Division of Neonatal Medicine,
Department of Pediatric and Adolescent Medicine and.
Pediatrics. 2021 Apr;147(4). doi: 10.1542/peds.2020-1865. Epub 2021 Mar 3.
Antenatal consultation between a neonatologist and expectant parent(s) may determine if resuscitation is provided for or withheld from neonates born in the gray zone of viability. In this study, we sought to gain a deeper understanding of uncertainties present and neonatologists' communication strategies regarding such uncertainties in this shared decision-making.
A prospective, qualitative study using transcriptions of audio-recorded antenatal consultations between a neonatologist and expectant parent(s) was conducted. Pregnant women were eligible if anticipating delivery in the gray zone of viability (22 0/7-24 6/7 weeks' gestation). Over 18 months, 25 of 28 pregnant women approached consented to participate. Applied thematic analysis was used to inductively derive and examine conceptual themes.
Inductive analysis of consult transcripts revealed uncertainty as a central theme. Several subthemes relating to uncertainty were also derived, including the timing of delivery, NICU course, individual characteristics (of physician, expectant parent(s), and fetus or neonate), and consequences of the decision for the expectant parent(s). Analysis revealed that uncertainty was actively managed by neonatologists through a variety of strategies, including providing more information, acknowledging the limits of medicine, acknowledging and accepting uncertainty, holding hope, and relationship building.
Uncertainty is pervasive within the antenatal consultation for periviable neonates and likely plays a significant role in decision-making toward postnatal resuscitative efforts. Uncertainty complicated, or even paralyzed, decision-making efforts while also providing reassurance toward a positive outcome. Directions for future study should consider whether advanced communication training modulates the impact that uncertainty plays in the shared decision-making encounter.
新生儿科医生与准父母之间的产前咨询可能会决定是否对处于可存活灰区出生的新生儿进行复苏。在这项研究中，我们试图更深入地了解在这种共同决策中存在的不确定性以及新生儿科医生在沟通这些不确定性时的策略。
采用前瞻性、定性研究方法，对新生儿科医生与准父母之间的音频记录产前咨询进行转录。如果孕妇预计在可存活灰区（22 0/7-24 6/7 周妊娠）分娩，则有资格参加。在 18 个月的时间里，有 28 名接近分娩的孕妇中，有 25 名同意参与。应用主题分析方法对咨询记录进行归纳分析，以得出和检查概念性主题。
对咨询记录的归纳分析显示，不确定性是一个核心主题。还衍生出几个与不确定性相关的子主题，包括分娩时间、NICU 病程、个体特征（医生、准父母、胎儿或新生儿）以及对父母的决策后果。分析表明，新生儿科医生通过多种策略积极管理不确定性，包括提供更多信息、承认医学的局限性、承认和接受不确定性、抱有希望和建立关系。
在极早产儿的产前咨询中，不确定性普遍存在，并且可能在决定是否进行复苏方面发挥重要作用。不确定性使决策复杂化，甚至使决策陷入瘫痪，同时也对积极结果提供了保证。未来的研究方向应考虑高级沟通培训是否会调节不确定性在共同决策中的影响。
