Withdrawing Assisted Nutrition in Neonates: A Survey on Attitudes and Insights in Argentina

Abstract

Objective This study aimed to assess beliefs and attitudes of Argentinean neonatologists and neonatal nurses regarding end-of-life care of newborn infants, including withdrawal of clinically assisted nutrition and hydration (CANH).

Study Design A five-domain survey was sent to 465 neonatal health care workers, which included demographic data, general ethical concepts, participation in end-of-life decisions, beliefs about end-of-life care practices, and presentation of four clinical scenarios. Standard statistical tests were used, and a multivariable analysis was done to evaluate variables independently associated with rejecting the withdrawal of CANH.

Results A total of 227 questionnaires were anonymously completed, 60% by physicians and 40% by nurses. More respondents agreed to withdraw mechanical ventilation in comparison to CANH in patients under certain circumstances (88 vs. 62%, p < 0.01). The most accepted variables when deciding to withdraw care were the quality of life perceived by parents (86%) and their religious beliefs (73%). A total of 93% agreed that parents should be included in the decision, but only 74% acknowledged they are included in real practice. Considering the scenario of a newborn with severe and irreversible neurological compromise, 46% of respondents were opposed to suspending enteral nutrition. No independent variables were found to be associated with opposing the withdrawal of CANH. Of those agreeing to withdraw enteral feeds under certain circumstances, for the severely neurologically affected neonate 58% would either refuse to limit enteral feeds or consult with an ethics committee before doing so. When given the scenario of their own severe and irreversible neurological compromise, 68% agreed to have enteral feeds withdrawn to themselves, and they were more likely to agree with withdrawing feeds for the severely compromised neonate (odds ratio: 7.2; 95% confidence interval: 2.7–24.1).

Conclusion While most health care providers agreed to withdraw life-sustaining support under certain conditions, many were reluctant to suspend CANH. Many responses differed when being asked as general statements versus actual clinical scenarios.

Key Points

• Withdrawal of assisted nutrition is supported by the American Academy of Pediatrics in certain scenarios.

• Many neonatal intensive care units health care providers from Argentina are reluctant to suspend assisted nutrition.

• There is a need to learn how to deal with complex bioethical issues.

Keywords

health care providers attitudes - neonates - life support care/ethics - withdrawing treatment

