Indian Journal of Palliative Care
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 »  Abstract
 » Introduction
 » Case Report
 » Discussion
 » Conclusion
 »  References
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Table of Contents 
CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 3  |  Page : 388-391

Peaceful end of life in an unviable newborn: A case report


Department of Nursing, Faculty of Nursing, Universidad Nacional De Colombia Sede Bogotá, Bogotá, Colombia

Date of Submission07-Dec-2019
Date of Acceptance31-Dec-2019
Date of Web Publication29-Aug-2020

Correspondence Address:
Lucy Marcela Vesga Gualdrón
Faculty of Nursing, Universidad Nacional De Colombia Sede Bogotá, Bogotá
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPC.IJPC_215_19

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 » Abstract 


The limit of viability is a period of uncertainty regarding the prognosis and treatment, where palliative care (PC) is important to dignify death, although, in several countries, they are not implemented as in Colombia. The peculiarities of newborns make PC differ from care at other stages of life and which are rarely accepted by professionals who consider them overwhelming. The case of a newborn of 23 weeks of gestation is exposed where nursing care is revealed to the newborn and his family according to the theory of the peaceful end of life (PEL). The theory of the PEL is useful in the development of neonatal PC, which must be differentiated, improving well-being, and family support. Furthermore, health systems must recognize emotional risks for professionals.


Keywords: Extremely premature, fetal viability, infant, infant, newborn, nursing care, palliative


How to cite this article:
Saldana Agudelo G, Guiza Romero AF, Vesga Gualdrón LM. Peaceful end of life in an unviable newborn: A case report. Indian J Palliat Care 2020;26:388-91

How to cite this URL:
Saldana Agudelo G, Guiza Romero AF, Vesga Gualdrón LM. Peaceful end of life in an unviable newborn: A case report. Indian J Palliat Care [serial online] 2020 [cited 2020 Oct 22];26:388-91. Available from: https://www.jpalliativecare.com/text.asp?2020/26/3/388/293875





 » Introduction Top


In Colombia, 2499 newborns (NB) were born between 22 and 27 weeks of gestation during 2017 (extremely premature),[1] in a period that includes the limit of the viability, where the prognosis of life and clinical treatment are uncertain. Health professionals move between therapeutic incarnation, their obligation to save lives and the uncertainty of the benefits of palliative care (PC) in such small humans. This case reveals the nursing care framed in the theory of the peaceful end of life (PEL) and reflects on the care of ultra-premature NB.


 » Case Report Top


It is presented using the nursing situation methodology proposed by Boykin and Schoenhofer;[2] influenced by modern philosophies that recognize other forms of knowledge and board the human in an integral way.

The calm of the shift was interrupted by the arrival of a patient with 23 weeks of gestation, who needed an emergency cesarean section, by a rupture of membranes of a week of evolution with the signs of infection. Based on the calculated estimated weight, it was expected that the newborn would not be so immature, the health team agreed to be ready for revival.

When Jerome was born, the team agreed in that was better not to revive him for his immaturity. Jerome remained in deep apnea, hypotonic, and cyanotic, however, with the minimum stimulus of taking anthropometric measurements, he began to sob and cry. He had his eyes fused and weighed 600 g. He was crying with such vitality that I asked again the conduct to follow; the pediatrician repeated that the baby was very immature, and it was not fair to subject him to an infamous quality of life (decision that was taken with the parents).

Once the medical evaluation was completed, the entire team left the site. I started talking to him, I performed all the protocol prophylaxis, I cleaned him, I got a nappy, I made a hat with a sterile compress, and I wrapped him with hot fields. I spoke with Jerome's father and facilitated his entry into the room, confirmed his religious beliefs with him and I applied sterile water to him making the sign of the cross, in a ritual that resembles the baptism of Catholics. The very shocked father left quickly. Again, Jerome and I alone, he looked cyanotic and with dyspnea, I wanted to run away and not hear his crying, but I stayed there to accompany him, to make his position changes, monitor his temperature and all those things proper to the attention of the NB. Three hours later, before finishing my shift, I handed him to my colleagues in the neonatal unit, saturating 69% and with great vitality in his expression. Finally, the newborn died in his mother's arms, 7 h after birth.

