Retrospective cohort study of all deaths among infants born between 22 and 27 completed weeks of gestation in Switzerland over a 3-year period.

OBJECTIVES: The aim of this research is to assess causes and circumstances of deaths in extremely low gestational age neonates (ELGANs) born in Switzerland over a 3-year period. DESIGN: Population-based, retrospective cohort study. SETTING: All nine level III perinatal centres (neonatal intensive care units (NICUs) and affiliated obstetrical services) in Switzerland. PATIENTS: ELGANs with a gestational age (GA) <28 weeks who died between 1 July 2012 and 30 June 2015. RESULTS: A total of 594 deaths were recorded with 280 (47%) stillbirths and 314 (53%) deaths after live birth. Of the latter, 185 (59%) occurred in the delivery room and 129 (41%) following admission to an NICU. Most liveborn infants dying in the delivery room had a GA ≤24 weeks and died following primary non-intervention. In contrast, NICU deaths occurred following unrestricted life support regardless of GA. End-of-life decision-making and redirection of care were based on medical futility and anticipated poor quality of life in 69% and 28% of patients, respectively. Most infants were extubated before death (87%). CONCLUSIONS: In Switzerland, most deaths among infants born at less than 24 weeks of gestation occurred in the delivery room. In contrast, most deaths of ELGANs with a GA ≥24 weeks were observed following unrestricted provisional intensive care, end-of-life decision-making and redirection of care in the NICU regardless of the degree of immaturity.

[First-trimester-test--support-tool for the individual decision or screening-tool for public health planning?]. / Der Ersttrimester-Test - persönliche Entscheidungshilfe oder Screeningtool der öffentlichen Gesundheitsvorsorge?

International studies about women's knowledge of the first-trimester-test show that they are quite often not sufficiently informed for their personal decision-making: The information needed is not given in an understandable way; they are not informed that the test is only a risk assessment and not a diagnosis; and they often don't understand the concept of false positive and false negative results. Other studies show, that this sophisticated and complex information about the first-trimester-test can be given in an understandable way. But even with adequate information most women are unable to make an informed choice as long as the test is presented as a routine for screening. However, for an informed and free choice, an individual decision-making-process has to take place. For this reason a counseling concept has been developed in Switzerland. It introduces the first-trimester-test not as a screening-tool for the public health planning but as a support-tool for the individual decision. It consists of an information brochure for the pregnant woman and her partner, a counseling framework for the physicians and a two days training program. The counseling concept has been evaluated by a research project of the Swiss National Science Foundation and has been adopted as an official counseling standard by the Swiss Society of Obstetrics and Gynaecology. Recommendations for the communication skills together with a short time training program were added, such that the concept can serve as an integrative tool for decision-making support concerning first-trimester tests.

[Genetic technology and the thorn of ambivalence]. / Die Gentechnologie und der Stachel der Ambivalenz.

The following article reflects on the relationship between man and the world. The world not only surrounds man, but man participates in it. This participation has various implications for research and the application of genetic engineering. The article focuses on man's restricted capacity to know and foresee all the consequences of his actions and his ambivalence for good and bad. Man must be aware of his own limits and show due concern for mankind and the world.

[Ethical problems in the use of prenatal diagnosis]. / Ethische Probleme bei der Anwendung der pränatalen Diagnostik.

The ethical problems of prenatal diagnosis are outlined, with chief emphasis on the procedural level. On the procedural level this involves not only ethical structuring of the type of prenatal investigations on offer, i.e. acquisition of information and care of the patient, but also scientific investigation of the individual procedures and their effects on the fetus and pregnancy experience. Special attention is focused on the question of establishing legitimate indications for the use of prenatal diagnosis. Finally, as part of a discussion on human freedom, the fundamental problem of human selection according to criteria of genetic efficiency is briefly raised.

[Bad news and the successful life]. / Bad news und das gelungene Leben.

The following article analyses the context of time and structure for discussions about bad news. Patient and the physician live in different time frames: physician is in an ongoing hurry, meanwhile the patient is constantly waiting for something. The patient/physician relationship has to offer the patient the possibility to transform bad news successfully into the patient's life plan. This is possible only in an atmosphere of trust. Personal openness by the physician and helpful structures in a hospital are basic conditions for such a process. The process consumes time and energy of all people involved. To let things be as they are and to accept slowness as another option will bring new opportunities for patients and physicians to deal responsibly with bad news.