Communicating prognosis with parents of critically ill infants: direct observation of clinician behaviors.

OBJECTIVE: Delivering prognostic information to families requires clinicians to forecast an infant's illness course and future. We lack robust empirical data about how prognosis is shared and how that affects clinician-family concordance regarding infant outcomes. STUDY DESIGN: Prospective audiorecording of neonatal intensive care unit family conferences, immediately followed by parent/clinician surveys. Existing qualitative analysis frameworks were applied. RESULTS: We analyzed 19 conferences. Most prognostic discussion targeted predicted infant functional needs, for example, medications or feeding. There was little discussion of how infant prognosis would affect infant/family quality of life. Prognostic framing was typically optimistic. Most parents left the conference believing their infant's prognosis to be more optimistic than did clinicians. CONCLUSIONS: Clinician approach to prognostic disclosure in these audiotaped family conferences tended to be broad and optimistic, without detail regarding implications of infant health for infant/family quality of life. Families and clinicians left these conversations with little consensus about infant prognosis.

Palliative care in neonatal neurology: robust support for infants, families and clinicians.

Infants with neurological injury and their families face unique challenges in the neonatal intensive care unit. As specialty palliative care support becomes increasingly available, we must consider how to intentionally incorporate palliative care principles into the care of infants with neurological injury. Here, we review data regarding neonatal symptom management, prognostic uncertainty, decision making, communication and parental support for neonatal neurology patients and their families.

Neonatal Critical Care Communication (NC3): training NICU physicians and nurse practitioners.

OBJECTIVE: Communicating with families is a core skill for neonatal clinicians, yet formal communication training rarely occurs. This study examined the impact of an intensive interprofessional communication training for neonatology fellows and nurse practitioners. STUDY DESIGN: Evidence-based, interactive training for common communication challenges in neonatology incorporated didactic sessions, role-plays and reflective exercises. Participants completed surveys before, after, and one month following the training. RESULT: Five neonatology fellows and eight nurse practitioners participated (n=13). Before the training, participants overall felt somewhat prepared (2.6 on 5 point Likert-type scale) to engage in core communication challenges; afterwards, participants overall felt very well prepared (4.5 on Likert-type scale) (P<0.05). One month later, participants reported frequently practicing the taught skills and felt quite willing to engage in difficult conversations. CONCLUSION: An intensive communication training program increased neonatology clinicians' self-perceived competence to face communication challenges which commonly occur, but for which training is rarely provided.

Mother-clinician discussions in the neonatal intensive care unit: agree to disagree?

OBJECTIVE: To compare mothers' and clinicians' understanding of an infant's illness and perceptions of discussion quality in the neonatal intensive care unit. STUDY DESIGN: English-speaking mothers with an infant admitted to the intensive care unit for at least 48 h were interviewed using a semi-structured survey. The clinician whom the mother had spoken to and identified was also surveyed. Interviews were audiotaped and transcribed. RESULT: A total of 101 mother-clinician pairs were interviewed. Most mothers (89%) and clinicians (92%) felt that their discussions had gone well. Almost all mothers could identify one of their infant's diagnoses (100%) and treatments (93.4%). Mothers and clinicians disagreed on infant illness severity 45% of the time. The majority of mothers (62.5%) who disagreed with clinician estimate of infant illness severity believed their infant to be less sick than indicated by the clinician. CONCLUSION: Mother-clinician satisfaction with communication does not ensure mother-clinician agreement about an infant's medical status.

Health-related quality of life for infants in the neonatal intensive care unit.

When discussing the benefits and burdens of medical interventions for critically ill infants, clinicians and families are challenged to weigh the uncertainties of treatment success with infant pain and suffering. Concrete measures of infant suffering or quality of life, which could inform infant care and decision-making are lacking. Although consistent and reliable health-related quality of life (HRQOL) definitions and measures have been extensively developed for adults and older children, they have not been relevant to neonates or infants. Advancing HRQOL research methodology is an objective of Healthy People 2020. This paper will review the evidence and practices relevant to HRQOL with a focus on intensive care and pediatric settings. We will highlight existing HRQOL measures, which could be adapted for neonates and existing neonatal intensive care unit measures and practices, which could inform new measures of HRQOL.

Adolescent mothers in the NICU: how much do they understand?

OBJECTIVE: We aimed to characterize adolescent parents' understanding of their infant's diagnosis, treatment and illness severity in the intensive care unit. STUDY DESIGN: Adolescent mothers were interviewed and neonatal medical records were reviewed. RESULT: Forty-two teens were interviewed. All had spoken with providers: 86% with nurses, 60% with physicians and 45% with both. Most teens could name their infant's diagnosis and treatment but often underestimated the illness severity. Teens reported reluctance to ask providers to clarify technical language. Those who said they spoke with a physician were less likely to understand their infant's illness severity than those who said they had not spoken with a physician (48 vs 82%). Parents' knowledge was better if physicians had documented explicit efforts to communicate with parents. CONCLUSION: Teens often underestimated the critical nature of their infant's illness. Future work should target adolescent willingness to ask questions and provider ability to accurately gauge parent knowledge.

