Limits of viability: dilemmas, decisions, and decision makers

Buy-in and breakthroughs: the Overton window in neonatology for the resuscitation of extremely preterm infants

To understand the future of neonatology, it is important to reflect upon the past and the factors that lead to significant advances in the field. In this article, we explore the evolving landscape of neonatology and the shifting practices in the resuscitation of extremely premature infants, with a particular focus on societal influences that have driven these changes. Using the political policy concept of an Overton Window, we explore how breakthroughs move from unthinkable to acceptable practice and how the increasing involvement of parents and their advocacy efforts have played a pivotal role in that progress. In the era of expanded shared decision making, it is crucial that we apply that same approach to setting priorities in our field, acknowledging the crucial perspectives of both parents and former premature infants in shaping the future of neonatology.

Developing eHealth in neonatal care to enhance parents' self-management

BACKGROUND

Discharge from a neonatal care unit is often experienced as a vulnerable time for parents. By communicating through digital technology, it may be possible to improve the support for parents and thereby make the transition from hospital to home less stressful.

AIM

To develop an eHealth device supporting the transition from hospital to home for parents with a preterm-born child in Sweden using participatory design.

METHOD

Employing a framework of complex interventions in health care using participatory design. Parents of preterm-born infants and professionals at a neonatal department identified specific technical requirements for an eHealth device to be developed in the context of neonatal care and neonatal home care. The prospective end-users - parents and professionals - were continuously involved in the process of designing solution prototypes through meetings, verbal and written feedback, and interviews. The interviews were analysed using thematic analysis.

RESULTS

Technical development was carried out with the perspectives of professionals and parents in mind, resulting in an eHealth application for computer tablets. The findings from the interviews with the parents and professionals revealed three categories: The tablets felt secure, easy to use and sometimes replaced visits to hospital and at home.

CONCLUSION

The use of participatory design to develop an eHealth device to support a safe transition from hospital to home can benefit parents, the child, the family, and professionals in neonatal care.

Decision-making at the border of viability: determining the best interests of extremely preterm infants

This paper proposes and employs a framework for determining whether life-saving treatment at birth is in the best interests of extremely preterm infants, given uncertainty about the outcome of such a choice. It argues that given relevant data and plausible assumptions about the well-being of babies with various outcomes, it is typically in the best interests of even the youngest preterm infants-those born at 22 weeks gestational age-to receive life-saving treatment at birth.

The importance of shared decision-making in the neonatal intensive care unit

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.

Values-based shared decision-making in the antenatal period

Despite advances in life-saving technology for critically ill neonates, challenges continue to arise for infants delivered with extreme prematurity, congenital anomalies, and genetic conditions that exceed the limits of currently available interventions. In these situations, parents are forced to make cognitively and emotionally difficult decisions, in discussion with a neonatologist, regarding how aggressively to provide supportive measures at the time of delivery and at what point burdens of therapy outweigh benefits. Current guidelines recommend that parents' values should guide these decisions; however, little is known about the values parents hold, and how those values are employed in the context of complexity, uncertainty, and emotionality of these situations. Systematic investigation of how parents derive their values and how clinicians should engage with parents about those values is necessary to guide the development of interventions to enhance shared decision-making processes, ultimately improving satisfaction, coping, and resilience and minimizing the potential for regret.

Antenatal corticosteroids for neonates born before 25 Weeks-A systematic review and meta-analysis

BACKGROUND

Efficacy of antenatal corticosteroids before 25 weeks of gestation is unclear.

OBJECTIVE

To assess and compare neonatal outcomes following ANC exposure at 22, 23 and 24 weeks of gestation by conducting systematic review and meta- analysis.

METHODS

A systematic review of randomised controlled trials (RCT) and non-RCTs reporting on neonatal outcomes after exposure to ANC up to 246 weeks of gestation using the Cochrane systematic review methodology. Databases Pubmed, CINAHL, Embase, Cochrane Central library, and online abstracts of conference proceedings including the Pediatric Academic Society (PAS) were searched in Feb 2017. Primary outcome was in-hospital mortality defined as death before discharge during the first admission. Secondary outcomes included severe intraventricular hemorrhage (IVH> grade III and IV)/or periventricular leukomalacia (PVL), necrotising enterocolitis (NEC >stage II) and chronic lung disease (CLD). Meta-analysis was performed using a random-effects model. The level of evidence (LOE) was summarised using the GRADE guidelines.

MAIN RESULTS

There were no RCTs; 8 high quality non-RCTs were included in the review. Meta-analysis showed reduction in mortality [N = 10109; OR = 0.47(0.39-0.56), p<0.00001; LOE: Moderate] and severe IVH and PVL [N = 5084; OR = 0.71(0.61-0.82), p<0.00001; LOE: Low] after exposure to ANC in neonates born <25 weeks. There was no significant difference in CLD [N = 4649; OR = 1.19(0.85-1.65) p = 0.31; LOE: Low] and NEC [N = 5403; OR = 0.95 (0.76-1.19) p = 0.65; LOE: Low]. Mortality was comparable in neonates born at 22, 23 or 24 weeks.

