End-of-life decisions in neonatal care: a conversation analytical study

Abstract

Objective: To understand the dynamics of conversations between neonatologists and parents concerning limitation of life-sustaining treatments.

Design: Formal conversations were recorded, transcribed and analysed according to the conventions and methods of conversation analysis.

Setting: Two tertiary neonatal intensive care units.

Participants: Consultant neonatal specialists and families.

Main outcome measures: We used conversation analysis and developed an inductive coding scheme for conversations based on the introduction of limiting life-sustaining treatments and on the parental responses.

Results: From recordings with 51 families, we identified 27 conversations about limiting life support with 20 families and 14 doctors. Neonatologists adopted three broad strategies: (1) 'recommendations', in which one course of action is presented and explicitly endorsed as the best course of action, (2) a 'single-option choice' format (conditional: referring to a choice that should be made, but without specifying or listing options), and (3) options (where the doctor explicitly refers to or lists options). Our conversation analysis-informed coding scheme was based on the opportunities available for parents to ask questions and assert their preference with minimal interactional constraint or pressure for a certain type of response. Response scores for parents presented with conditional formats (n=15, median 5.0) and options (n=10, median 5.0) were significantly higher than for those parents presented with 'recommendations' (n=16, median 3.75; p=0.002) and parents were more likely to express preferences (p=0.005).

Conclusion: Encouraging different approaches to conversations about limitation of life-supporting treatment may lead to better parent engagement and less misalignment between the conversational partners.

Keywords: neonatology; palliative care.