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International variations in application of the best-interest standard across the age spectrum

Journal of Perinatology volume 37, pages 208–213 (2017)Cite this article

Subjects

Abstract

Objective:

Ethically and legally, assertions that resuscitation is in a patient’s best interest should be inversely correlated with willingness to forego intensive care (and accept comfort care) at the surrogate’s request. Previous single country studies have demonstrated a relative devaluation of neonates when compared with other critically ill patients.

Study Design:

In this international study, physicians in Argentina, Australia, Canada, Ireland, The Netherlands, Norway and the United States were presented with eight hypothetical vignettes of incompetent critically ill patients of different ages. They were asked to make assessments about best interest, respect for surrogate autonomy and to rank the patients in a triage scenario.

Results:

In total, 2237 physicians responded (average response rate 61%). In all countries and scenarios, participants did not accept to withhold resuscitation if they estimated it was in the patient’s best interest, except for scenarios involving neonates. Young children (other than neonates) were given high priority for resuscitation, regardless of existing disability. For neonates, surrogate autonomy outweighed assessment of best interest. In all countries, a 2-month-old-infant with meningitis and a multiply disabled 7-year old were resuscitated first in the triage scenario, with more variable ranking of the two neonates, which were ranked below patients with considerably worse prognosis.

Conclusions:

The value placed on the life of newborns is less than that expected according to predicted clinical outcomes and current legal and ethical theory relative to best interests. Value assessments on the basis of age, disability and prognosis appear to transcend culture, politics and religion in this domain.

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References

  1. Fontana MS, Farrell C, Gauvin F, Lacroix J, Janvier A . Modes of death in pediatrics: differences in the ethical approach in neonatal and pediatric patients. J Pediatr 2013; 162 (6): 1107–1111.

    Article  Google Scholar 

  2. Verhagen A, Janvier A . THe continuing importance of how neonates die. JAMA Pediatr 2013; 167 (11): 987–988.

    Article  Google Scholar 

  3. Leuthner SR . Decisions regarding resuscitation of the extremely premature infant and models of best interest. J Perinatol 2001; 21 (3): 193–198.

    Article  CAS  Google Scholar 

  4. Dupont-Thibodeau A, Barrington KJ, Farlow B, Janvier A . End-of-life decisions for extremely low-gestational-age infants: why simple rules for complicated decisions should be avoided. Semin Perinatol 2014; 38 (1): 31–37.

    Article  Google Scholar 

  5. Janvier A, Leblanc I, Barrington KJ . Nobody likes premies: the relative value of patients' lives. J Perinatol 2008; 28 (12): 821–826.

    Article  CAS  Google Scholar 

  6. Hansen TW, Janvier A, Aasland O, Forde R . Ethics, choices, and decisions in acute medicine: a national survey of Norwegian physicians' attitudes. Pediatr Crit Care Med 2013; 14: 2.

    Article  Google Scholar 

  7. Armstrong K, Ryan CA, Hawkes CP, Janvier A, Dempsey EM . Life and death decisions for incompetent patients: determining best interestss—the Irish perspective. Acta Paediatr 2011; 100 (4): 519–523.

    Article  CAS  Google Scholar 

  8. Laventhal N, Spelke MB, Andrews B, Larkin LK, Meadow W, Janvier A . Ethics of resuscitation at different stages of life: a survey of perinatal physicians. Pediatrics 2011; 127 (5): 2010–1031.

    Article  Google Scholar 

  9. Mills BA, Janvier A, Argus BM, Davis PG, Froisland DH . Attitudes of Australian neonatologists to resuscitation of extremely preterm infants. J Paediatr Child Health 2015; 51 (9): 870–874.

    Article  Google Scholar 

  10. Williams A . The rationing debate: rationing health care by age: the case for. BMJ 1997; 314 (7083): 820–825.

    Article  CAS  Google Scholar 

  11. Janvier A, Leblanc I, Barrington KJ . The best-interest standard is not applied for neonatal resuscitation decisions. Pediatrics 2008; 121 (5): 963–969.

    Article  Google Scholar 

  12. Janvier A, Mercurio MR . Saving vs creating: perceptions of intensive care at different ages and the potential for injustice. J Perinatol 2013; 33 (5): 333–335.

