Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia.
| | - Dominic Wilkinson
- Discipline of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia. .,John Radcliffe Hospital Oxford, Director of Medical Ethics, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK.
| | - Jane Sullivan
- Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Australia. .,The Centre for Health Equity, The University of Melbourne, Melbourne, Australia.
| |
Collapse
|
45
|
Xafis V, Wilkinson D, Gillam L, Sullivan J. Balancing obligations: should written information about life-sustaining treatment be neutral? JOURNAL OF MEDICAL ETHICS 2015; 41:234-239. [PMID: 24763219 PMCID: PMC4345516 DOI: 10.1136/medethics-2013-101965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 03/04/2014] [Accepted: 04/02/2014] [Indexed: 06/03/2023]
Abstract
Parents who are facing decisions about life-sustaining treatment for their seriously ill or dying child are supported by their child's doctors and nurses. They also frequently seek other information sources to help them deal with the medical and ethical questions that arise. This might include written or web-based information. As part of a project involving the development of such a resource to support parents facing difficult decisions, some ethical questions emerged. Should this information be presented in a strictly neutral fashion? Is it problematic if narratives, arguments or perspectives appear to favour stopping over continuing life-sustaining treatment? Similar questions might arise with written materials about decisions for adults, or for other ethically contentious decisions. This paper explores the meaning of 'balance' in information provision, focusing particularly on written information about life-sustaining treatment for children. We contrast the norm of non-directiveness in genetic counselling with the shared decision-making model often endorsed in end-of-life care. We review evidence that parents do not find neutrality from medical professionals helpful in discussions. We argue that balance in written information must be understood in the light of the aim of the document, the most common situation in which it will be used, and any existing biases. We conclude with four important strategies for ensuring that non-neutral information is nevertheless ethically appropriate.
Collapse
Affiliation(s)
- Vicki Xafis
- Perinatal Ethics Unit, Discipline of Obstetrics and Gynaecology, Robinson Institute, The University of Adelaide, North Adelaide, South Australia, Australia
| | - Dominic Wilkinson
- Department of Neonatal Medicine, Robinson Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jane Sullivan
- Centre for Health and Society, University of Melbourne, Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
46
|
Characterization of health care provider attitudes toward parental involvement in neonatal resuscitation-related decision making in Mongolia. Matern Child Health J 2014; 18:920-9; quiz 927-8. [PMID: 23807716 DOI: 10.1007/s10995-013-1319-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to characterize attitudes and practices among health care providers (HCPs) in Mongolia regarding parental involvement in neonatal resuscitation (NR)-related decisions. A voluntary, anonymous questionnaire was administered to 210 HCPs across 19 of 21 Mongolia provinces. Eligible HCPs included midwives, neonatologists, pediatricians, and obstetricians involved in neonatal-perinatal care in both rural and urban hospitals. A total of 210 pediatric HCPs were surveyed and 100 % completed all questions (response rate 100 %). Despite the absence of nation-wide guidelines, NR is uniformly performed at 32-weeks gestation across HCP professions and across rural/urban settings. Most HCPs (67 %) indicate that parents should be counseled about resuscitation, but only 9 % ask the parents if they want their extremely premature child resuscitated and only 17 % counsel the parents prior to birth of an at-risk infant. Most HCPs (72 %) prefer to unilaterally decide when to withdraw NR, and only 28 % indicated that both parents should be involved in the decision. Following a newborn's death, 75 % of all HCPs reported that they do explain the death to parents, although only 28 % reported receiving any training in parental grief counseling. For HCPs in Mongolia, a discrepancy exists between the perceived value of parental involvement and the actual practice of NR-related counseling. This report is a necessary first step toward understanding the factors that influence NR-related practices in Mongolia, and may serve as model for collecting these types of data in other low and middle income countries.
