Why Do Neonatologists in Scandinavian Countries and the Netherlands Make Life-and-death Decisions So Different?

Verhagen, Eduard

doi:10.1542/peds.2018-0478j

Cited by 9 publications

(5 citation statements)

References 31 publications

(16 reference statements)

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“…The present observations and previous research [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 ] raise several ethical concerns regarding the justification of interventions and life-sustaining treatments for threatening PTB before 24 weeks. The interventionist approach in Sweden and other Nordic countries contrast to the more restrictive approaches in other parts of the world [ 21 , 32 , 33 ]. A systematic review of guidelines for extremely preterm deliveries between 22 and 25 weeks in 20 highly developed countries finds a general agreement for comfort care at 22 weeks and active care at 25 weeks, but a wide variety of recommendations between 23 and 24 weeks [ 34 ].…”

Section: Discussionmentioning

confidence: 99%

“…A systematic review of guidelines for extremely preterm deliveries between 22 and 25 weeks in 20 highly developed countries finds a general agreement for comfort care at 22 weeks and active care at 25 weeks, but a wide variety of recommendations between 23 and 24 weeks [ 34 ]. National guidelines in the Netherlands recommend resuscitation of all newborns only at 24 weeks and thereafter, based on results from large national studies The ethical justification for this restrictive practice is that the amount of good, which is less than 10% intact survival, does not justify the amount of harm caused, with 10–20% disabilities and 70–80% mortality after extensive treatments [ 32 , 33 ].…”

Section: Discussionmentioning

confidence: 99%

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Increased Survival Concomitant with Unchanged Morbidity and Cognitive Disability among Infants Born at the Limit of Viability before 24 Gestational Weeks in 2009–2019

Christiansson,

Moberg,

Rakow

et al. 2023

JCM

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Introduction: The aim was to determine risk factors among mothers and outcomes for their children born at the limit of viability in 2009–2019, before and after the introduction of extended interventionist guidelines. Methods: A retrospective cohort study of births at 22 + 0–23 + 6 gestational weeks in a Swedish Region in 2009–2015 (n = 119), as compared to 2016–2019 (n = 86) after the introduction of new national interventionist guidelines. Infant mortality, morbidity, and cognitive functions at 2 years corrected age according to the Bayley-III Screening Test were monitored. Results: Maternal risk factors for extreme preterm birth were identified. The intrauterine fetal death rates were comparable. Among births at 22 weeks, the neonatal mortality tended to decrease (96 vs. 76% of live births (p = 0.05)), and the 2-year survival tended to increase (4 vs. 24% (p = 0.05)). Among births at 23 weeks, the neonatal mortality decreased (56 vs. 27% of live births (p = 0.01)), and the 2-year survival increased (42 vs. 64% (p = 0.03)). Somatic morbidity and cognitive disability at 2 years corrected age were unchanged. Conclusion: We identified maternal risk factors that emphasize the need for standardized follow-up and counseling for women at increased risk of preterm birth at the limit of viability. The increased infant survival concomitant with unchanged morbidity and cognitive disability highlight the importance of ethical considerations regarding interventionist approaches at threatening preterm birth before 24 weeks.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Increased Survival Concomitant with Unchanged Morbidity and Cognitive Disability among Infants Born at the Limit of Viability before 24 Gestational Weeks in 2009–2019

Christiansson,

Moberg,

Rakow

et al. 2023

JCM

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“…Strategies to improve SDM have been suggested to be useful in the setting of prenatal counseling in extreme prematurity, such as decision-aids, handbooks and value eliciting methods [39,[48][49][50]. It is unclear to what extent these supportive tools can be used in other settings since cross-cultural differences have been described extensively [3,[51][52][53]. Furthermore, training may also help physicians to increase their SDM performance, since the level of SDM can be physician-specific [16,35,54].…”

