The Window of Opportunity: Decision Theory and the Timing of Prognostic Tests for Newborn Infants

Wilkinson, Dominic

doi:10.1111/j.1467-8519.2009.01762.x

Cited by 24 publications

(21 citation statements)

References 8 publications

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“…However, there is the possibility that by 80 hours of age or soon after, infants will have resumed spontaneous breathing and no longer be ventilator dependent. If neonatologists wait until cooling has been completed before making decisions about treatment withdrawal the "window of opportunity" may have been missed (45). This concern is not borne out in previous trials, since decisions to withdraw treatment occurred at similar times in cooled and non-cooled infants(2,3).…”

Section: Cooling and Palliative Caresupporting

confidence: 94%

Ethical challenges in the use of therapeutic hypothermia in Indian neonatal units

2010

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Trials in developed countries have shown that therapeutic hypothermia reduces the risk of death or severe disability in infants with neonatal encephalopathy. Cooling has been adopted as a standard of care in some parts of the world. Some Indian neonatal units have considered or even embarked upon cooling encephalopathic term newborn infants. In this article we discuss some of the potential ethical questions that should be considered before introducing therapeutic hypothermia in an Indian setting. Evidence from previous trials may not be relevant given significant differences in the epidemiology of neonatal encephalopathy in countries like India. There is a possibility that hypothermia would be ineffective or harmful. The most appropriate way to answer these concerns would be to perform a large randomized controlled trial of cooling in India. However, such trials will also raise potential ethical challenges. Cooling may also affect decisions about treatment withdrawal, and may create uncertainty about prognosis. It may exacerbate ethical problems relating to lack of neonatal intensive care bed space.

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Section: Cooling and Palliative Caresupporting

confidence: 94%

Ethical challenges in the use of therapeutic hypothermia in Indian neonatal units

2010

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“…Death on the neonatal unit may occur when intensive care support is withdrawn, there is a conscious limitation to the escalation of intensive care, or the baby cannot be kept alive despite all attempts to continue care [3, 4]. Australian data suggests that three quarters of deaths in the neonatal context occur after intensive care is withdrawn [5]. US data shows similarly high levels of withdrawal as a mode of death, particularly in babies with congenital anomalies, whilst withholding care is more common in extremely preterm babies.…”

Section: Introductionmentioning

confidence: 99%

Palliative care in the neonatal unit: neonatal nursing staff perceptions of facilitators and barriers in a regional tertiary nursery

Kilcullen

Ireland

2017

BMC Palliat Care

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BackgroundNeonatology has made significant advances in the last 30 years. Despite the advances in treatments, not all neonates survive and a palliative care model is required within the neonatal context. Previous research has focused on the barriers of palliative care provision. A holistic approach to enhancing palliative care provision should include identifying both facilitators and barriers. A strengths-based approach would allow barriers to be addressed while also enhancing facilitators. The current study qualitatively explored perceptions of neonatal nurses about facilitators and barriers to delivery of palliative care and also the impact of the regional location of the unit.MethodsThe study was conducted at the Townsville Hospital, which is the only regional tertiary neonatal unit in Australia. Semi-structured interviews were conducted with a purposive sample of eight neonatal nurses. Thematic analysis of the data was conducted within a phenomenological framework.ResultsSix themes emerged regarding family support and staff factors that were perceived to support the provision of palliative care of a high quality. Staff factors included leadership, clinical knowledge, and morals, values, and beliefs. Family support factors included emotional support, communication, and practices within the unit. Five themes emerged from the data that were perceived to be barriers to providing quality palliative care. Staff perceived education, lack of privacy, isolation, staff characteristics and systemic (policy, and procedure) factors to impact upon palliative care provision. The regional location of the unit also presented unique facilitators and barriers to care.ConclusionsThis study identified and explored facilitators and barriers in the delivery of quality palliative care for neonates in a regional tertiary setting. Themes identified suggested that a strengths-approach, which engages and amplifies facilitating factors while identified barriers are addressed or minimized, would be successful in supporting quality palliative care provision in the neonatal care setting. Study findings will be used to inform clinical education and practice.

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“…One qu estion eme rging from the interviews is how to respond to the potential window of oppo rt unity for treatment withdraw al. T he difficu lty in expeditio usly arra ngi ng MRI not ed by several neon atol ogists risks exacerba t ing th e prob lem" O ne app roa ch th at might help clinicians and parents resolve the conflicting values at stake would be to use decision theory (Wilkinson 2009b) . Some clinicians expressed ambivalence about the window of opportunity.…”

Section: Discussionmentioning

confidence: 99%

‘We Dont Have a Crystal Ball …’

Wilkinson

2010

Monash Bioethics Review

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Birth asphyxia is the most common single cause of death in term newborn infants. The majority of deaths indeveloped countries followdecisions to withdraw intensive care. Recent technological advances, particularly the use ofmagnetic resonance imaging (MRI) ofthe brain. may affect theprocess of prognostication and decision-making. There is little existing evidence about how prognosis is determined in newborn infants and howthis relates to treatment withdrawal decisions.Anexploratory Qual itative study was performed using in-depth semi-structured interviews with a sample of ten neonatologists from tertiary intensivecare units in the UK. Participants were purposively selected to ensure a range of experience and type of unit. They were asked about the process of prognostication for infants with birth asphyxia and decisions about treatment withdrawal. Interviewsweretranscribed and thematically analysed.MRI played a significant role indecision-making about life-sustaining treatment fora number of clinicians. Clinicians did not identify particular ethical concerns related to MRI. though wider discussionrevealed issues relating to uncertaintyaround predictions. the timing ofprognostication and decision-making. and difficulty in predicting Quality of life.

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The Window of Opportunity: Decision Theory and the Timing of Prognostic Tests for Newborn Infants

Cited by 24 publications

References 8 publications

Ethical challenges in the use of therapeutic hypothermia in Indian neonatal units

Ethical challenges in the use of therapeutic hypothermia in Indian neonatal units

Palliative care in the neonatal unit: neonatal nursing staff perceptions of facilitators and barriers in a regional tertiary nursery

‘We Dont Have a Crystal Ball …’

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