On leaving, I was able to release what I felt, I needed a few minutes of crying to understand that my profession is beautiful and demanding, requires strength and personal balance to face difficult decisions, but each one of the lived experiences broadens the vision of care and edifies a more integral human being.

The case allows to identify as protagonists the NB, his family and the nurse; transcending the positivist vision of the human divided into parts and the professional as an observer that does not change with the experience of caring. The focus is the PEL theory, as can be seen in [Figure 1].[3],[4]
Figure 1: Peaceful end of life theory in the case. The five concepts of the theory are defined; show a fragment of the case and the nursing care that was performed. Def: Definition, Fr: Case fragment, Cr: Care

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 » Discussion Top


An element of PC is assistance for dignified death. Colombia decriminalizes assisted death in adults in 1997 and 20 years later materializes it; being the only country in Latin America to legislate on this aspect, but children are not included yet. Assisted death is not the only way to dignify death; however in such small and fragile bodies, the limit between comfort and assistance can be a very fine line. This circumstance creates anguish in health professionals, tension and distancing of PC; socially, the death of those who have just been born is not conceived. Therefore, neonatal and PC care is poorly boarded and defined in the care units.

The peculiarities of NB do not allow PC activities to be inferred from care at other stages of life. In [Figure 2][3],[21] are the arguments that support the care activities reflected in the case.
Figure 2: Scientific evidence of the care oriented by peaceful end of life theory

Click here to view


The attention of the NB to the limit of viability requires a look focused on PC, to avoid suffering and dignify life and death.[22],[23] The role of the nurse is: to support families for decision making that helps clear information; take care not only of physiological aspects but also participate in the defense of the patient and allow time, closeness and intimacy between the parents and the newborn;[23] as well as the other environmental aspects that favor tranquility and respond to the individual needs of each family.

The proximity to suffering and death leads professionals to emotional overload, intense sadness, and a sense of loss, so they feel fear of PC, relating to the lack of motivation.[22],[24] This is seen as one of the most stressful activities for nurses and can be a cause of disinterest in the care, as they often experience great frustration. However, sensitive and differentiated care of families living this painful experience should be a priority.

Another circumstance that concerns health staff is the continuous balance between the beneficence and maleficence of treatments or the limitation of therapeutic efforts. As well as the constant reflection on the elements that constitute the well-being and quality of life of the NB.[19]

It should not be forgotten that the case on which it is reflected, exposes a highly sensitive moment where human treatment must be gentle, considerate, and honest.[25] These require that the health staff involved receive frequent training, and this topic is involved in the agendas of the neonatal care units.


 » Conclusion Top


  • Neonatal PC is important to promote a dignified death in those who have just been born
  • The care must be multifactorial, sensitive, and differentiated, improving the well-being of the NB, and promoting family support
  • Professionals working in neonatal units must commit to the attention of NB to the limit of viability and health systems must recognize the risks to the emotional health of professionals and the needs of special training
  • The PEL theory is useful in generating the comprehensive neonatal or perinatal PC plan and favors evidence-based practice.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
National Administrative Department of Statistics. Demography and Population Statistics. Available from: https://www.dane.gov.co/index.php/estadisticas-por-tema/demografia-y-poblacion/nacimientos-y-defunciones. [Last accessed on 2019 Oct 17].  Back to cited text no. 1
    
2.
Boykin A, Schoenofer S, Valentine K. Health Care System Transformation for Nursing and Health Care Leaders: Implementing a Culture of Caring, Springer Publishing Company; 2013. ProQuest Ebook Central. Available from: http://ebookcentral.proquest.com/lib/unal/detail.action?docID=1600439. [Last accessed on 2019 Oct 16].  Back to cited text no. 2
    
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Gómez O, Carrillo G, Arias E. Nursing theories for research and health care practice in palliative care. Revista Latinoamericana de Bioética 2016;17:60-79.  Back to cited text no. 3
    
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Ruland CM, Moore SM. Theory construction based on standards of care: A proposed theory of the peaceful end of life. Nurs Outlook 1998;46:169-75.  Back to cited text no. 4
    
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Gao H, Li M, Gao H, Xu G, Li F, Zhou J, et al. Effect of non-nutritive sucking and sucrose alone and in combination for repeated procedural pain in preterm infants: A randomized controlled trial. Int J Nurs Stud 2018;83:25-33.  Back to cited text no. 8
    
