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Curso de Reanimación neonatal, lección 9 de 9.
American Heart Association. American Academy of Pediatrics.

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  • In lesson 9 you will learn
    The ethical principles associated with starting and stopping neonatal resuscitation
    How to communicate with parents and to involve them in ethical decision making
    When it may be appropriate to withhold resuscitation
    What to do when the prognosis is uncertain
    How long to continue resuscitation attempts when the baby does not respond
    What to do when a baby dies
    How to help parents through the grieving process
    How to help staff through the grieving process
  • The ethical principles that govern these decisions are no different than those applied to older children and adults. Common ethical principals that apply to all medical care include
    Respect the individual’s rights to liberty and freedom (autonomy).
    Do good things for people (beneficence).
    Do not harm people (nonmaleficence).
    Treat people truthfully and fairly (justice).
  • Newborns cannot make decisions for themselves or express their desires. A surrogate decision maker (generally the parents) must be identified to assume the responsibility of guarding the newborn’s best interest. The decision maker(s) must have relevant, accurate, and honest information about the risks and benefits of all treatment options. Oftentimes, there is inadequate opportunity to achieve fully informed consent regarding all treatment options. In rare cases, the health care team may conclude that a decision made by a parent is not reasonable and not in the baby’s best interest.
  • Laws and the regulations that implement them vary among jurisdictions and can change quickly. Health care providers should be aware of the laws in the areas that they practice. No law mandates attempt at resuscitation in all circumstances. If further medical intervention would serve no useful purpose (ie, would be futile), withdrawal of support is considered appropriate. If there is disagreement between the parent and the health care team, most hospitals can consult an ethics committee or legal counsel.
    Instructor Tip: Ask participants who makes the decision in their hospitals regarding starting or stopping resuscitation.
  • Where gestation, birth weight, and/or congenital anomalies are associated with almost certain early death, and unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples include
    Newborns with confirmed gestational age of less than 23 weeks or birth weight less than 400 g
    Confirmed Trisomy 13 or Trisomy 18 syndrome
  • An example may include a baby born at 23 to 24 weeks’ gestation. In such cases, the parents’ views on either initiating or withholding resuscitation should be supported.
    Borderline survival, high morbidity rate
    Burden to child is high
    Support parents’ request
  • Unless conception occurred via in vitro fertilization, techniques used for obstetrical dating are accurate to only +/- 1 to 2 weeks and estimates of fetal weight are accurate only to +/- 15% to 20%. Even small discrepancies of 1 to 2 weeks in gestational age or 100 to 200 g in birth weight may have implications for survival and long-term morbidity. Also, fetal weight can be misleading if there has been growth restriction. These uncertainties underscore the importance of not making firm commitments about withholding resuscitation until you have the opportunity to examine the baby after birth.
    Gestation: accurate only to +/- 1 to 2 weeks
    Weight: accurate only to +/- 15% to 20%
    Resuscitation decisions dependent on baby’s condition at birth
  • In conditions associated with a high rate of survival and acceptable rate of morbidity, resuscitation is nearly always indicated. On rare occasions, parents and health care providers may disagree about what risk of mortality and morbidity are acceptable and what treatment is in the baby’s best interest. In these circumstances, it may become necessary to consult the hospital ethics committee or legal counsel. If there is not enough time to consult these additional resources, and the responsible physician concludes the parents’ decision is not in the best interest of the child, it is appropriate to resuscitate the newborn even over the parents’ objections. Accurate documentation of the discussion with the parents, as well as documentation of the basis for the decision, is essential.
  • Prenatal discussions provide an opportunity to share important information with the parents and establish a trusting relationship. Parents should receive consistent information from both the obstetric and pediatric teams and should be assured that their baby will receive coordinated care. This will assist the parents in making informed decisions for their baby. During the discussion, the following issues may be covered:
    Assessment of the baby’s chances for survival and possible disability.
    The possibility of “comfort care only” if viability is considered marginal.
    If comfort care treatment is agreed upon, assure the parents that care will focus on preventing or relieving pain and suffering.
    Explain where the resuscitation will take place and who will be in the delivery room.
    Offer time to consult with family members and/or clergy.
    After meeting with the parents, document a summary of your conversation in the mother’s chart.
  • If there is no heart rate after 10 minutes of complete and adequate resuscitation efforts and there is no evidence of other causes of newborn compromise, discontinuation of resuscitation efforts may be appropriate. Current data indicate that, after 10 minutes of asystole, newborns are very unlikely to survive, or likely to survive with severe disability. However, more than 10 minutes after birth may have been required to assess the baby and optimize the resuscitation efforts.
    There is no obligation to continue life support if it is the judgment of experienced clinicians that such support would not be in the best interest of the baby or would serve no useful purpose (ie, would be futile). In the case of withdrawal of critical care interventions and institution of comfort care support after successful initial resuscitation, the parents should be in agreement with this judgment.
