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In their report on neonatal death from Canada, Hellmann and colleagues1 indicate a propensity for neonatologists to employ a consensus deriving process that engages both families and the neonatal intensive care unit (NICU) interdisciplinary team. This is certainly in alignment with the process of shared decision-making, a strategy espoused by the American Academy of Pediatrics, the Nuffield Council and others. To their credit, the authors excluded stillbirths and infants <500 g and/or <23 completed weeks of gestation, but included infants admitted to the NICU, who may have died elsewhere in the hospital or at home receiving palliative care.
Within Hellmann et al's report, three things stand out.
First, certainty in a poor prognosis was reported to be from moderate to absolute by 88% of physicians. Clinicians may occasionally be confronted by colleagues, staff members or families who ask, ‘How certain are you?’ The degree of certainty need not be absolute in order to make recommendations for implementing, or withdrawing, care.2 There is an often missed, or misread, notion of certainty that characterises physicians in the intensive care unit. We expect of ourselves relative certainty—as best discernible by available evidence—in a scientific sense as we go about diagnosing and treating critically ill newborns. Yet, our practice involves a practical application of knowledge coloured by our best understanding of evidence and outcome expectations based on our experiences and those shared by others. Can we prognosticate with certainty? No, not absolutely, but our Canadian colleagues may be more accepting of this reality than what is …
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