Primary palliative care in the delivery room: patients’ and medical personnel’s perspectives

Abstract

Caregiver's emotional distress primarily originates from providing support to parents and not from providing medical care to the dying newborn. Implications for future practice include the need for structured education to improve DR staff's communication and counselling skills related to parents in PPC situations.

Delivery room deaths of extremely preterm babies: an observational study

“…The route should be painless and easy to handle to facilitate parental proximity. An umbilical9 16 catheter was used in most of our cases, much more frequently than in other studies; a single patient had a peripheral catheter and some had less invasive routes. Little is known about the efficacy of minimally invasive routes; one study has suggested that intranasal fentanyl limits laboured breathing in dying neonates 26…”

“…This proportion is high for DR comfort care, compared with other studies, but fairly low compared with NICU deaths. Four studies of DR comfort care have mentioned medication use 16. A study of four  units (two in the USA, one in Canada and one in the Netherlands) reported 23 extremely preterm newborns who died with DR comfort care: none received comfort medication;17 a French unit reported that 3 of 19 babies received medication 9.…”

“…Several factors might explain the rarer use of comfort medications in DRs compared with NICUs for eol care. The model of comfort care in the DR aims to avoid unnecessary handling, stress and invasive procedures and to offer babies reassuring skin contact that protects them from pain and anxiety 16. Low gestational and/or postnatal ages are possible reasons to use fewer medications, as found in NICU populations 19 20.…”

“…In our study, pain/discomfort was assessed subjectively, without the scores normally used in NICUs; as signs of eol discomfort are difficult to assess in these newborns, it is difficult to know when to start or modify treatment. In Garten's study, DR professionals related babies' distress to dyspnoea or agitation in this context 16. Given the specificity of the eol period in extremely preterm babies, tools validated for prolonged pain assessment in the NICU may not be fully appropriate 29…”

“…In France, guidelines on management of extremely low GA neonates (ELGANs) published in 2010 by a perinatal group only briefly mentioned the nature of ‘palliative care’, without detailed recommendations 8. Since then, many countries have published guidelines recommending comfort (or palliative) care for ELGANs not receiving active care immediately after birth 7 16. Nonetheless, little is known about the clinical course of these babies and especially the procedures actually used for their care: we found four retrospective studies, based on chart reviews 9 16–18.…”