Implementing structured, multiprofessional medical ethical decision-making in a neonatal intensive care unit.
BACKGROUND
In neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical case deliberations do take place, participants may not always know how to perform to the fullest.


METHODS
A level-IIID neonatal intensive care unit of a paediatric teaching hospital in the Netherlands.


METHODS
Structured multiprofessional medical ethical decision-making (MEDM) was implemented to help overcome problems experienced. Important features were: all professionals who are directly involved with the patient contribute to MEDM; a five-step procedure is used: exploration, agreement on the ethical dilemma/investigation of solutions, analysis of solutions, decision-making, planning actions; meetings are chaired by an impartial ethicist. A 15-item questionnaire to survey staff perceptions on this intervention just before and 8 months after implementation was developed.


RESULTS
Before and after response rates were 91/105 (87%) and 85/113 (75%). Factor analysis on the questionnaire suggested a four-factor structure: participants' role; structure of MEDM; content of ethical deliberation; and documentation of decisions/conclusions. Effect sizes were 1.67 (p<0.001), 0.69 (p<0.001) and 0.40 (p<0.01) for the first three factors respectively, but only 0.07 (p=0.65) for the fourth factor. Nurses' perceptions of improvement did not significantly exceed those of physicians.


CONCLUSIONS
Professionals involved in ethical case deliberation perceived that the process of decision-making had improved; they were more positive about the structure of meetings, their own role and, to some extent, the content of ethical deliberation. Documentation of decisions/conclusions requires further improvement.
Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre, Sophia Children's Hospital, Dr Molewaterplein 60, PO Box 2060, 3000 CB Rotterdam, Netherlands. j.boer@erasmusmc.nl
Jacoba Coby
JC
de Boer
Geja
G
van Blijderveen
Gert
G
van Dijk
Hugo J
HJ
Duivenvoorden
Monique
M
Williams
D000328:Adult; D001291:Attitude of Health Personnel; D002604:Chaplaincy Service, Hospital; D003657:Decision Making / Q000941:ethics*; D004992:Ethics, Medical; D004993:Ethics, Nursing; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D015931:Intensive Care, Neonatal / Q000941:ethics / Q000379:methods / Q000639:trends; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010327:Pastoral Care; D010348:Patient Care Team / Q000941:ethics / Q000592:standards / Q000639:trends; D012947:Social Work; D011795:Surveys and Questionnaires