CONCLUSION

Moderate to low quality evidence indicates that exposure to ANC is associated with reduction in mortality and IVH/or PVL in neonates born before 25 weeks.

Does diagnosis influence end-of-life decisions in the neonatal intensive care unit?

OBJECTIVE

To determine the influence of physiological status and diagnosis at the time of death on end-of-life care.

STUDY DESIGN

Retrospective descriptive study in a regional referral level IV neonatal intensive care unit (NICU) of infants who died from 1 January 1999 to 31 December 2008. Infants were categorized based on diagnosis (very preterm, congenital anomalies or other) and level of stability. Primary outcome was level of clinical service provided at end of life (care withheld, care withdrawn or full resuscitation).

RESULT

From 1999 to 2008, there were 414 deaths in the NICU. Congenital anomaly was the leading diagnosis at the time of death, representing 45% of all deaths. Comparing mode of death, very preterm newborns were more likely than infants with congenital anomalies to have received cardio-pulmonary resuscitation (CPR) at the time of death (26% vs 13%, P < 0.01) and were significantly more unstable (75% vs 52%, P < 0.01). Infants aged 22 to 24 weeks were mostly unstable and significantly more likely to receive CPR than infants with any other diagnosis.

CONCLUSION

Over the 10-year period, very preterm infants were more likely to be physiologically unstable and to receive CPR at the time of death than infants with any other diagnosis. This finding was especially true for infants at the edge of viability (22 to 24 weeks). These differences in end-of-life care suggest that the quality of life and medical futility may be viewed differently for the least mature infants.

Characterization of health care provider attitudes toward parental involvement in neonatal resuscitation-related decision making in Mongolia

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.

Policy change for infants born at the "cusp of viability": a Canadian NICU experience

Resuscitation and life-support treatments for infants born at the "cusp of viability" continue to be subject to clinical and ethical debate. Reported positive outcomes for these infants led our Neonatal Program to critically review our historic practice of discouraging resuscitation of infants born at <24 weeks' gestational age. This practice change required a multifaceted, collaborative approach including neonatal, perinatal, and obstetric efforts. An exceptional experience was the formation of a dedicated working group that included invaluable input from parents who had lived the NICU experience. The inclusion of family members in the development of clinical policy was a novel experience for NICU staff, which we feel ultimately resulted in a more ethically sound approach to the care of these infants and their families. In this article, we explore our experience of the process of policy change, which although detailed and transparent was also complex and challenging in development and implementation.

Periviable birth: executive summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation), and the treatment options for the newborn. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (for example, antenatal steroid, tocolytic agents and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect and understanding, and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists

This is an executive summary of a workshop on the management and counseling issues of women anticipated to deliver at a periviable gestation (broadly defined as 20 0/7 through 25 6/7 weeks of gestation) and the treatment options for the newborn infant. Upon review of the available literature, the workshop panel noted that the rates of neonatal survival and neurodevelopmental disabilities among the survivors vary greatly across the periviable gestations and are significantly influenced by the obstetric and neonatal management practices (eg, antenatal steroid, tocolytic agents, and antibiotic administration; cesarean birth; and local protocols for perinatal care, neonatal resuscitation, and intensive care support). These are, in turn, influenced by the variations in local and regional definitions of limits of viability. Because of the complexities in making difficult management decisions, obstetric and neonatal teams should confer prior to meeting with the family, when feasible. Family counseling should be coordinated with the goal of creating mutual trust, respect, and understanding and should incorporate evidence-based counseling methods. Since clinical circumstances can change rapidly with increasing gestational age, counseling should include discussion of the benefits and risks of various maternal and neonatal interventions at the time of counseling. There should be a plan for follow-up counseling as clinical circumstances evolve. The panel proposed a research agenda and recommended developing educational curricula on the care and counseling of families facing the birth of a periviable infant.

Divergent views of hope influencing communications between parents and hospital providers

This study evaluated parents' and health care providers' (HCPs) descriptions of hope following counseling of parents at risk of delivering an extremely premature infant. Data came from a longitudinal multiple case study investigation that examined the decision making and support needs of 40 families and their providers. Semistructured interviews were conducted before and after delivery. Divergent viewpoints of hope were found between parents and many HCPs and were subsequently coded using content analysis. Parents relied on hope as an emotional motivator, whereas most HCPs described parents' notions of hope as out of touch with reality. Parents perceived that such divergent beliefs about the role of hope negatively shaped communicative interactions and reduced trust with some of their providers. A deeper understanding of how varying views of hope might shape communications will uncover future research questions and lead to theory-based interventions aimed at improving the process of discussing difficult news with parents.

