Parental involvement in neonatal critical care decision‐making

Abstract

The article analyses the decision-making process between doctors and parents of babies in neonatal intensive care. In particular, it focuses on cases in which the decision concerns the redirection of care from full intensive care to palliative care at the end of life. Thirty one families were recruited from a neonatal intensive care unit in England and their formal interactions with the doctor recorded. The conversations were transcribed and analysed using conversation analysis. Analysis focused on sequences in which decisions about the redirection of care were initiated and progressed. Two distinct communicative approaches to decision-making were used by doctors: 'making recommendations' and 'providing options'. Different trajectories for parental involvement in decision-making were afforded by each design, as well as differences in terms of the alignments, or conflicts, between doctors and parents. 'Making recommendations' led to misalignment and reduced opportunities for questions and collaboration; 'providing options' led to an aligned approach with opportunities for questions and fuller participation in the decision-making process. The findings are discussed in the context of clinical uncertainty, moral responsibility and the implications for medical communication training and guidance. A Virtual Abstract of this paper can be accessed at: https://www.youtube.com/watch?v=MyuymxDNupk&feature=youtu.be.

Short-term outcome of treatment limitation discussions for newborn infants, a multicentre prospective observational cohort study

“…We have not investigated the influence of parents' beliefs, their perceptions of conversations, socioeconomic class19 or educational background on decision outcome. Details of the actual conversations were not gathered 20. Neither have we been able to determine the degree to which the prior beliefs and conversational strategies of the doctors,21 22 or the clinical practice in each neonatal service23 may influence the outcome of these conversations, both of which may determine in part the outcome for the baby.…”

Communication practices that encourage and constrain shared decision making in health‐care encounters: Systematic review of conversation analytic research

“…Twenty‐eight records were identified (see Table for publication characteristics). We organized findings in chronological order: actions prior to commitment point(s) being reached (termed “broaching”); putting forward a course of action (commitment becomes relevant); how patients convey commitment (or not); and HCPs' responses to patients' resistance or withholding of commitment.…”

“…Seven publications documented HCPs eliciting patients'/companions' perspectives/preferences regarding possible courses of action before actual decision making. In an ICU study, physicians sought patients' views and relatives' understandings of patients' wishes concerning the continuation or withdrawal of life‐sustaining treatment:…”

“…HCPs may pre‐emptively justify recommendations by providing accounts, such as oncologists accounting for adjuvant therapy in advance of recommendations for chemotherapy and/or radiotherapy to post‐operative breast cancer patients or consultants justifying moving from intensive to supportive/palliative care though accounts of professional consensus or those rooted in the idiom of the “best interest” of the patient (in this particular case, the baby) . In a physiotherapy setting, therapists sometimes use accounts when the upcoming recommendation is counter to patient's expectation or report of current activity …”

“…The options may be fairly neutral or may display—strongly or weakly—a stance. In a neonatal ICU, some options were more persuasively presented than others . In mental health consultations, a psychiatrist flagged up three choices, discounted the first two before producing the third: the structure of offering multiple options can thus be a vehicle to recommend a single path .…”