Extremely premature birth and the choice of neonatal intensive care versus palliative comfort care: an 18-year single-center experience.

OBJECTIVE: Review all live births 22 0/7 through 26 6/7 weeks gestation born 1996 through 2013 at our institution to describe the decision process and immediate outcomes of palliative comfort care (PCC) versus neonatal intensive care (NICU) and whether any significant family complaints or quality assurance concerns arose. STUDY DESIGN: Retrospective chart review, physician and ethicist interview process and database review focused upon our established periviability counseling guidelines that are directive of PCC at 22 weeks gestation and NICU at 26 weeks but supportive of informed family choice of either option at 23, 24 and 25 weeks. RESULT: At 22 weeks--all 54 infants had PCC; at 23 weeks--29/78 (37%) chose NICU care, 6/29 (21%) infants survived; at 24 weeks--79/108 (73%) chose NICU care, 47/79 (59%) survived; at 25 weeks--147/153 (96%) chose NICU care, 115/147 (78%) survived; and at 26 weeks--all infants had NICU care, 176/203 (87%) survived. Over 18 years and 606 births, we identified only three significant concerns from families and/or physicians that required formal review. CONCLUSION: Most pregnant women and families choose NICU care for their extremely premature infant, but if given the option via shared decision making, a significant proportion will choose PCC at gestational ages that some NICUs mandate resuscitation. We support a reasoned dialogue and bioethical framework that recognizes human values to be irreducibly diverse, sometimes conflicting, and ultimately incommensurable--value pluralism. Respectful shared decision making requires thoughtful and compassionate flexibility, nuanced and individualized suggestions for PCC or NICU and the reduction of hierarchical directives from physicians to families. We continue to advocate and rely upon informed family preference between 23 and 25 weeks gestation in our updated 2015 periviability guidelines.

Covenant model of corporate compliance. "Corporate integrity" program meets mission, not just legal, requirements.

Catholic healthcare should establish comprehensive compliance strategies, beyond following Medicare reimbursement laws, that reflect mission and ethics. A covenant model of business ethics--rather than a self-interest emphasis on contracts--can help organizations develop a creed to focus on obligations and trust in their relationships. The corporate integrity program (CIP) of Mercy Health System Oklahoma promotes its mission and interests, educates and motivates its employees, provides assurance of systemwide commitment, and enforces CIP policies and procedures. Mercy's creed, based on its mission statement and core values, articulates responsibilities regarding patients and providers, business partners, society and the environment, and internal relationships. The CIP is carried out through an integrated network of committees, advocacy teams, and an expanded institutional review board. Two documents set standards for how Mercy conducts external affairs and clarify employee codes of conduct.

Mercy: an insufficient motive for euthanasia. Catholic ethical tradition requires that we temper our motives with reason and care before acting.

Some experts argue that acts of assisted suicide and euthanasia are ethically appropriate because they are merciful. Compelling though it is, this argument is not sufficient for determining the morality of these acts. The ethical tradition that calls for mercy has never suggested that mercy is, by itself, a sufficient criterion for determining an act's moral appropriateness. Human motives are rarely, if ever, pure and objective. For that reason, our ethical tradition has insisted on tempering motives with reason and care. The criteria for determining when it is merciful to assist in another's suicide or engage in an act of euthanasia are, for all practical purposes, impossible to define. Commonly writers refer to a person's hopeless condition to justify the merciful response of assisted suicide or euthanasia. But unless we can agree on whether hopelessness is an objective or subjective reality, and until the criteria to define this reality are evident, it is difficult to see how assisted suicide or euthanasia can be a careful and reasoned expression of mercy. Only by examining one's intention can one judge whether an act that may appear to be merciful in a hopeless situation is appropriate. "Intention" refers to the reasoned decision or judgment one makes about a goal and the means used to achieve that goal. Even if we cannot control our emotional response (our motives) in a particular situation, we can control our judgment (our intentions). Within our moral tradition, we can be sure we are being merciful in a careful and reasoned way when we intend to protect and promote the good of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Terminal care and the pregnant woman: ethical reflections on In Re: A.C.

In June 1987, a Washington, DC, court, stating that it had an interest in protecting viable fetal life, ordered a 27-year-old woman dying of cancer to undergo a cesarean section to deliver a 26 1/2-week fetus. The child died within hours, and the woman within days, of the surgery. The ruling was appealed. In April 1990, the court vacated its order, stating that because the court had not first determined the woman's wishes, either as expressed by herself or through a substituted judgment, it was not possible to find a state interest in protecting fetal life which outweighed her own. Beyond this legal issue lie the ethical questions of appropriate care for the pregnant, terminally ill woman. This article argues that it is important to distinguish a decision not to deliver at this time from a decision to terminate a pregnancy. Further, because a cesarean section, unless there is a threat to her life, is not of any clear benefit to the woman, it is wrong to insist that a dying woman must always endure burdensome treatment for the sake of a viable fetus. Should the mother decide to take on such burdens, it is important also to recognize that a cesarean section is not always in the interest of the fetus simply because it is viable. Given the ambiguity of the prognosis for survival and the risks of significant handicaps for the preterm or low birth weight fetus, it may be ethically appropriate to omit an act on behalf of the fetus. Finally, the fact that the fetus' only chance of survival is a preterm delivery does not make the delivery ethically mandatory. The issue is not whether a preterm delivery is the fetus' only hope, but whether a preterm delivery is in the interest of the fetus.

Balancing benefit and burden. Merely avoiding harm does not carry out the intent of the Hippocratic Oath.

Healthcare providers often seek to benefit their patients through the avoidance of harm. This approach to benefit is rooted in the common understanding of the Hippocratic oath as primum non nocere--first, do no harm. A need exists in medical-ethical decision making to rediscover the principle of benefit per se, independent of the principle of avoiding harm. In healthcare the invasive, painful, costly, or repugnant nature of the treatment reflects the burden. Benefit, on the other hand, is personal. Rev. Gerald Kelly, SJ, moved away from considering objective burdens as the principal factor in determining the ethical status of a treatment and toward the presence or absence of some benefit. He also gave insight into the nature of this benefit: The treatment being considered should have a reasonable chance of offering a "remedial" effect. Recent literature has considered the "extent" of improvement as an important element in determining whether a treatment is of benefit. Not just any improvement justifies the treatment, but an improvement that fulfills the patient's reasonable expectations. The Declaration on Euthanasia states that if a treatment will or does fall short of expectations, it may be withheld or withdrawn on the grounds that the burdens involved are disproportionate. To understand a treatment as having proportionate value, one must also take into account that aspect of benefit which has not resulted.

The effect of a relaxation technique on coronary risk factors.

This study examined the effect of a relaxation technique on plasma lipids, weight, blood pressure, and blood glucose. Sixteen outpatient males were randomly assigned to control or experimental groups. The experimental group was taught a relaxation technique that they used throughout the study. The control group was started in a reading program. Subjects were followed by a nurse practitioner and dietitian for eight weeks. Results revealed a significant reduction in systolic blood pressure and a marginally significant reduction in low density lipoprotein (LDL) cholesterol in the experimental group. Both control and experimental groups self-reported high compliance with diet and adherence to prescribed intervention. State anxiety was found to be inversely related to changes in total cholesterol and LDL cholesterol.