Ethical dilemmas in decision making at limits of neonatal viability

The survival rate for extremely preterm infants has improved over the last two decades. Although the incidence of such births is about 2%, the impact of preterm birth on these infants, their families, health-care providers, and society is profound. The birth of an extremely low birth weight (ELBW) and early gestational age infant poses complex medical, social, and ethical challenges to the family and health-care professionals. Survivors have an increased risk of chronic medical problems and disability. It is difficult to make decisions while trying to provide optimal medical care to the infant and supporting the family when delivery occurs at the threshold of viability because outcome at that time is highly unpredictable. Such decisions may have lifelong consequences for those involved.

An individualized prognostic strategy appears to be the most appropriate approach. While keeping the patient’s best interest as the primary objective, the goal is to reach, through a process of effective communication between the parents and physicians, a consensual decision that respects the parents’ wishes and promotes physician beneficence.

Family support and family-centered care in the neonatal intensive care unit: origins, advances, impact

Family-centered care (FCC) has been increasingly emphasized as an important and necessary element of neonatal intensive care. FCC is conceptualized as a philosophy with a set of guiding principles, as well as a cohort of programs, services, and practices that many hospitals have embraced. Several factors drive the pressing need for family-centered care and support of families of infants in NICUs, including the increase in the number of infants in NICUs; growth in diversity of the population and their concurrent needs; identification of parental and familial stress and lack of parenting confidence; and gaps in support for families, as identified by parents and NICU staff. We explore the origins of and advances in FCC in the NICU and identify various delivery methods and aspects of FCC and family support in the NICU. We examine the research and available evidence supporting FCC in the NICU and offer recommendations for increased dissemination and for future study.

Special health care needs of infants born at the limits of viability

OBJECTIVE

The objective of this study was to compare rates of survival and special health care needs (SHCN) from discharge to 18 months' corrected age between infants who were born between 22 and 24 weeks and 25 and 27 weeks and to determine predictors and persistence of SHCN.

METHODS

Data were collected on 508 infants who were born between 22 and 27 weeks from January 1, 1998, to December 31, 2002 at Women and Infants Hospital. SHCN was defined as need for home oxygen, medication, monitor, gastrostomy tube, or ventriculoperitoneal shunt. chi(2) was used to compare rates of survival and SHCN between groups. Regression analyses explored predictors of SHCN and their persistence.

RESULTS

Survival at 22 to 24 weeks was 53% vs 90% at 25 to 27 weeks. There were no 22-week survivors. Survivors at 23 to 24 weeks were more likely to be discharged on oxygen, a monitor, or medications; remain on oxygen or a monitor or require tube feeds at 18 months; and have a SHCN at any time than survivors who were born at 25 to 27 weeks. The strongest predictor of SHCN at discharge was chronic lung disease and at 18 months was public health insurance.

CONCLUSIONS

Rates of SHCN were high for infants who were born at the limits of viability. Although rates decreased with increasing age, 40% had persistent SCHN at 18 months. The association of public health insurance with persistent SHCN indicates a need for comprehensive health care and support services for infants with combined biological and environmental risks.

Ethical decision-making for extremely preterm deliveries: results of a qualitative survey among obstetricians and midwives

OBJECTIVE

To explore the practices, attitudes and feelings of obstetricians and midwives in cases of extreme prematurity.

METHODS

A qualitative study was conducted as part of a European Concerted Action (EUROBS) in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France. Semi-structured interviews lasted an average of 60 min and were tape-recorded. They were independently analyzed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated.

RESULTS

Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the fetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as being more inclined than the obstetric team to initiate intensive care. If the child was born alive, intensive care was started, in the knowledge that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, in particular when there was no emergency situation. Compared with obstetricians, midwives tended to have a less favorable perception of the neonatologists' practices, and to report less parental involvement in decision-making.

CONCLUSIONS

Decisions about the obstetric management and resuscitation of extremely preterm infants are usually made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

Supporting parents' decision making surrounding the anticipated birth of an extremely premature infant

Parents who are at risk for giving birth to an extremely premature infant, defined as 22 to 25 weeks' gestation, can find themselves faced with urgent treatment decisions for their unborn infant that have life-altering consequences. Despite the recommendation for involving parents in decision making for these infants, there is limited evidence regarding guidelines for involving parents. In this article, we describe a case from a larger collective case study that examines the decision making and the decision support needs of parents regarding life support decisions made over time (prenatally and postnatally) for extremely premature infants from the perceptions of parents, physicians, and nurses. For this case study, we describe decisions that were made during the antenatal hospitalization of the mother whose infant was stillborn, the support the parents received, and advice for healthcare professionals for improving care to families. For this case, the mother and father, a physician, and 2 nurses were interviewed before the birth of the infant. The findings in this case study demonstrate the importance of the nurse being present when information is given to parents, of informing with compassion, and helping parents to understand treatment options and decisions.

Outcomes for the extremely premature infant: what is new? And where are we going?

