Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining...
-
Upload
miranda-white -
Category
Documents
-
view
213 -
download
0
Transcript of Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining...
![Page 1: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/1.jpg)
Shedding Light on the Gray Zone:How much discretion should parents have
about life-sustaining treatment for newborn infants with birth asphyxia?
Shedding Light on the Gray Zone:How much discretion should parents have
about life-sustaining treatment for newborn infants with birth asphyxia?
Dominic WilkinsonOxford Nuffield Medical Research FellowJames Martin 21st Century School FellowUniversity of Oxford
![Page 2: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/2.jpg)
Case
Is it permissible to withdraw?
Is it permissible to continue treatment?
University Hospitals Bristol NHS Foundation Trust/PA WireRutherford Seminars in fetal & neonatal medicine (2005) vol. 10 (5) pp. 445-60
Shedding Light on the Gray Zone
![Page 3: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/3.jpg)
Shedding Light on the Gray Zone
Introduction
“The treatment of infants should be based on what is perceived to be in their best interest.”
Pediatrics 2007;119:403
![Page 4: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/4.jpg)
The Zero line view
0
Interests
Life worth living (LWL)
Life not worth living (LNWL)“Intolerable”
Burdens > Benefits
Shedding Light on the Gray Zone
![Page 5: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/5.jpg)
The gray zone
“The treatment of infants should be based on what is perceived to be in their best interest.”
Pediatrics 2007;119:403
“[where] the prognosis is uncertain but likely to be very poor and survival may be associated with a diminished quality of life for the child… parental desires should determine the treatment approach.”
Shedding Light on the Gray Zone
?????
![Page 6: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/6.jpg)
Outline
• What is the gray zone?
• Why is there a gray zone?
• Are newborns different?
• Where are the edges of the gray zone?
Shedding Light on the Gray Zone
?????
![Page 7: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/7.jpg)
The gray zone
• Cases or conditions where it would be permissible either to withdraw life-sustaining treatment, or to continue life-sustaining treatment and parental wishes may determine decision
Shedding Light on the Gray Zone
![Page 8: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/8.jpg)
Different gray zones
0
0
0
0
Shedding Light on the Gray Zone
![Page 9: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/9.jpg)
The Threshold view
0
Interests
Upper Threshold
Lower Threshold
Shedding Light on the Gray Zone
![Page 10: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/10.jpg)
0
Interests
Why parental discretion?
• Overlapping interests
Shedding Light on the Gray Zone
![Page 11: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/11.jpg)
0
Interests
Why parental discretion?
• Overlapping interests• Uncertainty
LWLLNWL
Shedding Light on the Gray Zone
![Page 12: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/12.jpg)
0
Interests
Why parental discretion?
• Overlapping interests• Uncertainty• Liberalism
Shedding Light on the Gray Zone
![Page 13: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/13.jpg)
0
Interests
Why parental discretion?
• Overlapping interests• Uncertainty• Liberalism• Parental interests
?
Shedding Light on the Gray Zone
![Page 14: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/14.jpg)
Are newborns different?
• Uncertainty?• Duration of uncertain prognosis?• Strength of parental rights or interests?• Harm of death?
?????
Shedding Light on the Gray Zone
![Page 15: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/15.jpg)
Where are the edges of the gray zone?
• Vagueness• Incommensurability
Too hard?
Shedding Light on the Gray Zone
?????
![Page 16: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/16.jpg)
Where are the edges of the gray zone?
Normative criteria: Upper ThresholdTreatment withdrawal is permissible for infants with
conditions that:
C1. Reduce future wellbeing, either by reducing benefits or by imposing substantial burdens on the child (or both) AND
C2. Are close to the level of a LNWL, AND EITHER
C3. Involve a significant risk of a LNWL OR
C4. Impose a substantial burden of care on others
?????
Shedding Light on the Gray Zone
![Page 17: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/17.jpg)
Where are the edges of the gray zone?
Normative criteria: Lower ThresholdTreatment withdrawal is not permissible for infants with
conditions that:
C1. Reduce future wellbeing, either by reducing benefits or by imposing substantial burdens on the child (or both) AND
C5. Render it highly likely that the infant will have a LNWL and be harmed by continuing treatment
?????
Shedding Light on the Gray Zone
![Page 18: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/18.jpg)
Where are the edges of the gray zone?Practical criteria:
Interests
0Severe Cerebral palsy / Severe Cognitive impairment
Multiple severe impairments - especially combined with ongoing painful illness or medical intervention
Moderate impairments
Shedding Light on the Gray Zone
![Page 19: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/19.jpg)
Advantages of this account
Avoids claim that severe impairments are LNWL
Allows scope for parental discretion
Advantages for care of older children
More consistency in decision-making
Shedding Light on the Gray Zone
?????
![Page 20: Shedding Light on the Gray Zone: How much discretion should parents have about life-sustaining treatment for newborn infants with birth asphyxia? Dominic.](https://reader036.fdocuments.in/reader036/viewer/2022081603/56649e9e5503460f94ba0183/html5/thumbnails/20.jpg)
Acknowledgements
Professor Tony HopeProfessor Julian Savulescu
Nuffield Dominions Trust (Oxford Nuffield Medical Fellowship)
Eric Burnard Fellowship RACP Astra-Zeneca Medical Fellowship Royal Children’s Hospital Traveling Scholarship
Questions, comments suggestions?
Shedding Light on the Gray Zone