    Article  Google Scholar 

  13. Janvier A, Barrington KJ, Aziz K, Lantos J . Ethics ain't easy: do we need simple rules for complicated ethical decisions? Acta Paediatr 2008; 97 (4): 402–406.

    Article  Google Scholar 

  14. Hester DM . Interests and neonates: there is more to the story than we explicitly acknowledge. Theor Med Bioeth 2007; 28 (5): 357–372.

    Article  Google Scholar 

  15. Bello M, Becerril-Montekio VM . [The health system of Argentina]. Salud publica de Mexico 2011; 53 (Suppl 2): s96–s108.

    PubMed  Google Scholar 

  16. Janvier A, Bauer K, Lantos J . Are newborns morally different from older children? Theor Med Bioeth 2007; 28 (5): 413–425.

    Article  Google Scholar 

  17. Pignotti MS, Donzelli G . Perinatal care at the threshold of viability: an international comparison of practical guidelines for the treatment of extremely preterm births. Pediatrics 2008; 121 (1): e193–e198.

    Article  Google Scholar 

  18. Verloove-Vanhorick SP . Management of the neonate at the limits of viability: the Dutch viewpoint. BJOG 2006; 113: 13–16.

    Article  Google Scholar 

  19. Robertson J, Newby DA, Walkom EJ . Health care spending: changes in the perceptions of the Australian public. PloS One 2016; 11 (6): e0157312.

    Article  Google Scholar 

  20. Zamberlin N, Romero M, Ramos S . Latin American women's experiences with medical abortion in settings where abortion is legally restricted. Reprod Health 2012; 9 (1): 34.

    Article  Google Scholar 

  21. Sheeran P . Intention—behavior relations: a conceptual and empirical review. Eur Rev Soc Psychol 2002; 12 (1): 1–36.

    Article  Google Scholar 

  22. Guevara-Aguirre J, Balasubramanian P, Guevara-Aguirre M, Wei M, Madia F, Cheng C-W et al. Growth hormone receptor deficiency is associated with a major reduction in pro-aging signaling, cancer, and diabetes in humans. Sci Transl Med 2011; 3 (70): 70ra13.

    Article  Google Scholar 

Download references

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Authors and Affiliations

  1. Department of Pediatrics and Communicable Diseases, 8-621 Mott C&W Hospital, University of Michigan School of Medicine, Ann Arbor, MI, USA

    N Laventhal

  2. Department of Pediatrics, University Medical Center Groningen, University of Groningen, The Netherlands

    A A E Verhagen

  3. Department of Neonatology, Division of Child and Adolescent, Oslo University Hospital, Clinical Ethics, Oslo, Norway

    T W R Hansen

  4. University of Oslo, Institute of Clinical Medicine, Faculty of Medicine, Oslo, Norway

    T W R Hansen

  5. INFANT Centre, Cork University Maternity Hospital, University College, Cork, Ireland

    E Dempsey

  6. The Royal Women’s Hospital, Melbourne, VIC, Australia,

    P G Davis

  7. The University of Melbourne, Parkville, Melbourne, VIC, Australia

    P G Davis

  8. Department of Maternal and Child Health Hospital Universitario Austral–Universidad Austral, Buenos Aires, Argentina

    G A Musante

  9. Rosalind Franklin University Chicago Medical School, Chicago, IL, USA

    A Wiles

  10. Department of Pediatrics, University of Chicago, Chicago, IL, USA

    W Meadow

  11. Department of Pediatrics and Department of Clinical ethics, University of Montreal, Monreal, QC, Canada

    A Janvier

  12. Department of Neonatology, Clinical Ethics Unit, CHU Sainte-Justine, Montreal, QC, Canada

    A Janvier

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  1. N Laventhal
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  2. A A E Verhagen
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  6. G A Musante
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  7. A Wiles
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  8. W Meadow
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Corresponding author

Correspondence to N Laventhal.

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The authors declare no conflict of interest.

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Supplementary Information accompanies the paper on the Journal of Perinatology website

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Laventhal, N., Verhagen, A., Hansen, T. et al. International variations in application of the best-interest standard across the age spectrum. J Perinatol 37, 208–213 (2017). https://doi.org/10.1038/jp.2016.168

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  • DOI: https://doi.org/10.1038/jp.2016.168

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