Two approaches were taken to determine what is new and where we are going in terms of outcomes for the extremely premature infant: publications from 2004 to 2007 were reviewed, and the 30-year outcome at the authors' institutions was assessed. Recent literature documents improving early childhood outcomes in the face of improved survival. Childhood cerebral palsy prevalence rates have been reported to be as low as 19 per 1000 live births for infants born at 20-27 weeks gestation. Vision and hearing loss have been reported in fewer than 1% of survivors. The rate of overall intellectual impairment has not improved, although impairment was reduced in a recent trial of caffeine therapy for apnea of prematurity, and this remains an important area for study. In sum, recent findings herald a more positive perspective on the outcome for extremely premature survivors. It can thus be expected that new intensive-care trials will attempt to reduce the proportion of survivors with adverse outcomes. Childhood assessments will have a greater focus on function and participation. Information on improved outcomes for preterm infants will inform guidelines of decision making used to help parents to determine what is best for their child. The audit component of follow-up studies will expand and more cohort and trial studies will become multicenter, national, and international.

Message framing and perinatal decisions

OBJECTIVES

The purpose of this study was to explore the effect of information framing on parental decisions about resuscitation of extremely premature infants. Secondary outcomes focused on elucidating the impact of other variables on treatment choices and determining whether those effects would take precedence over any framing effects.

METHODS

This confidential survey study was administered to adult volunteers via the Internet. The surveys depicted a hypothetical vignette of a threatened delivery at gestational age of 23 weeks, with prognostic outcome information framed as either survival with lack of disability (positive frame) or chance of dying and likelihood of disability among survivors (negative frame). Participants were randomly assigned to receive either the positively or negatively framed vignette. They were then asked to choose whether they would prefer resuscitation or comfort care. After completing the survey vignette, participants were directed to a questionnaire designed to test the secondary hypothesis and to explore possible factors associated with treatment decisions.

RESULTS

A total of 146 subjects received prognostic information framed as survival data and 146 subjects received prognostic information framed as mortality data. Overall, 24% of the sample population chose comfort care and 76% chose resuscitation. A strong trend was detected toward a framing effect on treatment preference; respondents for whom prognosis was framed as survival data were more likely to elect resuscitation. This framing effect was significant in a multivariate analysis controlling for religiousness, parental status, and beliefs regarding the sanctity of life. Of these covariates, only religiousness modified susceptibility to framing; participants who were not highly religious were significantly more likely to be influenced to opt for resuscitation by the positive frame than were participants who were highly religious.

CONCLUSIONS

Framing bias may compromise efforts to approach prenatal counseling in a nondirective manner. This is especially true for subsets of participants who are not highly religious.

The search for objective criteria at the limit of viability

BACKGROUND

Defining the limit of viability among very preterm infants remains a difficult issue. A recent study suggested severity of intrauterine growth retardation as a decisive criterion, reporting very poor survival for infants born at </=28 weeks with birth weight <2nd centile.

OBJECTIVE

To check whether the above criterion can be confirmed in a similar analysis of German data.

METHODS

Analyses were based on German population-based data from Lower Saxony, including preterm neonates (22-28 weeks) without severe congenital malformations (n = 3,453), born 1991-1999. For the definition of growth retardation postnatal (<3rd, <10th centile) and antenatal (<3rd centile) reference values were used.

RESULTS

Depending on the definition used, proportions of growth retarded infants varied considerably (4-16%). Survival rates increased from 0 to 64%, arguing against considering infants <28 weeks' GA as a homogenous group with regard to their odds for survival.

CONCLUSION

There is an association between severity of growth retardation and VLBW mortality in general, but overinterpreting results from single studies may lead to dangerous conclusions. Data from preterm infants should be stratified by week of gestation.

Problèmes éthiques posés par l'extrême prématurité: résultats d'une étude qualitative auprès des obstétriciens et des sages-femmes

OBJECTIVE

Our objective was to explore the practices, attitudes and feelings of obstetricians and midwives in case of extreme prematurity.

POPULATION AND METHODS

A qualitative study was conducted as part of a European Concerted Action (EUROBS) in 1999 and 2000 in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France respectively. Semi-structured, tape-recorded interviews were conducted and were independently analysed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated.

RESULTS

Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the foetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as more inclined than the obstetrical team to initiate intensive care. If the child was born alive, intensive care was started, knowing that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, less frequently at birth or after birth.

