Thierry Daboval

How we teach ethics and communication during a Canadian neonatal perinatal medicine residency: An interactive experience

Background: Ethically challenging clinical situations frequently confront health care professionals in neonatology. These situations require neonatologists to exercise professionalism by communicating effectively throughout evolving physician–parent relationships in order to arrive at shared decisions for care that are in the best interest of the neonate and grounded solidly in ethical precepts. Aim: This article describes the process by which a well-delineated, interactive program to teach ethical reasoning and skillful communication with parents was implemented at the University of Ottawa, Canada. Methods: A revised ethics program implemented in 2009 identified competencies that should be demonstrated at the end of the Neonatal-Perinatal Medicine (NPM) residency. Several seminars were refined while new workshops, problem-based learning in ethics, and a personal portfolio were added. Results: All teaching strategies were well received based on the average level of satisfaction (5.8 out of 7, SD 0.4). We are now moving forward by formally assessing our program including the impact on knowledge acquisition and behavior. Conclusion: A dedicated, interactive competency-based neonatal ethics teaching program is vital to support NPM trainees in learning how to integrate ethical thinking with competencies in communication.

Field testing of decision coaching with a decision aid for parents facing extreme prematurity

Objective:The objective of this study is to assess and modify an existing decision aid and field-test decision coaching with the modified aid during consultations with parents facing potential delivery at 23 to 24 weeks gestation.Study Design:International Patient Decision Aid Standards instrument (IPDASi) scoring deficits, multi-stakeholder group feedback and α-testing guided modifications. Feasibility/acceptability were assessed. The Decisional Conflict Scale was used to measure participants’ decisional conflict before (T1) and immediately after (T2) the consultation.Results:IPDASi assessment of the existing aid (score 11/35) indicated it required updated data, more information and a palliative care description. Following modification, IPDASi score increased to 26/35. Twenty subjects (12 pregnancies) participated in field-testing; 15 completed all questionnaires. Most participants (89%) would definitely recommend this form of consultation. Decisional conflict scores decreased (P<0.001) between T1 (52±25) and T2 (10±16).Conclusion:Field testing demonstrated that consultations using the aid with decision coaching were feasible, reduced decisional conflict and may facilitate shared decision-making.

Accidental overheating of a newborn under an infant radiant warmer: a lesson for future use

A fully functional radiant warmer induced rapid and continuous increases in regional skin temperatures, heart rate, mean arterial blood pressure and respiratory rate in a newborn patient without corrective action. We report this case of passive overheating to create awareness of the risks associated with regulating radiant heat output based upon a single servo-controlled temperature.

ASQ3 and/or the Bayley-III to support clinicians' decision making

Background Appropriate tools are essential to support a clinician’s decision to refer very preterm infants to developmental resources. Streamlining the use of developmental assessment or screening tools to make clinical decisions offers an alternative methodology to help to choose the most effective way to assess this very high-risk population. Objective To examine the influence of the Ages and Stages Questionnaire-3rd edition (ASQ3) and the Bayley Scales of Infant Development-3rd edition (Bayley-III) scores within a clinically-based decision-making process. Methods This retrospective cohort study includes children born at less than 29 weeks gestation who had completed both psychologist-administered Bayley-III and physician-observed ASQ3 assessments at 18 months corrected age. Theoretical referral decisions (TRDs) based on each assessment results were formulated, using cut-off scores between the lower first and second standard deviation values and below the lower second standard deviation values. TRDs to refer to developmental resources were evaluated in light of the multidisciplinary team’s actual final integrated decisions (FID). Results Complete data was available for 67 children. The ASQ3 and the Bayley-III had similar predictive value for the FID, with comparable kappa values. Comparisons of the physicians’ and psychologists’ TRDs with the FIDs demonstrated that the ASQ3 in conjunction with the medical and socio-familial findings predicted 93% of referral decisions. Conclusion Taking into consideration potential methodological biases, the results suggest that either ASQ3 or Bayley-III, along with socio-environmental, medical and neurological assessment, are sufficient to guide the majority of clinicians’ decisions regarding referral for specialty services. This retrospective study suggests that the physician-supervised ASQ3 may be sufficient to assess children who had been extremely preterm infants for referral purposes. The findings need to be confirmed in a larger, well-designed prospective study to minimize and account for potential sources of bias.

Innovative Holistic Teaching in a Canadian Neonatal Perinatal Residency Program

Ethically complex and challenging cases confront health care professionals in neonatal-perinatal medicine more often than in most other subspecialties in medicine. Neonatologists regularly encounter situations where crucial life-or-death decisions need to be made in the best interest of an infant and its family. While physicians and their professional societies seem to dictate this best interest standard by weighing the risk of mortality and morbidities, parents may have other perspectives to be considered. Our review of programs for teaching ethics in Canadian neonatal-perinatal residency programs has revealed that 90 percent of them incorporated formal and informal medical ethics education, meeting the Royal College of Physician and Surgeons of Canada requirements, but that the teaching strategies, topics covered, and time devoted to teaching ethics are not standardized. Lectures and case presentations—the pedagogic strategy used by most programs—are not ideal for teaching communication skills. We propose, therefore, a holistic approach to teaching and training that imparts (1) a traditional understanding of ethical theory and reasoning, (2) advanced skills in communication and counseling, and (3) a disposition to engage in self-reflection and to be aware of the emotional and spiritual dimensions of neonatal-perinatal medicine.

