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J Pediatr. 2017 May 11. pii: S0022-3476(17)30469-9. doi: 10.1016/j.jpeds.2017.03.057. [Epub ahead of print]

Provider Perspectives Regarding Resuscitation Decisions for Neonates and Other Vulnerable Patients.

Author information

1
Division of Neonatology and Palliative Care Unit, CHU Sainte-Justine, Montréal, Québec, Canada; Clinical Ethics Unit, Centre de Recherche du CHU Sainte-Justine, Montréal, Québec, Canada; Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada; Unité de Recherche en Éthique Clinique et Partenariat Famille, CHU Sainte-Justine, Montréal, Québec, Canada.
2
Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada.
3
Clinical Ethics Unit, Centre de Recherche du CHU Sainte-Justine, Montréal, Québec, Canada; Unité de Recherche en Éthique Clinique et Partenariat Famille, CHU Sainte-Justine, Montréal, Québec, Canada.
4
Division of Neonatology and Palliative Care Unit, CHU Sainte-Justine, Montréal, Québec, Canada; Clinical Ethics Unit, Centre de Recherche du CHU Sainte-Justine, Montréal, Québec, Canada; Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada; Unité de Recherche en Éthique Clinique et Partenariat Famille, CHU Sainte-Justine, Montréal, Québec, Canada. Electronic address: anniejanvier@hotmail.com.

Abstract

OBJECTIVES:

To use structured surveys to assess the perspectives of pediatric residents and neonatal nurses on resuscitation decisions for vulnerable patients, including neonates.

STUDY DESIGN:

Pediatric providers were surveyed using scenarios for 6 critically ill patients of different ages with outcomes explicitly described. Providers were asked (1) whether resuscitation was in each patient's best interest; (2) whether they would accept families' wishes for comfort care (no resuscitation); and (3) to rank patients in order of priority for resuscitation. In a structured interview, each participant explained how they evaluated patient interests and when applicable, why their answers differed for neonates. Interviews were audiotaped; transcripts were analyzed using thematic analysis and mixed methods.

RESULTS:

Eighty pediatric residents and neonatal nurses participated (response rate 74%). When making life and death decisions, participants considered (1) patient characteristics (96%), (2) personal experience/biases (85%), (3) family's wishes and desires (81%), (4) disease characteristics (74%), and (5) societal perspectives (36%). These factors were not in favor of sick neonates: of the participants, 85% reported having negative biases toward neonates and 60% did not read, misinterpreted, and/or distrusted neonatal outcome statistics. Additional factors used to justify comfort care for neonates included limited personhood and lack of relationships/attachment (73%); prioritization of family's best interest, and social acceptability of death (36%). When these preconceptions were discussed, 70% of respondents reported they would change their answers in favor of neonates.

CONCLUSIONS:

Resuscitation decisions for neonates are based on many factors, such as considerations of personhood and family's interests (that are not traditional indicators of benefit), which may explain why decision making is different for the neonatal population.

KEYWORDS:

best interest principle; bioethics; clinical ethics; death; end-of-life decisions; medical education; neonatal intensive care; neonatology; palliative care; personhood; prematurity; resuscitation

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