DISCUSSION AND CONCLUSION

Compared with obstetricians, midwives tended to have a less favourable perception of the neonatologists' practices, and to deplore the lack of parental information and involvement in decision-making. Decisions about the obstetrical management and resuscitation of extremely preterm infants are essentially always made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

Perinatal care at the borderlines of viability: a consensus statement based on a NSW and ACT consensus workshop

Perinatal care at the borderlines of viability demands a delicate balance between parents' wishes and autonomy, biological feasibility, clinicians' responsibilities and expectations, and the prospects of an acceptable long-term outcome - coupled with a tolerable margin of uncertainty. A multi-professional workshop with consumer involvement was held in February 2005 to agree on management of this issue in New South Wales and the Australian Capital Territory. Participants discussed and formulated consensus statements after an extensive consultation process. Consensus was reached that the "grey zone" is between 23 weeks' and 25 weeks and 6 days' gestation. While there is an increasing obligation to treat with increasing length of gestation, it is acceptable medical practice not to initiate intensive care during this period if parents so wish, after appropriate counselling. Poor condition at birth and the presence of serious congenital anomalies have an important influence on any decision not to initiate intensive care within the grey zone. Women at high risk of imminent delivery within the grey zone should receive appropriate and skilled counselling with the most relevant up-to-date outcome information. Management plans can thus be made before birth. Information should be simple, factual and consistent. The consensus statements developed will provide a framework to assist parents and clinicians in communication, decision making and managing these challenging situations.

Neonatal end-of-life care: a review of the research literature

While advances in neonatal medicine have increased the possibility of sustaining life for many infants, more infants still die in the neonatal period (birth to 27 days of life) than those in any other time in childhood. Despite this statistic, there still remains much that is unknown about both the needs and the care of these critically ill babies. Palliative care is a viable option for many of these infants and their families. However, palliative care is rarely provided as an option for families. To provide healthcare providers with an overview of palliative and end-of-life care for infants in the neonatal period, we conducted an integrative review of the current research literature. A total of 10 articles were selected for the review. Findings from these studies were summarized in 1 of 4 categories: practices of withdrawing or withholding life-sustaining treatment, pain management during ventilator withdrawal, parents and the decision-making process, and the dying process.

Survival and major neonatal complications in infants born between 22 0/7 and 24 6/7 weeks of gestation (1999-2003)

OBJECTIVE

This study was undertaken to compare survival and morbidity until discharge in infants born after 22-23 versus 24 weeks' gestational age (GA).

STUDY DESIGN

Cohort study of all infants 25 weeks or less, born in 3 tertiary perinatal centers (1999-2003).

RESULTS

Of a total of 336 infants, 133 (40%) died before or immediately after birth without the provision of life support, 203 (60%) received active neonatal treatment. Infants with life support (n = 82 at 22 to 23 weeks, n = 121 at 24 weeks) differed with respect to antenatal steroid prophylaxis (44% vs 62%) and cesarean section rate (51% vs 71%). Survival was 67% compared with 82% (P = .016). The incidence of intraventricular hemorrhage III or greater or periventricular leukomalacia (15/15%), severe retinopathy of prematurity (18/15%), and chronic lung disease (40/47%) was similar in both GA groups.

CONCLUSIONS

The provision of life support for extremely preterm infants increases their chance of survival without more neonatal morbidity.

Early prediction of poor outcome in extremely low birth weight infants by classification tree analysis

OBJECTIVE

To predict death or neurodevelopmental impairment (NDI) in extremely low birth weight infants by classification trees with recursive partitioning and automatic selection of optimal cut points of variables.

STUDY DESIGN

Data from the Trial of Indomethacin Prophylaxis in Preterms were randomly divided into development (n=784) and validation sets (n=262). Three models were developed for the combined outcome of death (8 days to 18 months) or NDI (cerebral palsy, cognitive delay, deafness, or blindness at 18 months corrected age): antenatal: antenatal data; early neonatal: antenatal+first 3 days data; and first week: antenatal, first 3 days, and 4th to 8th days data. Decision trees were tested on the validation set.

RESULTS

Variables associated with death/NDI in each model were: Antenatal: Gestation<or=25.5 weeks and antenatal steroids<7 days. Early neonatal: Birth weight<or=787 g and fluid intake>01 mL/kg/d. First week: Birth weight<or=787 g: transfusion>3 mL/kg/d. Birth weight>787 g: cranial echodense intraparenchymal lesion and transfusion>1 mL/kg/d. Correct classification rates were 61% to 62% for all models.

CONCLUSIONS

The ability to predict long-term morbidity/death in extremely low birth weight infants does not improve significantly over the first week of life. Effects of different variables depend on age.

Prenatal consultation practices at the border of viability: a regional survey

OBJECTIVE

We undertook a survey of all practicing neonatologists in New England to determine their attitudes and practices regarding prenatal consultations for infants at the border of viability.

METHODS

A self-administered anonymous survey, mailed to every practicing neonatologist in the 6 Northeast states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont, explored respondent attitudes and practices with respect to a hypothetical clinical scenario of a prenatal consultation for an infant at the border of viability.

