Implementing structured, multiprofessional medical ethical decision-making in a neonatal intensive care unit
- Jacoba (Coby) de Boer1,
- Geja van Blijderveen1,
- Gert van Dijk2,
- Hugo J Duivenvoorden3,
- Monique Williams1
- 1Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre, Sophia Children's Hospital, Rotterdam, Netherlands
- 2Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Centre, Rotterdam, Netherlands
- 3Erasmus University Medical Centre, Rotterdam, Netherlands
- Correspondence to Jacoba (Coby) de Boer, Department of Paediatrics, Division of Neonatology, Erasmus University Medical Centre, Sophia Children's Hospital, Dr Molewaterplein 60, PO Box 2060, 3000 CB Rotterdam, Netherlands;
Contributors CdB had responsibility for development of structured multiprofessional medical ethical decision-making (MEDM), introduction, assessment, data analysis and writing of the manuscript. GvB had responsibility for development of structured multiprofessional MEDM, introduction, assessment. MW had responsibility for development and introduction of structured multiprofessional MEDM and commented on earlier drafts of this manuscript. GvD had responsibility for development of structured multiprofessional MEDM and introduction, chaired MEDM and commented on earlier drafts of this manuscript. HJD supervised the design and performed the final data analyses.
- Received 21 September 2011
- Revised 23 April 2012
- Accepted 26 April 2012
- Published Online First 25 May 2012
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.
Setting 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.
Conclusion 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.
- Clinical ethics
- codes of/position statements on professional ethics
- occupational health
- health personnel
- informed consent
- quality/value of life/personhood
- minors/parental consent
- education for healthcare professionals
- care of dying minors, end-of-life decisions
- organisational change
- quality of healthcare
Competing interests None.
Ethics approval The Erasmus University Medical Centre (Rotterdam, the Netherlands) institutional review board waived the need for approval (MEC-2010-312).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement We agree that this manuscript should be published in a scientific journal. The corresponding investigator will directly respond to requests from other researchers for raw data or additional analyses. We will unlock the article, if accepted for publication, for open access via RePub.