Structured deliberation improves neonatal decision-making process

Oct 3 2012

By Sarah Guy, medwireNews Reporter

The implementation of a structured multiprofessional medical ethical decision-making (MEDM) process could improve decision-making in neonatal intensive care units (NICUs), show study results from the Netherlands.

Eight months after the novel MEDM process was put in place, the researchers found that physician and nurse perceptions of the structure of MEDM as well as understanding of the participants' roles improved significantly, while impartial chairpersons were routinely present, and all disciplines represented.

Documenting decisions and conclusions made in MEDM did not improve, however, with the research team noting it is "to be expected" in light of improved access to shared electronic MEDM files in the participating ICU.

"Ethical deliberations in neonatal care should include all professionals involved and appreciate their different perspectives to achieve balanced patient/family centered decisions about continuity of treatment and care, symptom management and (spiritual) support," suggest Jacoba (Coby) de Boer (Erasmus University Medical Centre, Rotterdam) and colleagues.

"Awareness of the pros and cons of proposed solutions and the weighing of arguments that underlie the final decision, prevents uncertainty," they add, in the Journal of Medical Ethics.

The team devised the MEDM process, implemented it, appointed an impartial chair, and evaluated the views of 105 and 113 healthcare professionals working in the NICU before and after implementation, respectively.

The MEDM process included regular meetings held to discuss patients for whom the moral justification of treatment is questioned. Proposed solutions are explored, analyzed, and decided, and an electronic form is filled that captures the ethical deliberation as well as medical detail (diagnosis, etc.)

After 8 months of running the MEDM process, de Boer and co-workers report a 100% adherence rate for all elements except documentation of conclusions, which was only complete in 63% of cases.

Furthermore, participant responses indicated a significant positive effect for three of the four factors identified in the questionnaire; the structure of the MEDM (including whether policy is clear and the chair is impartial), the role of participants (including whether individual roles are clear), and the content of the ethical deliberation (including whether all treatment options and views are considered).

This latter finding indicates that discussion "might have been more focused," note the authors.

"In future research it will be worth trying to reproduce the effects of this intervention in other wards, where healthcare workers probably meet the same problems," they conclude.

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