  • When a baby is dying or has died, the most important goal is to provide humane and compassionate care. Prepare the baby by removing unnecessary tubes and placing him or her in a clean blanket, covering any significant open incisions or malformations. Allow the parents to hold the baby. Offer the parents privacy but be sure they know you are available. It is helpful to understand the cultural and religious expectations surrounding death in the community that you serve.
  • The entire staff should have a consistent, sensitive, and compassionate approach to families of babies who have died. If the mother is still an inpatient in the hospital, you may want to move her to a room elsewhere in the facility. A protocol for perinatal death prepared in advance and coordinated among all team members may help avoid inconsistencies from well-meaning staff. Skillful communication from the health care team is extremely important. There are no words that will make conversation with the family less painful. The attending physician may schedule a follow-up appointment to answer any questions and assess the family’s needs. Some hospitals sponsor parent-to-parent support groups. Remember that some families may not want any additional contact from the hospital and that this desire should be respected.
    Staff members who participated in care of the baby and family may also need support. Consider holding a debriefing session, but remember that issues regarding care decisions should only be discussed in a qualified peer-review session.
    Instructor Tip: Give participants resources to find protocols for care of families experiencing perinatal loss. Ask participants who supports/debriefs staff after this type of event in their hospital.
  • Reanimación Neonatal, lección 9: PRINCIPIOS ÉTICOS Y CUIDADOS AL FINAL DE LA VIDA

    2. 2. Principios Éticos y Cuidados Al Final De La Vida Contenido de la Lección: • Principios éticos para iniciar y detener la reanimación • Comunicación con los padres • Suspendiendo la reanimación • Pronóstico incierto • Criterios para detener la reanimación • Que hacer cuando el bebé fallece • Consolación (padres y equipo médico) 9-2
    3. 3. Principios Éticos para la Reanimación Neonatal • Los principios éticos para el recién nacido no deben ser diferentes de aquellos para los niños mayores o los adultos  • Principios Éticos Comunes – – – – Autonomía Beneficencia No Perjuicio Justicia 9-3
    4. 4. Sustitución En La Toma De Decisiones • Se considera a los padres los mejores sustitutos para tomar decisiones en nombre de sus hijos • Se les debe ofrecer a los padres información precisa y relevante acerca de los riesgos y beneficios de cada opción de tratamiento • Lo que sea mejor para el recién nacido • Puede no haber tiempo para que se dé información consentida a los padres  9-4
    5. 5. Leyes y Reanimación Neonatal • Las leyes varían en cada lugar • Ninguna ley federal obliga a llevar a cabo reanimación en todas las circunstancias • Suspenda la reanimación si considera que ésta es “inútil”  9-5
    6. 6. No Inicio de la Reanimación: Pronóstico de Certeza • Cuando el embarazo, el peso al nacimiento y/o malformaciones congénitas estan asociadas a la casi certeza de muerte temprana, y una inaceptable alta morbilidad es común entre los raros sobrevivientes, entonces no está indicado iniciar maniobras de reanimación  9-6
    7. 7. No Inicio de la Reanimación: Pronóstico Incierto • En condiciones asociadas a pronóstico incierto, donde hay una supervivencia mínima pero existe, una alta morbilidad y cuando el riesgo del bebé es alto, la decisión de los padres respecto a iniciar la reanimación debe ser apoyada  9-7
    8. 8. Calculando la Edad y Peso Fetal Antes del Nacimiento • A menos que haya sido por fertilización in vitro, el tiempo de embarazo solamente se puede calcular con +/- 1 a 2 semanas • En casos de prematurez extrema, avise a los padres que las decisiones hechas antes del nacimiento pueden ser modificadas en la sala de partos dependiendo de la evaluación postnatal  9-8
    9. 9. Reanimación En Contra De Los Deseos De Los Padres • Taza alta de sobrevida, riesgo aceptable de morbilidad • Compromiso ético y legal con el bebé • Comité de ética/consejo legal • Documentación precisa 9-9
    10. 10. Consulta Prenatal Antes De Un Nacimiento De Alto Riesgo • Establezca una buena relación con los padres • Decisión informada y atención coordinada • Aspectos – Probabilidades de sobrevida y discapacidad – “Cuidados de comfort exclusivamente ” – Prevención de dolor y sufrimiento • Documentación 9-10
    11. 11. Sin Respuesta a la Reanimación • La suspensión de las maniobras de reanimación puede ser apropiado después de 10 minutos de ausencia de frecuencia cardíaca a pesar de esfuerzos adecuados y completos de reanimación  9-11
    12. 12. Implicaciones De Los Padres Después De La Muerte Del Bebé • Sugiera a los padres que estén presentes o carguen a su bebé • Reduzca/maneje el dolor y sufrimiento de los padres • Sea sensible ante las prácticas culturales y necesidades espirituales 9-12
    13. 13. Cuidado De La Familia Después De La Muerte Del Bebé • Ofrecer cuidado constante, sensible, y empático • Tener una preparación avanzada y coordinada con entrenamiento y práctica • Desarrollar habilidades de comunicación • Ofrezca visitas de seguimiento y grupos de apoyo 9-13