RESULTS

Our final sample included 149 surveys from 175 eligible neonatologists, giving a response rate of 85%. Seventy-seven percent of respondents indicated that they thought neonatologists and parents should make the decision jointly to withhold resuscitation. Only 40% indicated that the decision actually is made by both parties. A majority of neonatologists (58%) saw their primary role during the prenatal consultation as providing factual information to the parents. Far fewer (27%) thought that their main role was to assist the parents in weighing the risks and benefits of various management options. A majority of respondents indicated that parental understanding of the mother's current medical situation (96%), desired parental role (77%), and parental prior experience with premature or handicapped children (64%) were frequently or always discussed. However, far fewer respondents reported frequently or always asking about parental interpretations of a "good quality of life" (42%), parental prior experiences with death or dying (30%), and parental religious or spiritual beliefs (25%). Short-term outcomes and complications such as the need for surfactant/respiratory distress syndrome (89%) and the risk of intraventricular hemorrhage (81%) were discussed more extensively than long-term outcomes such as motor delays or cerebral palsy (68%), cognitive delays or learning disabilities (63%), and chronic lung disease (61%). Multivariate logistic regression analysis revealed 2 characteristics that were significant predictors of shared decision-making for the final decision regarding resuscitation in the delivery room for extremely premature infants, ie, believing that the main role of the neonatologist during prenatal consultations is to help parents weigh the risks and benefits of each resuscitation option (odds ratio: 4.1; 95% confidence interval: 1.6-10.9) and having >10 years of clinical experience (odds ratio: 3.6; 95% confidence interval: 1.5-8.8).

CONCLUSIONS

Overall, our results showed that neonatologists are quite consistent in discussing clinical issues but quite varied in discussing social and ethical issues. If neonatologists are to perform complete prenatal consultations for infants at the border of viability as described by the latest American Academy of Pediatrics guidelines, then they will be expected to address quality-of-life values more robustly, to explain long-term outcomes, and to incorporate parental preferences during their conversations. Potential barriers to shared decision-making have yet to be outlined.

International comparison of care for very low birth weight infants: parents' perceptions of counseling and decision-making

OBJECTIVE

To characterize parent perceptions and satisfaction with physician counseling and delivery-room resuscitation of very low birth weight infants in countries with neonatal intensive care capacity.

STUDY DESIGN

Convenience sample of 327 parents of 379 inborn very low birth weight infants (<1501 g) who had received resuscitation and neonatal intensive care in 9 neonatal intensive care units (NICUs) in 6 Pacific Rim countries and in 2 California hospitals. The sample comprised mostly parents whose infants survived, because in some centers interviews of parents of nonsurviving infants were culturally inappropriate. Of 359 survivors for whom outcome data were asked of parents, 29% were reported to have long-term sequelae. Half-hour structured interviews were performed, using trained interpreters as necessary, at an interval of 13.7 months after the infant's birth. We compared responses to interview questions that detailed counseling patterns, factors taken into consideration in decisions, and acceptance of parental decision-making.

RESULTS

Parents' recall of perinatal counseling differed among centers. The majority of parents assessed physician counseling on morbidity and mortality as adequate in most, but not all, centers. They less commonly perceived discussions of other issues as adequate to their needs. The majority (>65%) of parents in all centers felt that they understood their infant's prognosis after physician counseling. The proportion of parents who expected long-term sequelae in their infant varied from 15% (in Kuala Lumpur, Malaysia) to 64% (in Singapore). The majority (>70%) of parents in all centers, however, perceived their infant's outcome to be better than they expected from physician counseling. A majority of parents across all centers feared that their infant would die in the NICU, and approximately one third continued to fear that their infant might die at home after nursery discharge. The parents' regard for physicians' and, to a lesser extent, partners' opinions was important in decision-making. Less than one quarter of parents perceived that physicians had made actual life-support decisions on their own except in Melbourne, Australia, and Tokyo, Japan (where 74% and 45% of parents, respectively, reported sole physician decision-making). Parents would have preferred to play a more active, but not autonomous, role in decisions made for their infants. Counseling may heighten parents' anxiety during and after their infant's hospitalization, but that does not diminish their recalled satisfaction with counseling and the decision-making process.

CONCLUSIONS

Counseling differs by center among these centers in Australasia and California. Given that parents desire to play an active role in decision-making for their premature infant, physicians should strive to provide parents the medical information critical for informed decision-making. Given that parents do not seek sole decision-making capacity, physicians should foster parental involvement in life-support decisions to the extent appropriate for local cultural norms.

Ethical Considerations in Neonatal Respiratory Care

Recent advances in neonatal care have greatly improved the chances for survival of very sick and/or very preterm neonates and have in fact changed the concept and the limits of viability. However, in some situations, when the infant's demise can only be postponed at the price of great suffering or when survival is associated with severe disabilities and an intolerable life for the patient and the parents, it may be unwise to employ the full armamentarium of modern neonatal intensive care. In those circumstances withholding or withdrawing mechanical ventilation and other life-saving, though invasive and painful, procedures might be a better option. This review examines the ethical principles underlying those difficult decisions, the most frequent circumstances where they should be considered, the role of parents and other parties in the decision-making process and the reported behavior of neonatologists in many American and European neonatal intensive care units.

