A qualitative exploration of neonatologists’ implicit biases towards extremely pre term infants

Annie Janvier and her colleagues conducted research, which revealed an inconsistency in the application of the best interest principle for critically ill extremely preterm infants requiring resuscitation. Janvier and her colleagues carried out quantitative surveys, which used hypothetical clinical vignettes of critically ill incompetent patients of different ages in need of resuscitation. These surveys were conducted in nine countries and the findings were similar across; culturally different groups, physicians from a variety of specialties and in a non-medically educated population. The results of the surveys showed that the respondents were significantly more willing to respect the parents wishes for non resuscitation for the critically ill extremely preterm infant than for the critically ill two month old infant despite their initial judgment that resuscitation was both infant’s best interests and despite the fact that both infants had the same prognosis. This phenomenon, coined the ‘differential treatment’, demonstrates a different approach to resuscitation decision making for the extremely preterm infant, which is out of proportion to the prognosis. However, further work is needed to explore the reasons why clinicians responded differently to the extremely preterm infant clinical vignette compared with the other infant vignettes.

The aim of my research is to explore the clinical factors that influence the resuscitation decision-making process for critically ill infants of different ages. It also aims explore how neonatologists’ balance or weigh their clinical judgment of the infant’s best interest with the parental wishes. Finally, it aims to explore neonatologists’ reasons for the differential treatment of the critically ill extremely preterm infant compared with the critically ill two-month-old infant when both require resuscitation and have similar prognoses.

I conducted thirteen qualitative semi-structured interviews with English neonatologists. The interviews were divided into two parts: Participants were first asked to respond to three clinical vignettes similar to those used in Janvier’s surveys and secondly were asked open-ended questions based on concepts drawn from existing literature and designed to explore the underlying reasons for Janvier’s findings.

The results of this study confirmed and illuminated the differential treatment of critically ill extremely preterm infants, but also offered a deeper glimpse into how certain clinical factors as well as the parental wishes influenced the neonatologists’ responses. In addition, my results revealed the neonatologists’ reasons for the differential treatment of critically ill extremely preterm infants found in Janvier et al.’s surveys. Their reasons can be organized into four overarching themes which arose from the analysis of the interview data: The Influence of Personal Experiences and Previous Training, The Power of Emotions, The Fundamental Attitudes Towards Extremely Preterm Infants and The Responses to the Hypotheses From the Literature.

This project shows that resuscitation decision making for critically ill extremely preterm infants frequently involves complex behavioural decisional processes, which differ depending on an individual’s experiences, emotions, perceptions and attitudes. These factors contribute to and explain the differential treatment of critically ill extremely preterm infants demonstrated in Janvier et al.’s studies.

Drawing on these findings, I conclude that the neonatal medical community, through open and honest dialogue, should come to a consensus about how to apply the best interest principle when making resuscitation decisions for extremely preterm infants as well as to determine whether the differential treatment of critically ill extremely preterm infants is ethically justifiable in the context of resuscitation. Finally, I provide recommendations for further research.

Advisor: Parker, M
Horn, R
Kelley, M