Body temperature mapping in critically ill newborn infants nursed under radiant warmers during intensive care

Objective:The objectives of this study were to assess (i) the agreement between servo-control temperature (Tfeedback) and rectal temperature (Tre) and (ii) the distribution of regional skin temperatures (Tsk) of neonates nursed under a radiant warmer (RW) in a neonatal intensive care unit.Study design:An observational study of 13 neonates nursed under a RW device set to servo-control mode (Tfeedback set-point: 36.5 °C) who were monitored for Tfeedback, Tre and Tsk at six sites for a period of 105 min.Results:Mean bias for Tfeedback relative to Tre was +0.01 °C, but 95% limits of agreement were ±0.99 °C, and only 66% of Tfeedback values were within the acceptable limits determined a priori (±0.5 °C). Tfeedback was maintained within a range of 1.4 °C (35.9 to 37.3 °C), whereas the range observed for regional skin temperatures spanned from 9.5 °C (27.3 to 36.8 °C; foot) to 4.8 °C (33.1 to 37.9 °C; chest).Conclusion:Although Tfeedback is maintained within narrow limits, the level of agreement with Tre is poor. In addition, large fluctuations in regional skin temperatures occur with a consistent caudal-to-rostral temperature gradient, irrespective of Tfeedback.

The birth of scenario‐oriented learning in ethics

research component of CHEF despite monetary incentives (enrolment was optional: one could participate in the seminar without participating in the research). With hindsight, we instead would have worked with our institutional review board to further streamline the consent process. In addition, we realise after reflection that our experimental design should have employed a waitlist control group, which would have greatly added to our ability to capture the impact of the intervention. We plan to scale up in subsequent semesters to fully evaluate the effects of CHEF and welcome collaboration with other institutions on this critical issue in medical education.

Qualitative evaluation of a guideline supporting shared decision making for extreme preterm birth

Abstract Background and objectives: The decision to attempt resuscitation or provide palliative care at birth for extremely preterm infants between 22 and 25 weeks remains complex. The purpose of this study was to identify facilitators and barriers to implementation of a clinical practice guideline developed to support shared decision-making for these cases. Methods: A purposeful sample of healthcare providers, involved in the care of one of five cases of anticipated extremely preterm birth, was recruited for interviews. Participants shared their views on the guideline content, implementation process, and facilitators and barriers encountered. Interviews were audio-recorded and transcribed verbatim. Qualitative content analysis was used to code, categorize, and thematically describe the data. The Knowledge-Attitudes-Behaviours framework was used to organize the findings. Results: Twenty-five key informants (16 physicians, nine nurses) were interviewed. Participants described varying levels of knowledge of the guideline. Facilitators to implementation included: (1) an awareness of, familiarity with and belief in the content; (2) hard copy and electronic guideline accessibility; and, (3) institutional expertise to provide necessary care. Barriers included: (1) minimal awareness or familiarity with the content; (2) lack of agreement with the recommendations; (3) inadequate evidence and applicability to support changes in practice; and, (4) lack of resources to care for the most immature infants. Conclusions: Identified facilitators and barriers will inform the development of tailored strategies for improved local and future broader implementation. Other institutions can use the results to facilitate implementation of their guidelines on this ethically charged area.

A Newborn with Simmering Bleeding after Circumcision

We present a case of a healthy male neonate born at term, circumcised on Day 1 of life. Facing ongoing bleeding at the incision site, the baby was transferred to a level III neonatal intensive care unit for further investigation and management. His family history was unremarkable for bleeding disorders. On arrival, the baby was hemodynamically stable with abnormal coagulation values. Further investigations revealed a diagnosis compatible with severe hemophilia A. He deteriorated on Day 2, developing acute severe anemia which required two red blood cell transfusions. This rare but potentially fatal event reminds clinicians to remain extremely vigilant with minor surgical procedures such as circumcision even in the absence of family history.

Developing a Knowledge Test for a Neonatal Ethics Teaching Program

Objective The innovative Neonatal-Perinatal Medicine (NPM) Ethics Teaching Program at the University of Ottawa provides NPM trainees with vital foundational knowledge required to manage ethically contentious clinical scenarios frequently encountered in practice. In this study, our aim was to develop a knowledge test to assess the impact of the NPM Ethics Teaching Program on trainees’ knowledge about ethics. Study design Using an iterative four-step process, we developed a test for assessing pre- and post-training knowledge of NPM ethics. We first created a blueprint of the test, identifying its purpose, length, and format. We then weighted the learning outcomes of the NPM Ethics Teaching Program sessions to determine the number of questions that would be asked to assess to each learning outcome. Next, we populated the question bank and constructed a draft test. We obtained feedback from content experts on the draft test and piloted the draft test with former trainees from the NPM Ethics Teaching Program. Results We developed a pre- and post-knowledge test in NPM ethics consisting of 44 multiple choice questions (MCQs), each with five response options. The test takes approximately 60 minutes to complete. It took roughly 15 months to design and pilot the NPM ethics test. Conclusions This test can aid in the assessment of the amount of NPM ethics gained by trainees and contribute to the identification of areas for improvement in teaching and in the overall ethics program. Further iterations of the test will allow for additional assessment of its validity and the efficacy of the teaching program. Given the lack of structured evaluative ethics teaching programs in NPM nationally, this project will act as another step towards the introduction of our NPM Ethics Teaching Program to other Canadian NPM residencies.