Effectiveness of an intervention to improve parent-professional collaboration in neonatal intensive care

OBJECTIVE

This study tested the effect of an intervention to strengthen parent-professional collaboration by increasing the accuracy of parents' understanding of medically relevant information and providing parent-professional meetings to plan infants' care.

METHODS

A tri-ethnic sample of mothers of 154 very-low-birth-weight infants participated, with parents of 77 infants in a control group and parents of 77 infants in an intervention group. Comprehension of infant medical condition and satisfaction with collaboration in treatment decisions in the 2 groups were measured 3 times during the first 28 days after admission using 9 collaboration scales. Intervention effects were analyzed with ANOVA and ANCOVA.

RESULTS AND CONCLUSIONS

Statistically significant change was found in 6 of 9 scales used to measure collaboration and accuracy of parents' understanding. The intervention group had fewer unrealistic concerns (P = .018), and less uncertainty about infant medical conditions (P = .003); less decision conflict (P < or = .001), more satisfaction with the process by which medical decisions were made (P = .012) and with the amount of decision input they had (P = .058), and reported more shared decision making with professionals (P = .010). There were no statistically significant differences between the groups in satisfaction with infants' care, satisfaction with relationships with physicians and nurses, and satisfaction with the decisions made for their infants' treatment. Infant birth weight and gestational age and maternal demographic characteristics were found to influence collaboration results. The intervention was especially effective in improving understanding and collaboration in low-income, young, minority mothers.

Talking about the unthinkable: perinatal/neonatal communication issues and procedures

Clinician-parent conversations in perinatology and neonatology are demanding. They take place over a period of time and ask much of the clinician. Many parents insist that they want thorough explanations so they can understand the medical information and its impact on them. These cases involve copious amounts of medical and resource information and parents cannot assimilate it all at one time; thus, these conversations are extended dialogs. Conversational skills that seem essential for clinicians in this work include giving bad news, sharing information, and expressing empathy. Underlying the conversational skills are those habits that form the complete physician: curiosity that leads one to learn the parents' values; the skill to help parents apply these values as they make difficult decisions; patience to listen to and stick with these suffering people who are full of strong emotions; and finally, the courage and endurance to confront these difficult situations day after day.

Short-term outcome in infants with a birthweight less than 501 grams

AIM

To report survival and morbidity until discharge in preterm infants <501 g with life support started immediately after birth.

METHODS/STUDY DESIGN

Cohort study of all preterm infants with birthweights < 501 g born in three tertiary perinatal centres between 1 January 1998 and 31 December 2001 (gestational age (GA) 25.2 [21.0-30.7] wk; birthweight 435 [290-500] g; median [range]).

RESULTS

A total of 107 infants with birthweights <501 g were born. Twenty-nine were stillborn. A prenatal decision to initiate life support immediately after birth was reached in 9/37 (24%) infants <24.0 wk GA and in 39/42 (93%) infants > or =24.0 wk GA. Survival was 3/37 (8%) and 26/41 (63%) in infants <24 wk GA and > or =24.0 wk GA, respectively. Twenty-nine of the 48 infants with immediate life support (60%) survived (95% CI: 46-75%). Forty-two of these 48 (88%) infants were small for gestational age. No infant without immediate life support survived (0/30). Twenty-three (79%) survivors developed chronic lung disease (CLD) and eight (28%) received photocoagulation for retinopathy of prematurity (ROP).

CONCLUSION

In this population of extremely low birthweight infants, survival was higher than in previous studies when life support was provided immediately after birth. Short-term morbidity was similar to other studies. The presented data on survival support our concept to offer immediate life support after birth in preterm infants with birthweights <501 g. The long-term outcome of these infants needs to be assessed urgently.

Multiple gestation and infertility treatment: registration, reflection and reaction—the Belgian project

Multiple pregnancies associated with infertility treatment are recognized as an adverse outcome and are responsible for morbidity and mortality related to prematurity and very low birthweight population. Due to the epidemic of iatrogenic multiple births, the incidence of maternal, perinatal and childhood morbidity and mortality has increased. This results in a hidden healthcare cost of infertility therapy and this may lead to social and political concern. Reducing the number of embryos transferred and the use of natural cycle IVF will surely decrease the number of multiple gestations. Consequently, optimized cryopreservation programmes will be essential. For non-IVF hormonal stimulation, responsible for more than one-third of all multiple pregnancies after infertility treatment, a strict ovarian stimulation protocol aiming at mono-ovulation is crucial. Multifetal pregnancy reduction is an effective method to reduce high order multiplets but carries its own risk of medical and emotional complications. Excellent data collection of all infertility treatments is needed in our discussion with policy makers. The Belgian project, in which reimbursement of assisted reproduction technology-related laboratory activities is linked to a transfer policy aiming at substantial multiple pregnancy reduction, is a good example of cost-efficient health care through responsible, well considered clinical practice.