Collapse
|
47
|
Abstract
Comparative effectiveness research (CER) is a relatively new term for clinical research that directly assists patients, clinicians, and policymakers in making informed decisions to improve health care. In neonatology, there are similarities and differences between CER and existing clinical research and quality improvement literature. This article uses existing examples in neonatal literature to describe CER methodology and list some future directions and challenges in neonatal CER.
Collapse
|
48
|
Salmeen K, Janvier A, Sayeed SA, Drey EA, Lantos J, Partridge JC. Perspectives on anticipated quality-of-life and recommendations for neonatal intensive care: a survey of neonatal providers. J Matern Fetal Neonatal Med 2014; 28:1461-6. [PMID: 25164615 DOI: 10.3109/14767058.2014.957668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Explore associations between neonatal providers' perspectives on survival, quality of life (QOL) and treatment recommendations. METHODS Providers attending a workshop on neonatal viability were surveyed about survival, perceived QOL and treatment recommendations for marginally viable infants. We assessed associations between estimated survival and perceived QOL and treatment recommendations. RESULTS In the 44 included surveys, estimates of survival and QOL varied widely. Maximum care was recommended 80% of the time when anticipated QOL was high, versus 20% when anticipated QOL was low (p < 0.001). Adjusted for confounders, odds of recommending maximum intervention were 4.4 times higher when anticipated QOL was high (95% CI 1.9 - 10.2, p = 0.001). CONCLUSIONS The perspectives of practitioners who provide care to critically ill neonates regarding potential survival and QOL vary dramatically and are associated with the treatments those practitioners recommend. Practitioners should take care to avoid basing treatment recommendations on their own perspectives if they are not well aligned with those of the parents.
Collapse
Affiliation(s)
- Kirsten Salmeen
- a Department of Obstetrics , Gynecology, and Reproductive Sciences, University of California , San Francisco , CA
| | | | | | | | | | | |
Collapse
|
49
|
|
50
|
Allen KA. Parental decision-making for medically complex infants and children: an integrated literature review. Int J Nurs Stud 2014; 51:1289-304. [PMID: 24636443 DOI: 10.1016/j.ijnurstu.2014.02.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 01/13/2014] [Accepted: 02/08/2014] [Indexed: 11/13/2022]
Abstract
BACKGROUND Many children with life-threatening conditions who would have died at birth are now surviving months to years longer than previously expected. Understanding how parents make decisions is necessary to prevent parental regret about decision-making, which can lead to psychological distress, decreased physical health, and decreased quality of life for the parents. OBJECTIVE The aim of this integrated literature review was to describe possible factors that affect parental decision-making for medically complex children. The critical decisions included continuation or termination of a high-risk pregnancy, initiation of life-sustaining treatments such as resuscitation, complex cardiothoracic surgery, use of experimental treatments, end-of-life care, and limitation of care or withdrawal of support. DESIGN PubMed, Cumulative Index of Nursing and Allied Health Literature, and PsycINFO were searched using the combined key terms 'parents and decision-making' to obtain English language publications from 2000 to June 2013. RESULTS The findings from each of the 31 articles retained were recorded. The strengths of the empirical research reviewed are that decisions about initiating life support and withdrawing life support have received significant attention. Researchers have explored how many different factors impact decision-making and have used multiple different research designs and data collection methods to explore the decision-making process. These initial studies lay the foundation for future research and have provided insight into parental decision-making during times of crisis. CONCLUSIONS Studies must begin to include both parents and providers so that researchers can evaluate how decisions are made for individual children with complex chronic conditions to understand the dynamics between parents and parent-provider relationships. The majority of studies focused on one homogenous diagnostic group of premature infants and children with complex congenital heart disease. Thus comparisons across other child illness categories cannot be made. Most studies also used cross-sectional and/or retrospective research designs, which led to researchers and clinicians having limited understanding of how factors change over time for parents.
Collapse
Affiliation(s)
- Kimberly A Allen
- University of Washington, Biobehavioral Nursing and Health Systems, United States.
| |
Collapse
|