Section: Discussionmentioning

confidence: 99%

Decision-making in imminent extreme premature births: perceived shared decision-making, parental decisional conflict and decision regret

et al. 2021

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To describe levels of perceived shared decision making (SDM), decisional conflict (DC), and decision regret (DR) in prenatal counseling by pregnant women, partners, neonatologists, and obstetricians regarding decision-making around imminent extreme premature birth in which a decision about palliative comfort care versus early intensive care had to be made. STUDY DESIGN: Multicenter, cross-sectional study using surveys to determine perceived SDM at imminent extreme premature birth in parents and physicians, and to determine DC and DR in parents. RESULTS: In total, 73 participants from 22 prenatal counseling sessions were included (21 pregnant women, 20 partners, 14 obstetricians, 18 neonatologists). High perceived levels of SDM were found (median 82,2), and low levels of DC (median 23,4) and DR at one month (median 12, 5). CONCLUSIONS: Reported levels of self-perceived SDM in the setting of prenatal counseling in extreme prematurity were high, by both the parents and the physicians. Levels of DC and DR were low.

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“…Shared decision making about WWLST requires the involvement of the infant’s parents. Clinicians usually raise the discussion about WWLST (83% of the time in 19 tertiary units in Canada) ( 50 ), but parents are very involved in the subsequent decisions between 86.5% and 98% of the time ( 49 , 52 , 55 , 60 ). This involvement has increased over the last 20 years ( 57 ).…”

Section: Literature Reviewmentioning

confidence: 99%

Withdrawal and withholding of life sustaining treatment (WWLST): an under recognised factor in the morbidity or mortality of periviable infants?—a narrative review

Galloway,

Roehr,

Tan

2024

Transl Pediatr

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Background and Objective The morbidity and mortality of infants born extremely preterm varies substantially across networks, within countries and throughout the globe. Most of the literature tends to focus on the management at birth and choices around active resuscitation of extremely preterm infants. Withdrawal and withholding of life sustaining treatment (WWLST) is an important and central process in the neonatal intensive care unit (NICU) and practices vary substantially. As such, our objective in this review was to explore whether end of life decisions also contribute to variations in the morbidity and mortality of periviable infants. Methods This narrative literature review is based on studies from the last 15 years found using several searches of medical databases (OVID Medline, Scopus and Cochrane Systematic Reviews) performed between March 2021 and December 2023. Key Content and Findings Just as outcomes in periviable infants vary, the rates of and processes behind WWLST differ in the periviable population. Variation increases as gestational age decreases. Parental involvement is crucial to share decision making but the circumstances and rates of parental involvement differ. Strict guidelines in end-of-life care may not be appropriate, however there is a need for more targeted guidance for periviable infants as a specific population. The current literature available relating to periviable infants or WWLST is minimal, with many datasets rapidly becoming outdated. Conclusions Further research is needed to establish the role of WWLST in variation of periviable infants’ outcomes. The unification of data, acquisition of more recent datasets and inclusion of variables relating to end-of-life decisions in data collection will aid in this process.

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Why Do Neonatologists in Scandinavian Countries and the Netherlands Make Life-and-death Decisions So Different?

Abstract: An examination of the policies regarding the care of extremely premature newborns reveals unexpected differences between Scandinavian countries and the Netherlands. Three topics related to decision-making at the beginning and at the end of life are identified and discussed.

Cited by 9 publications

References 31 publications

Increased Survival Concomitant with Unchanged Morbidity and Cognitive Disability among Infants Born at the Limit of Viability before 24 Gestational Weeks in 2009–2019

Increased Survival Concomitant with Unchanged Morbidity and Cognitive Disability among Infants Born at the Limit of Viability before 24 Gestational Weeks in 2009–2019

Decision-making in imminent extreme premature births: perceived shared decision-making, parental decisional conflict and decision regret

Withdrawal and withholding of life sustaining treatment (WWLST): an under recognised factor in the morbidity or mortality of periviable infants?—a narrative review

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