End-of-life decisions for fragile neonates: navigating between opinion and evidence-based medicine

Janvier, Annie; Farlow, Barbara; Verhagen, Eduard; Barrington, Keith J.

doi:10.1136/archdischild-2016-311123

Cited by 15 publications

(5 citation statements)

References 7 publications

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“…15,[33][34][35] Managing a delivery in which an infant dies in the DR, either as a planned palliative care event or a failed resuscitation, is an integral part of practicing neonatology. 36 This study reveals that ∼500 VLBW infants die in the DR per year at the participating fellowship sites, slightly fewer than the number of NPM fellows in training any given year. All fellows should have opportunities to lead families and teams through these difficult decisions and events, making these simulations especially important to include in NPM fellowship training.…”

Section: Figurementioning

confidence: 78%

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network

et al. 2020

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BACKGROUND: Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown. METHODS:The number of VLBW (#1500 g) and extremely low birth weight (ELBW) (,1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program.RESULTS: Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see #23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine.

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Section: Figurementioning

confidence: 78%

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network

et al. 2020

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“…Family-centred care is well developed in neonatal intensive care 10. There may be a lack of shared knowledge and collaborative working when an infant presents with a neonatal surgical emergency and has a massive bowel resection.…”

Section: Discussionmentioning

confidence: 99%

Neonatal intestinal failure - improved outcomes

Protheroe

Sugarman

2022

Frontline Gastroenterol

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“…These issues are demonstrated by questionable decisions to initiate medical interventions that serve to sustain life despite catastrophic brain injury and dire prognostic outcomes. Likewise, diagnostic tests may predict imminent death in a fragile neonate who subsequently disproves senior neonatologists' prognostication and thrives when care is redirected to palliation . These situations, although relatively rare, can cause significant moral distress in health professionals such as nurses .…”

Section: Notable Heuristic Biases That Lead To Cognitive Dispositionsmentioning

confidence: 99%

“…Likewise, diagnostic tests may predict imminent death in a fragile neonate who subsequently disproves senior neonatologists' prognostication and thrives when care is redirected to palliation. 23 These situations, although relatively rare, can cause significant moral distress in health professionals such as nurses. 24 Experienced clinicians accustomed to a technocratic approach may also struggle if they are used to controlling the clinical environment primarily by managing the medical technology, adjusting ventilation and perfusion and titrating doses unchallenged for the good of their patients.…”

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confidence: 99%

Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision‐making

Preisz

2019

J Paediatrics Child Health

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Expertise in a medical specialty requires countless hours of learning and practice and a combination of neural plasticity and contextual case experience resulting in advanced gestalt clinical reasoning. This holistic thinking assimilates complex segmented information and is advantageous for timely clinical decision‐making in the emergency department and paediatric or neonatal intensive care units. However, the same agile reasoning that is essential acutely may be at odds with the slow deliberative thought required for ethical reasoning and weighing the probability of patient morbidity. Recent studies suggest that inadequate ethical decision‐making results in increased morbidity for patients and that clinical ethics consultation may reduce the inappropriate use of life‐sustaining treatment. Behavioural psychology research suggests there are two systems of thinking – fast and slow – that control our thoughts and therefore our actions. The problem for experienced clinicians is that fast thinking, which is instinctual and reflexive, is particularly vulnerable to experiential biases or assumptions. While it has significant utility for clinical reasoning when timely life and death decisions are crucial, I contend it may simultaneously undermine the deliberative slow thought required for ethical reasoning to determine appropriate therapeutic interventions that reduce future patient morbidity. Whilst health‐care providers generally make excellent therapeutic choices leading to good outcomes, a type of substitutive thinking that conflates clinical reasoning and ethical deliberation in acute decision‐making may impinge on therapeutic relationships, have adverse effects on patient outcomes and inflict lifelong burdens on some children and their families.

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End-of-life decisions for fragile neonates: navigating between opinion and evidence-based medicine

Cited by 15 publications

References 7 publications

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network

Neonatal intestinal failure - improved outcomes

Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision‐making

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