Delivery room decision-making at the threshold of viability

OBJECTIVES

To assess attitudes of neonatologists toward parental wishes in delivery room resuscitation decisions at the threshold of viability.

STUDY DESIGN

Cross-sectional survey of the 175 practicing level II/III neonatologists in six New England states.

RESULTS

Response rate was 85% (149/175). At 24 1/7-6/7 weeks' gestation, 41% of neonatologists considered treatment clearly beneficial, and at 25 1/7-6/7 weeks' gestation, 84% considered treatment clearly beneficial. When respondents consider treatment clearly beneficial, 91% reported that they would resuscitate in the delivery room despite parental requests to withhold. At or below 23 0/7 weeks' gestation, 93% of neonatologists considered treatment futile. Thirty-three percent reported that they would provide what they consider futile treatment at parental request. When respondents consider treatment to be of uncertain benefit, all reported that they would resuscitate when parents request it, 98% reported that they would resuscitate when parents are unsure, and 76% reported that they would follow parental requests to withhold.

CONCLUSIONS

Variation in neonatologists' beliefs about the gestational age bounds of clearly beneficial treatment and attitudes toward parental wishes in the context of uncertainty is likely to impact the manner in which they discuss options with parents before delivery. This supports the importance of transparency in neonatal decision-making.

Views of bereaved multiple-birth parents on life support decisions, the dying process, and discussions surrounding death

OBJECTIVE

This study assessed the experiences of bereaved parents of multiples with resuscitation and life-support discussions, the death process, and conversations with health-care professionals about death.

STUDY DESIGN

In all, 71 bereaved parents of multiples recruited from Internet support groups completed a narrative e-mail survey assessing many facets of bereavement. Numeric data were analyzed using simple quantitative analysis, with a grounded theory approach used for qualitative data.

RESULTS

Most decisions were collaborative, with occasional directive comments. Some decisions were made during crises. Occasionally, parents initiated life-support discussions. Multidisciplinary meetings occurred with 30%, but were desired by more parents. A total of 18% of parents encountered criticism of choices. Most parents attended resuscitation, and found meaning in holding their dying children. Many desire privacy, availability of symptom management, and family or clergy involvement. Photographs of multiples together are valued. Parents offered many suggestions for compassionate death notification, which most felt should occur in person if parents are not present for the death. Respondents valued clear, prompt discussion of the cause of death, and clinician availability for later review of clinical events or decisions.

CONCLUSIONS

Multiple-birth parents' choices resemble those of singleton parents at the end of an infant's life.

Expectant management of midtrimester premature rupture of membranes: a plea for limits

OBJECTIVE

Our aim was to assess neonatal and maternal complications of the expectant management of pregnancies with preterm premature rupture of membranes (P-PROM) prior to 24 weeks of gestation and to delineate a patient consult strategy.

STUDY DESIGN

We included all consecutive cases of early midtrimester P-PROM (16-24 weeks gestation). Information coded in our perinatal database was analyzed. Descriptive statistics, Student's t-test and Mann-Whitney test, and a logistic regression model were built accordingly.

RESULTS

A total of 28 women presented with P-PROM at 16-24 weeks (mean 22.7+/-1.0 weeks). Two patients declined conservative management and one was lost to follow-up (10.7%). In all, 25 (89.2%) were followed until the onset of labor or development of chorioamnionitis. Overall, 8/25 (32%) Of the neonates survived. Pulmonary hypoplasia accounted for three deaths (3/25, 12%). Of 10 pregnancies with P-PROM before 22 weeks gestation, two (20%) neonates survived. The amount of amniotic fluid and gestational age at the time of diagnosis were crucial independent factors determining overall survival. Pulmonary hypoplasia (12%) and skeletal deformities (0%) were infrequent. The 21-day mean maternal antenatal hospital stay was further complicated by a high cesarean rate delivery (33.7%) and by postpartum infectious morbidity (32%).

CONCLUSION

In cases of early midtrimester P-PROM (<24 weeks) expectantly managed, neonatal survival is positively associated with the amount of amniotic fluid present and with the gestational age at the time of diagnosis. The mothers are at increased risk of prolonged antenatal hospitalization, cesarean delivery, preterm birth, and postpartum infection. In very early midtrimester P-PROM (<22 weeks), the maternal complication rate outweighs the poor neonatal outcome and expectant management should be reconsidered.

Mourning and psychological issues in multiple birth loss

Grief after the death of some or all multiples differs from mourning for a singleton loss in many important respects. A review of the unique features of grief for a multiple birth loss is followed by practical suggestions for empathic care. Cherished mementos and photos, and disposition options for deceased children are discussed. Counselling needs of parents and siblings are detailed, and management options for many complex pregnancy and infant loss scenarios are presented. The abundant resources listed will help caregivers and families better cope with one of the most difficult complications of plural parenthood.