Secret patterns: validation of a screening tool to detect bulimia.

We prospectively validated a two-item screening tool for bulimia. Subjects recruited from a women's health practice completed the previously developed two-item screening tool ("Do you ever eat in secret?" and "Are you satisfied with your eating patterns?") at their initial office visit. This was validated against a telephone interview with a licensed psychologist. The prevalence of current bulimia was 16% in 75 subjects, determined by psychologists' assessment (sensitivity 75%, specificity 49%) and 4% by DSM-III-R criteria. The positive and negative predictive values of one screening question positive were 22% and 91%, respectively, when compared with the psychologists' assessments as the gold standard. This screening tool allows physicians to identify patients who warrant further valuation for bulimia.

Care during menopause: comparison of a women's health practice and traditional care.

Despite the growth in primary care-based women's health centers, little is known about the characteristics of women's health patients and the quality of care provided in women's health centers versus traditional practices. Our objective was to compare a women's health practice and a general internal medicine practice on issues of care during menopause. A cross-sectional survey was administered simultaneously to patients aged 50-70 and their primary care physicians in a women's health practice and an affiliated general internal medicine practice. The survey asked patients about health behaviors, past and current hormone use, menopausal symptoms, and attitudes about menopause. Physicians were asked to estimate their patients' attitudes. Patients in women's health practices were younger, more likely to be smokers, and more likely to have had a prior hysterectomy. Women's health patients were somewhat more likely to report concerns related to menopausal symptoms. Women's health patients and patients attending the general internal medicine practice reported similar rates of past or current use of hormone therapy, after adjusting for prior hysterectomy and age. Physicians in women's health and general medicine were similar in their ability to estimate their patients' attitudes. In the general internal medicine practice, female physicians tended to better estimate their patients' attitudes than their male colleagues. Patients seeking care in a women's health practice differed in symptoms and concerns about the menopause compared with patients in a traditional primary care setting. Physicians' understanding of patients' menopausal concerns did not differ between the two practices. However, there may be gender differences in physicians' understanding of patients' concerns.

Menopausal hormone therapy: physician awareness of patient attitudes.

BACKGROUND: Physicians need to be aware of their patients' attitudes toward menopause when counseling women regarding hormone therapy, because menopausal attitudes may affect women's satisfaction with their decisions to use or not to use hormone therapy. Our objectives were to assess physician awareness of patient attitudes on issues surrounding the menopause and hormone therapy, and to determine the prevalence and correlates of hormone use. METHODS: This cross-sectional survey study was conducted in the primary care outpatient practices of an academic medical center. Surveys were simultaneously administered to female patients aged 50 to 70 years (n = 182) and their primary care physicians immediately after clinical encounters. The surveys contained questions from four established (five-point) attitudinal scales (autonomy, desire for information, philosophy of the menopause, barriers to use of hormone therapy), and questions addressing patients' degree of concern about developing various conditions. Physicians were asked to estimate their patients' attitudes. PATIENTS AND METHODS: Physicians were generally aware of patients' desire for autonomy (3.2 versus 3.2, P = 1.0), but tended to underestimate patients' desire for information (3.7 versus 4.5, P = 0.0001) and patients' perceptions of barriers to using hormone therapy (3.2 versus 3.4, P = 0.0001). They also underestimated the extent to which patients view menopause as a medical problem (3.0 versus 3.2, P = 0.0001). Physicians overestimated patients' general concern about heart disease (scale difference 0.40, P = 0.0001) and breast cancer (difference 0.23, P = 0.02). Physicians were less aware of their patients' attitudes when they were male (versus female), interns/residents (versus faculty/fellows), and less knowledgeable about menopausal hormone therapy (versus more knowledgeable). The significant predictors of hormone use on multivariate analysis were past hysterectomy, urinary incontinence, alcohol intake, and possession of knowledge regarding hormone therapy. CONCLUSIONS: Physicians incorrectly estimate some aspects of their patients' attitudes regarding menopause and hormone therapy, and certain physician characteristics may be associated with decreased awareness. To optimize hormone therapy counseling, physicians may need to increase their attention to patients' menopausal attitudes.

Noise effects in an electronic model of a single neuron.

We consider a simple electronic circuit model of a single neuron. The neuron is assumed to be driven by an external signal comprising constant (dc) and random components. In addition, the nonlinearity parameter in the circuit is assumed to fluctuate, thereby giving rise to critical behavior including the onset of hysteresis phenomena even for system parameter values that would not otherwise support such behavior. This "noise-induced critical behavior" is analysed, in the long time limit, through a study of the probability density function describing the neural response.