Ethical Cultures in Perinatal Care: Do They Exist? Correlation of Provider Attitudes with Periviability Practices at Six Centers

Abstract

Objective This study aimed to compare attitudes of providers regarding perinatal management and outcomes for periviable newborns of caregivers at centers with higher resuscitation (HR) and lower resuscitation (LR) rates in the delivery room. Study Design All obstetric and neonatal clinical providers at six U.S. sites were invited to complete an anonymous online survey. Survey responses were compared with clinical data collected from a previous retrospective study comparing centers' rates of planned resuscitation. Responses were analyzed by multivariable logistic and linear regression to assess how HR versus LR center respondents differed in management preferences and outcome predictions. Results Paradoxically, HR versus LR respondents, when adjusting for other variables, were less likely to respond that interventions such as antenatal steroids (odds ratio: 0.61, 95% confidence interval [CI]: 0.42–0.88, p < 0.009) and resuscitation (OR: 0.59, 95% CI: 0.44–0.78, p < 0.001) should be given at 22 weeks. HR versus LR respondents also reported lower likelihood of survival and acceptable quality of life (OR: 0.7, 95% CI: 0.53–0.93, p = 0.012) at 23 weeks. Conclusion Despite higher rates of planned resuscitation at 22 and 23 weeks, steroid usage and survival rates did not differ between HR and LR sites. In this subsequent survey, respondents from HR centers had a less favorable outlook on interventions for these newborns than those at LR centers, suggesting that instead of driving practices, attitudes may be more closely associated with experiences of clinical outcomes.

What Information Do Clinicians Deem Important for Counseling Parents Facing Extremely Early Deliveries?: Results from an Online Survey

“…13,14 Neonatologists in past studies have tended to favor offering resuscitation at earlier ages than MFM physicians, both as trainees 15 and attending physicians. 16 However, in our survey, gestational weeks at which respondents reported "usually" offering both comfort care and active treatment were not significantly different between specialists. It is possible that SDM and more regular practices of allowing resuscitation at 22 weeks in recent years (as reported by a study of neonatology fellowship directors) 17 has narrowed gaps between specialties; contemporary surveys comparing group preferences would need to confirm this.…”

Trial of Therapy on Trial: Inconsistent Thresholds for Discussing Withdrawal of Life-Sustaining Therapies in the Neonatal Intensive Care Unit

“…Individual providers' personal experiences, and the extent to which they base decisions on anecdotes versus population data, may influence what morbidities they feel should prompt discussion of WLST. 23 A related source of variability may be the attending's valuation of quality of life with disabilities. Even if all providers could agree on a complication's predictive value for future severe disability, providers may have very different views on whether that disability is a poor enough outcome to merit discussing WLST.…”

“…But individual patient courses are virtually impossible to predict, and there are former preemies who sustained these complications and are thriving today. Individual provider's personal experiences, and the extent to which they base decisions on anecdotes versus population data, may influence what morbidities they feel should prompt discussion of WLST 23 . A related source of variability may be the attending's valuation of quality of life with disabilities.…”

“…The phenomenon of parents encountering different sets of expectations from different providers is not isolated to attending physicians. Unit culture in the NICU both has 22 and has not 23 been shown to contribute to outcomes at the margins of viability. We therefore evaluated the unit culture to see how attendings' opinions compared with the rest of the staff, as we feel it is important to understand all clinicians' perspectives on a concept of trial of therapy to better understand the practice itself.…”

Understanding family-centered care in the NICU: a scoping review protocol

“…This can make navigating the unfamiliar environment of the NICU quite difficult for families, with complex interpersonal relationships between families and health care professionals evolving throughout an infant’s time in the NICU 11 . Additionally, individual NICUs vary widely in multiple ways, including levels of care, staffing models, resources, and local unit “cultures.” 12–14 Due to disconnects between families and systems, the broad implementation of practices (clinical approaches informed by evidence) and interventions (single or combined strategies designed to bring about change through quality improvement or research initiatives) that foster FCC remain inconsistent, despite acknowledgment of the benefits by both the team and the families.…”