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Group processes in deciding about viability of neonates – A formative evaluation

Journal title
Z. Arbeits-und Organ.
Publication year
Maffezzoni, M.; Wunder, K.; Baumann-Holzle, R.; Stoll, F.

The investigation is an external evaluation of the ethical decision-making model that was developed at the Clinic of Neonatology at the University Hospital in Zurich (see Siebenthal & Baumann-Holzle, 1999). According to this model, the framework for the decision-making process is a discussion group, consisting of a team of care providers and various specialists who make decisions on medical interventions. The aim of the evaluation was to examine the current realization of the framework and to analyze the consequences of the discussion groups for the nurses and the doctors. The data were taken from protocols and questionnaires. The decision-making framework foresees that an independent moderator who is not involved in the care of the infant leads die discussion group. Final decision-making authority is carried by the so-called "inner circle" of medical unit staff who are directly involved in the care of the neonate. The participating "outer circle" consists of various experts (such as neurologists and cardiologists) and other interested unit staff members. In the first step, the treating physician and the care provider present the medical and care situation of the neonate. The group of concerned professionals then addresses the medical and ethical problem with the aid of criteria for risk and benefit in providing interventions (survival, dying, suffering and pain, probable and possible outcomes, future socio-emotional life context of the child). The group must develop and discuss three scenarios of options. The "inner circle" and the head of the clinic must then agree on a decision with respect to the nature of the medical care to be administered to the newborn child. In the final step, the parents are informed about the multiple perspectives and the decision reached by the group of concerned professionals. The analysis of the protocols showed that it was rare for one nurse alone to request the convening of a discussion group. In addition, it was found that one single person was moderating nearly half of the discussions. Group participants rated the discussion groups positively overall; they valued mainly both the interdisciplinary constitution of the group and the inclusion of all parties concerned in the decision-making process. They reported a desire to see better assessment of and stronger consideration of parents’ perspectives and the future environment of the neonate in the decision-making process. Their criticisms of the implementation of the framework changed over time. When the process was newly implemented, participants criticized the scheduling of the group discussions and the selection of the criteria. Later on, critiques focused on communication aspects. The evaluation revealed that the consequences of the discussion groups for the nurses and the doctors – attitude, benefit, overall judgment of the discussion groups, weighting of decision criteria, judgment of decision – varied over time, which can be attributed to both the roles that participants had in the groups (moderator, inner circle, or outer circle) and to the professions of persons participating in a group (physicians, care providers, other). Furthermore, evaluation results indicate that the framework for decision-making is suitable not only for broader application in other areas of intensive care but also for complex ethical problem-solving in nonmedical organizations.

Research abstracts