Antenatal counselling, resuscitation practices and attitudes among Australian neonatologists towards life support in extreme prematurity

Abstract

A questionnaire survey of Australian neonatologists was conducted to ascertain their antenatal counselling and resuscitation practices, and attitudes towards life support in the extremely preterm infant. This study showed that in antenatal parental counselling, whether a paediatrician was given the opportunity to participate depends on the gestation at the time of the threatened preterm delivery The counselling employed almost invariably covered mortality and morbidity. The obstetrician's opinion was considered to be of utmost importance. Both financial and moral obligations were found to be of little importance in counselling and resuscitation. Only one-third of institutions had guidelines for limiting resuscitation. The onus remained on the neonatologists concerning which infant to resuscitate, and the level of the resuscitation to be conducted. In Australia, resuscitation at birth was restricted to infants of 23 weeks' gestation or above, and neonatologists did not believe the legal system has a role to play in limiting or mandating resuscitation of extremely preterm infants. Neither were they concerned with the threat of litigation when they decide to limit resuscitation. The majority of neonatologists agreed with their institution's approach to life support in extremely preterm infants. One grey area was the question of withholding assisted feeding in an infant for which the decision to withdraw life support has been made. Australia lacked a current consensus policy on selective non-treatment. The establishment of national guidelines would be helpful to aid Australian obstetricians and neonatologists in their clinical practice.

International Comparison of Care for Very Low Birth Weight Infants: Parents' Perceptions of Counseling and Decision-Making

“…19,29,30,32 The results from this study show that the adequacy of parent counseling differs by center and topic. Discussions of morbidity and mortality adequately addressed the information needs of the majority of parents in only 5 of 9 centers.…”

“…Although several hospital-based studies and surveys have detailed physicians' attitudes and practices on life support and end-of-life decisions for premature infants, 19,29,30,[33][34][35][36]45,46 only a few have addressed parents' perspectives of counseling and decision-making. 42,45,47 To our knowledge, this is the first cross-cultural study of counseling and resuscitation decision-making from the perspective of parents of VLBW premature infants.…”

“…19,30 In contrast, 47% of Australian neonatologists often or always considered moral or religious considerations in resuscitation decisions for 23-to 25-week-old infants. 29 Variations in counseling among centers would be expected to the extent that local culture shapes phy- sicians' attitudes; for example, differing degrees of medical paternalism in these cultures could explain some of the variations in counseling. In Japan, a more paternalistic model of medical care is accepted by physicians and patients.…”

“…[22][23][24][25][26][27] Studies in several countries have characterized physician attitudes on life-sustaining therapies and providers' willingness to accept a parental voice in life-support decisions for extreme prematurity. 19,[28][29][30][31][32][33][34][35][36][37][38] In the emotional and often emergent milieu of the NICU, physician counseling may not suffice to help parents understand medical information necessary to engage them as active and informed participants in life-support decisions. 37,[39][40][41] We recently reported that parents in public hospitals in South Africa wanted more consistent counseling and a larger stake in decision-making.…”

Delivery room decision-making at the threshold of viability

“…20 Similarly, Munro et al reported that a neonatologist's treatment plan was more likely to be altered to accommodate parents' wishes at 23 or 24 weeks' gestation than at 22 or 25 weeks. 21 Respondents in our study did vary, however, in their attitudes toward parental wishes. A significant minority (24%) reported that when the benefit of treatment is uncertain, they would initiate resuscitation regardless of parental wishes and make future treatment decisions based on the infant's condition.…”