Physicians’ Attitudes on Resuscitation of Extremely Premature Infants: A Systematic Review

Cavolo, Alice; Casterlé, Bernadette Dierckx de; Naulaers, Gunnar; Gastmans, Chris

doi:10.1542/peds.2018-3972

Cited by 33 publications

(40 citation statements)

References 67 publications

(187 reference statements)

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“…Periviable deliveries and resuscitation remain a controversial topic. Different institutions have various thresholds for resuscitation based on patient-specific factors, local data and outcomes, physician attitudes and maternal characteristics (44). Population-based estimation of outcomes lacks the precision necessary to make decisions on an individual level.…”

Section: Periviabilitymentioning

confidence: 99%

Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It

Mills

Cortezzo

2020

Front. Pediatr.

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Moral distress is prevalent in the neonatal intensive care unit (NICU), where decisions regarding end-of-life care, periviable resuscitation, and medical futility are common. Due to its origins in the nursing literature, moral distress has primarily been reported among bedside nurses in relation to the hierarchy of the medical team. However, it is increasingly recognized that moral distress may exist in different forms than initially described and that healthcare professions outside of nursing experience it. Advances in medical technology have allowed the smallest, sickest neonates to survive. The treatment for critically ill infants is no longer simply limited by the capability of medical technology but also by moral and ethical boundaries of what is right for a given child and family. Shared decision-making and the zone of parental discretion can inform and challenge the medical team to balance the complexities of patient autonomy against harm and suffering. Limited ability to prognosticate and uncertainty in outcomes add to the challenges faced with ethical dilemmas. While this does not necessarily equate to moral distress, subjective views of quality of life and personal values in these situations can lead to moral distress if the plans of care and the validity of each path are not fully explored. Differences in opinions and approaches between members of the medical team can strain relationships and affect each individual differently. It is unclear how the various types of moral distress uniquely impact each profession and their role in the distinctively challenging decisions made in the NICU environment. The purpose of this review is to describe moral distress and the situations that give rise to it in the NICU, ways in which various members of the medical team experience it, how it impacts care delivery, and approaches to address it.

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Section: Periviabilitymentioning

confidence: 99%

Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It

Mills

Cortezzo

2020

Front. Pediatr.

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“…Cohort studies on extreme preterm gestation suggest that the approach to infants < 24 weeks of gestation is variable; some of them may not receive active resuscitation or care 22 . The results from our sensitivity analysis, after excluding infants < 24 weeks of gestation, were compatible with our main results with the notable exception of death after admission to NICU.…”

Section: Discussionmentioning

confidence: 99%

Temporal trends of care practices, morbidity, and mortality of extremely preterm infants over 10-years in South Wales, UK

Boel

Banerjee

Clark

et al. 2020

Sci Rep

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Contemporary outcome data of preterm infants are essential to commission, evaluate and improve healthcare resources and outcomes while also assisting professionals and families in counselling and decision making. We analysed trends in clinical practice, morbidity, and mortality of extremely preterm infants over 10 years in South Wales, UK. This population-based study included live born infants < 28 weeks of gestation in tertiary neonatal units between 01/01/2007 and 31/12/2016. Patient characteristics, clinical practices, mortality, and morbidity were studied until death or discharge home. Temporal trends were examined by adjusted multivariable logistic regression models and expressed as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). A sensitivity analysis was conducted after excluding infants born at < 24 weeks of gestation. In this population, overall mortality for infants after live birth was 28.2% (267/948). The odds of mortality (aOR 0.93, 95% CI [0.88, 0.99]) and admission to the neonatal unit (0.93 [0.87, 0.98]) significantly decreased over time. Non-invasive ventilation support during stabilisation at birth increased significantly (1.26 [1.15, 1.38]) with corresponding decrease in mechanical ventilation at birth (0.89 [0.81, 0.97]) and following admission (0.80 [0.68–0.96]). Medical treatment for patent ductus arteriosus significantly decreased over the study period (0.90 [0.85, 0.96]). The incidence of major neonatal morbidities remained stable, except for a reduction in late-onset sepsis (0.94 [0.89, 0.99]). Gestation and centre of birth were significant independent factors for several outcomes. The results from our sensitivity analysis were compatible with our main results with the notable exception of death after admission to NICU (0.95 [0.89, 1.01]). There were significant improvements in survival and reduction of late-onset sepsis of extreme preterm infants in South Wales between 2007 and 2016. The sensitivity analysis suggests that some of the temporal changes observed were driven by improved outcomes in the most preterm of infants. Clinical practices related to respiratory support have changed but significant variations in clinical practices and outcomes between centres remain unexplained. The adoption of regional evidence-based clinical guidelines is likely to improve outcomes and reduce variation.

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“…Triage may be defined as the clinical screening of patients to determine priority for treatment in a situation of resource scarcity. Absent of evidence, the authors' statement "neonatologists already triage" (Haward et al 2020) is an unsubstantiated assertion and not consistent with a large international literature (Cavolo et al 2019;Guill en et al 2015). We concur that physicians must certainly be wary of their own bias and cultural positions that might not be shared by families.…”

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confidence: 84%

Periviability in a Pandemic: Good Ethics Still Considered Essential

Dirksen

Kaempf

Kockler

2020

The American Journal of Bioethics

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Physicians’ Attitudes on Resuscitation of Extremely Premature Infants: A Systematic Review

Cited by 33 publications

References 67 publications

Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It

Moral Distress in the Neonatal Intensive Care Unit: What Is It, Why It Happens, and How We Can Address It

Temporal trends of care practices, morbidity, and mortality of extremely preterm infants over 10-years in South Wales, UK

Periviability in a Pandemic: Good Ethics Still Considered Essential

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