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Collados-Gómez L, Ferrera-Camacho P, Fernandez-Serrano E, Camacho-Vicente V, Flores-Herrero C, García-Pozo AM, et al. Randomised crossover trial showed that using breast milk or sucrose provided the same analgesic effect in preterm infants of at least 28 weeks. Acta Paediatr 2018;107:436-41.  Back to cited text no. 9
    
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Anand KJ, Eriksson M, Boyle EM, Avila-Alvarez A, Andersen RD, Sarafidis K, et al. Assessment of continuous pain in newborns admitted to NICUs in 18 European countries. Acta Paediatr 2017;106:1248-59.  Back to cited text no. 10
    
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Cremillieux C, Makhlouf A, Pichot V, Trombert B, Patural H. Objective assessment of induced acute pain in neonatology with the newborn infant parasympathetic evaluation index. Eur J Pain 2018;22:1071-9.  Back to cited text no. 11
    
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Kruijt A, Turin M. Do pain measurement instruments detect the effect of painreducing interventions in neonates? A systematic review on responsiveness. Pain 2018;46:257-69. Available from: https://www.cambridge.org/core/product/identifier/S0047404517000161/type/journa l_article. [Last accessed on 2019 Nov 20].  Back to cited text no. 12
    
13.
External Circular 037 of 2015 Issued Jointly by the National Administrative Department of Statistics (DANE) and Ministry of Health and Social Protection of Colombia; 2015. Available from: https://www.minsalud.gov.co/sites/rid/lists/bibliotecadigital/ride/de/dij/circular-externa-conjunta-0037-de-2015.pdf. [Last accessed on 2019 Oct 17].  Back to cited text no. 13
    
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Marty CM, Carter BS. Ethics and palliative care in the perinatal world. Semin Fetal Neonatal Med 2018;23:35-8.  Back to cited text no. 14
    
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Durrmeyer X, Scholer-Lascourrèges C, Boujenah L, Bétrémieux P, Claris O, Garel M, et al. Delivery room deaths of extremely preterm babies: An observational study. Arch Dis Child Fetal Neonatal Ed 2017;102:F98-103.  Back to cited text no. 16
    
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McCall E, Alderdice F, Halliday H, Vohra S, Johnston L. Interventions to hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2018;2:CD004210.  Back to cited text no. 17
    
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Rodríguez N. The Nursing care for newborns with low weight. Revista Uruguaya de Enfermería. Revista Uruguaya de Enfermería 2014;9:23-30.  Back to cited text no. 18
    
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Manuel J, Villares M, Pediatría S, de Octubre H, de Complutense U. Nutrition and hydration in newborns: Limiting treatment decisions. Cuad Bioética 2015;26:241-9.  Back to cited text no. 19
    
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Parravicini E. Neonatal palliative care. Curr Opin Pediatr 2017;29:135-40.  Back to cited text no. 20
    
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Parad RB. Non-sedation of the neonate for radiologic procedures. Pediatr Radiol 2018;48:524-30.  Back to cited text no. 21
    
22.
Solís Sánchez G, Pérez González C, García López E, Costa Romero M, Arias Llorente RP, Suárez Rodríguez M, et al. Peri-viability: Limits of prematurity in a regional hospital in the last 10 years. An Pediatr (Barc) 2014;80:159-64.  Back to cited text no. 22
    
23.
Arnaez J, Tejedor JC, Caserío S, Montes MT, Moral MT, González de Dios J, et al. Bioethics in end-of-life decisions in neonatology: Unresolved issues. An Pediatr (Barc) 2017;87:e2.  Back to cited text no. 23
    
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Cole JCM, Moldenhauer JS, Jones TR, Shaughnessy EA, Zarrin HE, Coursey AL, et al. A proposed model for perinatal palliative care. J Obstet Gynecol Neonatal Nurs 2017;46:904-11.  Back to cited text no. 24
    
25.
de Castro de Oliveira F, Cleveland LM, Darilek U, Borges Silva AR, Carmona EV. Brazilian neonatal nurses' palliative care experiences. J Perinat Neonatal Nurs 2018;32:E3-10.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2]



 

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