Publication History

Received: 15 October 2022

Accepted: 29 March 2023

Accepted Manuscript online:
01 April 2023

Article published online:
26 April 2023

• References

• 1 Weiner J, Sharma J, Lantos J, Kilbride H. How infants die in the neonatal intensive care unit: trends from 1999 through 2008. Arch Pediatr Adolesc Med 2011; 165 (07) 630-634
• 2 Hellmann J, Knighton R, Lee SK, Shah PS. Canadian Neonatal Network End of Life Study Group. Neonatal deaths: prospective exploration of the causes and process of end-of-life decisions. Arch Dis Child Fetal Neonatal Ed 2016; 101 (02) F102-F107
• 3 Wilkinson DJ, Savulescu J. Knowing when to stop: futility in the ICU. Curr Opin Anaesthesiol 2011; 24 (02) 160-165
• 4 Latour JM, Fulbrook P, Albarran JW. EfCCNa survey: European intensive care nurses' attitudes and beliefs towards end-of-life care. Nurs Crit Care 2009; 14 (03) 110-121
• 5 Feltman DM, Du H, Leuthner SR. Survey of neonatologists' attitudes toward limiting life-sustaining treatments in the neonatal intensive care unit. J Perinatol 2012; 32 (11) 886-892
• 6 Moreno Villares JM. Nutrition and hydration in newborns: limiting treatment decisions. Cuad Bioet 2015; 26 (87) 241-249
• 7 Porta N, Frader J. Withholding hydration and nutrition in newborns. Theor Med Bioeth 2007; 28 (05) 443-451
• 8 Williams C, Hellmann J. Withdrawal of artificial nutrition and hydration in neonatal critical care. In: Rajendram R, Preedy VR, Patel VB, eds. Diet and Nutrition in Critical Care. New York, NY: Springer Science + Business Media; 2014: 823-834
• 9 Huxtable R. Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after Re Y. BMC Med Ethics 2019; 20 (01) 91-101
• 10 Royal College of Physicians. Prolonged disorders of consciousness following sudden onset brain injury: national clinical guidelines; 2020; London, UK. Accessed August 1, 2022 at: https://www.rcplondon.ac.uk/guidelines-policy/prolonged-disorders-consciousness-following-sudden-onset-brain-injury-national-clinical-guidelines
• 11 Heuberger RA. Artificial nutrition and hydration at the end of life. J Nutr Elder 2010; 29 (04) 347-385
• 12 How it feels to withdraw feeding from newborn babies. BMJ 2012; 345: e7319
• 13 Lantos JD. What we talk about when we talk about ethics. Hastings Cent Rep 2014; 44 (01) (1, suppl): S40-S44
• 14 Silberberg AA, Gallo JE. Ethical dilemmas associated with clinicians' decisions about treatment in critically ill infants born in Córdoba, Argentina. J Child Health Care 2017; 21 (01) 121-126
• 15 Silberberg A, Herich LC, Croci I, Cuttini M, Villar MJ, Requena Meana P. Limitation of life-sustaining treatment in NICU: physicians' beliefs and attitudes in the Buenos Aires region. Early Hum Dev 2020; 142: 104955
• 16 Mariani G, Contrera P, Fernandez A. et al. End of life care for newborn infants in Argentina. Prospective multicenter study. [Abstract] Paper presented at: Pediatric Academic Societies Annual Meeting; 2022; Denver, CO
• 17 Sharma A, Minh Duc NT, Luu Lam Thang T. et al. A Consensus-Based Checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med 2021; 36 (10) 3179-3187
• 18 Council for International Organizations of Medical Sciences (CIOMS). International Ethical Guidelines for Health-Related Research Involving Humans, Fourth Edition; 2016; Geneva, Switzerland. Accessed August 1, 2022 at: https://cioms.ch/wp-content/uploads/2017/01/WEB-CIOMS-EthicalGuidelines.pdf
• 19 Langley G, Schmollgruber S, Fulbrook P, Albarran JW, Latour JM. South African critical care nurses' views on end-of-life decision-making and practices. Nurs Crit Care 2014; 19 (01) 9-17
• 20 Badır A, Topçu İ, Türkmen E. et al. Turkish critical care nurses' views on end-of-life decision making and practices. Nurs Crit Care 2016; 21 (06) 334-342
• 21 McCormick RA. The quality of life, the sanctity of life. Hastings Cent Rep 1978; 8 (01) 30-36
• 22 Cúneo MM. Limitación del Esfuerzo Terapéutico en Terapia Intensiva Neonatal: el caso de los extremadamente prematuros. Roma: Lateran University Press-Editiones Academiae Alfonsianae; 2012
• 23 Diekema DS, Botkin JR. Committee on Bioethics. Clinical report–Forgoing medically provided nutrition and hydration in children. Pediatrics 2009; 124 (02) 813-822
• 24 Larcher V, Craig F, Bhogal K, Wilkinson D, Brierley J. Royal College of Paediatrics and Child Health. Making decisions to limit treatment in life-limiting and life-threatening conditions in children: a framework for practice. Arch Dis Child 2015; 100 (suppl 2): s3-s23
• 25 Natarajan N, Pardo AC. Challenges in neurologic prognostication after neonatal brain injury. Semin Perinatol 2017; 41 (02) 117-123
• 26 Gillam L. The zone of parental discretion: an ethical tool for dealing with disagreement between parents and doctors about medical treatment for a child. Clin Ethics 2016; 11: 1-8
• 27 Mercurio MR. Ethics for the pediatrician: imperiled newborns: limiting treatment. Pediatr Rev 2010; 31 (02) 72-75
• 28 Fistolera S, Couceiro C, Goldsmit G. et al. Adecuación del esfuerzo terapéutico en neonatología: exploración de las actitudes y conductas clínica. Paper presented at: IV Congreso Argentino de Neonatología; 2019; Buenos Aires, Argentina [Abstract]. Accessed July 29, 2022 at : https://www.sap2.org.ar/i2/SAP_Trabajos_Libres_previo.php?Accion=Vista_Previa_SAP&Id_TL=3769