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Ethical Assignment – Case Scenario # 1 Presented to Dr. Debra Armentrout, Ph-D, NNP-BC, RN

Ethical Assignment – Case Scenario # 1 Presented to Dr. Debra Armentrout, Ph-D, NNP-BC, RN Leigh Ann Cates, MN, RN, NNP-BC,RRT-NPS In Partial Fulfillment Of the Requirements for the Course GNRS 5633 – NNP 3 By Chris Dischler, RN, SNNP Melissa Reljac , RN, SNNP

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Ethical Assignment – Case Scenario # 1 Presented to Dr. Debra Armentrout, Ph-D, NNP-BC, RN

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  1. Ethical Assignment – Case Scenario # 1 Presented to Dr. Debra Armentrout, Ph-D, NNP-BC, RN Leigh Ann Cates, MN, RN, NNP-BC,RRT-NPS In Partial Fulfillment Of the Requirements for the Course GNRS 5633 – NNP 3 By Chris Dischler, RN, SNNP Melissa Reljac, RN, SNNP Ashley Ilseng, RN, SNNP November 15, 2013

  2. Overview of Case • Mother • 23 y/o primigravida, no PNC, wants “everything done” for her baby, father not involved and refused financial responsibility • Infant • 23 wk, 500 gm, born by SVVD, APGARs 2 at 1 minute/3 at 5 min • Delivery Room • intubated, surfactant x 1 • Unit • placed on oscillator, FIO2 weaned 100 to 30%, amp and hertz also weaned

  3. Overview of Case • 4 hours of age • Anterior fontanel tense • HUS revealed bilateral grade IV with PVL • DOL 5 • all but 16 cm of terminal ileum removed • Blood Culture Results • 36 hours – Candida albicans

  4. Ethical Issues/Dilemmas • Grade IV with PVL • Infant had all but 16cm of ileum removed • Positive blood culture for candida albicans • Low apgar scores • Mother wants everything done • Should the infant be taken off life support • 23 weeks gestation

  5. Ethical Issues: Grade IV & PVL • Grade IV and PVL • 15-20% of infant’s that weigh less than 1500 grams develop IVH • Developing problems include hydrocephalus, cerebral palsy, mental retardation, and/or seizures (Wildrick, 1997)

  6. Ethical Issues: Grade IV & PVL • Grade IV and PVL • mortality is around 80% • 90% chance of severe neurological sequelae (cognitive and motor disturbances) (Annibale & Hill, 2012)

  7. Ethical Issues: Grade IV & PVL • Grade IV and PVL • Withdrawal of life support occurs in less than 5% of cases • According to the Journal of the American Academy of Pediatrics decisions to withdrawal life support in these types of cases should be based on a case by case basis • Bassan et al in a study reported infants with severe IVH, majority had the potential for human interaction, 80% adaptive scores, 87% adaptive communication scores both within 2 SD of normal (Bassan, 2007)

  8. Ethical Issues: Grade IV & PVL • Grade IV and PVL • Rhoden defined an unacceptably poor quality of life as one in which an individual “lacks potential for human interaction as a result of profound mental retardation • This definition is supported by many bioethicists and also the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research (Sawyer, 2008)

  9. Ethical Issues: Short Bowel Syndrome • Short Gut Syndrome • 4 year survival on parental nutrition is ~ 70% (11,50) • Cost for parental nutrition between 50 to 200,000 thousand per year (Cagir, 2012)

  10. Ethical Issues: Positive Blood Culture • Positive blood culture with Candida albicans • Neurodevelopment impairment is more common in infants that weigh < 1000 grams • Mortality rate in VLBW with candidemia 21-32% • Rate increased if less than 26 wks and less than 1000 grams correlated with increased mortality rate 40-50% • Mortality rate increased when sepsis is due to C albicans (Kaufman, 2012).

  11. Ethical Issues: Positive Blood Culture • Positive blood culture with Candida albicans • A study found that 41% infected infants and 57% fungal infections in ELBW infants had at least one adverse neurodevelopment outcome • Areas affected : mental development, psychomotor development, CP, visual impairment, hearing impairment • Development issues did not differ from fungus vsnonfungus. (Kaufman, 2012)

  12. Ethical Issues: Low Apgar Scores • Low apgar scores at birth • Apgar scores were 2 at 1 minute of age and 3 at 5 minutes of age • Low apgars scores have been associated with increased mortality in premature neonates • Low apgar scores can be a useful tool to assess prognosis of infant (Lee, Subeh, & Gould, 2011)

  13. Ethical Issues: 23 weeks gestation • Infant was born at 23 weeks gestation • Infant is considered ELBW • Study conducted in Boston revealed that 1/3 of infant born at 23 weeks gestation were discharged from hospital (McElrath, Robinson, Ecker, Ringer & Norwitz, 2001). • Fetal development information collected by Mayo clinic found that 63% of infants born at 23 weeks gestation will die (Donovan, 2013).

  14. Ethical Issues • Mother wants everything done • Should care of infant continue since mother wants everything done despite all of the diagnoses affecting the infant currently • Should the infant be taken off life support • Despite the mother wanting everything done for the infant, is the infant suffering?

  15. Legal Issues • Parent/family • Long term outcome of infant • Financial issues without father • Mother 24 y/o • Is the father going to be involved in decision making for the care of this infant? • Healthcare team • Stop life support • Continue treatment

  16. Role of NNP • Discuss with mother short term plan of care for infant – current treatment and medications • Discuss DNR versus full resuscitation • Keep the parents updated on changes in the infant’s care and condition at all times

  17. Role of NNP • Help parents understand what the long term outlook is with an infant having: • Grade IV with PVL • Having only 16 cm of ileum left • Blood culture positive for Candida albicans • 23 week gestation infant

  18. References • Annibale, D. & Hill, J. (2012). Periventricular hemorrhage – intraventricular hemorrhage follow up. Retrieved from http://emedicine.medscape.com/article/976654-followup#a2650 • Bassan H, Limperopoulos C, Visconti K, et al. Neurodevelopmental outcome in survivors of periventricular hemorrhagic infarction. Pediatrics.2007;120 (4):785– 792 • Cagir, B. (2012). Short bowel syndrome treatment & management. Retrieved from http://emedicine.medscape.com/article/193391-treatment#a25 • Donavan, C. (2013). Survival rates of premature babies born at 21-25 weeks improving. Retrieved from http://www.lifenews.com/2013/05/21/survival-rates-of-premature-babies-born-at-21-25- weeks-are-improving/ • Kaufman, D. (2012). Fungal infections in preterm infants. Retrieved from http://emedicine.medscape.com/article/980487-overview • Lee, H. , Subeh, M., & Gould, J. (2010). Low apgar score and mortality in extremely preterm neonates born in the United States. ActaPaediatrica, 99(12), 185-1789. Retrieved from http://www.ncbi.nih.gov/pmc/articles/PMC2970674/ • McElrath, T., Robinson, J. ,Ecker, J., Ringer, S.& Norwitz, E. (2001). Neonatal outcomeof infants born at 23 weeks’ gestation. Obstetrics & Gynecology, 97(1), 49-52. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11152906 • Sawyer, T. (2008). Withdrawing support for withdrawing support from premature infants with severe intracranial hemmorrhage. Journal of the American Academy of Pediatrics, 121(5), 1071-1072. • Wildrick, D. (1997). Intraventricularhemmorrhage and long-term outcome in the premature infant. The Journal of Neoscience Nursing, 29 (5), 281-290. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9361998

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