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Decisions in the Face of Uncertainty

Decisions in the Face of Uncertainty. Sharon E. Gregory RNC, MN Dekalb Medical Center Perinatal Loss Coordinator. BABY G. 23 week DNR per parents Staff and family discomfort with “living baby” Died at 10 hours. BABY M. 23 week Do everything

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Decisions in the Face of Uncertainty

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  1. Decisions in the Face of Uncertainty Sharon E. Gregory RNC, MN Dekalb Medical Center Perinatal Loss Coordinator

  2. BABY G • 23 week • DNR per parents • Staff and family discomfort with “living baby” • Died at 10 hours

  3. BABY M • 23 week • Do everything • NICU: Dopamine, steroids, Grade III IVH; PHH, CONS, Thrombocytopenia • MD told parents DNR • Died at 27 days

  4. Give life a chance Time for parents to bond Comfort care Time for parents to grieve Beneficence -Do Good

  5. Ventilation - progress IVH? Resuscitation futile Prolonging Death Non intervention Don’t start resuscitation late Nonmaleficence – Do no Harm

  6. Justice Fairness Use of resources equally Policy vs. individual How much does it cost?

  7. Autonomy • Parents = infant’s legal decision maker • Physician = medical care giver • Best interest for the infant. • Multifactorial and uncertain outcomes • Courts uphold the parents rights

  8. VideoParents at the ThresholdYou Are Not Alone

  9. NRP Chapter 9Ethics and Care at End of Life • Ethical principles same as for older child or adult. • No mandate to resuscitate in all circumstances. • OB dating +/= 2 weeks • Withdrawal of resuscitation or critical care are acceptable with parental agreement if futile, prolonging dying or benefit does not justify burden imposed.

  10. NRP Chapter 9Ethics and Care at End of Life • If gestation(< 22 wks), birth weight (< 400 g) or lethal congenital anomalies associated with certain early death or unacceptably high morbidity, resuscitation is not indicated. Exceptions may be reasonable to comply with parental wishes.

  11. Decision Factors • Prognosis • Mortality • High survival - > 25 weeks • Uncertain survival – 22-25 wks • Low survival - < 22 wks; lethal anomalies • Morbidity • Low – • Uncertain • High < 25 weeks

  12. Decision Factors • Parent response • Resuscitate • Comfort Care • Medical response • Resuscitate • Evaluate • Withdraw if no improvement • Continue • Comfort Care

  13. Keys to good ethical practice • Inform the parents • .Listen to the parents • .Provide quality care • .Stick to the facts • .Do not try to impose your values on the situation • Respect that this is rarely an easy decision for anyone.

  14. Effects on staff • Workload • Leave infant with parents • Prolonged dying is hard to watch • Avenues for staff to express views • Be creative – acknowledging grief by memorials, good bye notes, journal for the parents. • Options for staff opposed to DNR or prolonged dying.

  15. Conclusions • Ethical care is well informed parents • All caregivers on the same page • Avoid mixed messages: • Respect the parents. • Do what is reasonable quality care.

  16. Godgrant me the SERENITYto prioritize the thingsI cannot delegate,the COURAGEto say no when I need to,and the WISDOM to know whento go home!

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