The Use of Projected Autonomy in Antenatal Shared Decision-Making for Periviable Neonates: A Qualitative Study

Abstract

Background. In this study, we assessed the communication strategies used by neonatologists in antenatal consultations which may influence decision-making when determining whether to provide resuscitation or comfort measures only in the care of periviable neonates. Methods. This study employed a qualitative study design using inductive thematic discourse analysis of ‘naturally occurring data’ in the form of antenatal conversations around resuscitation decisions at the grey zone of viability. The study occurred between February 2017 and June 2018 on a labor and delivery unit within a large Midwestern tertiary care hospital. Participants included 25 mothers who were admitted to the study hospital with anticipated delivery in the grey zone of viability and practicing neonatologists or neonatology fellows who partnered in antenatal consultation. We used a two-stage inductive analytic process to focus on how neonatologists’ discourses constructed SDM in antenatal consultations. Megan J Thorvilson is with the Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (507)-255-0117, USA. Katherine Carroll is with the School of Sociology, College of Arts and Social Sciences, Australian National University, Canberra, Australia. Bethany D Kaemingk is with the Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (507)-255-0117, USA; the Division of Neonatal Medicine, Mayo Clinic, Rochester, MN, USA; the Department of Pediatrics, Sanford Children’s Hospital, Fargo, ND, USA; and the Department of Pediatrics, University of North Dakota, Grand Forks, ND, USA. Karen S Schaepe is with the Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA. Christopher A Collura is with the Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (507)-255-0117, USA; and the Division of Neonatal Medicine, Mayo Clinic, Rochester, MN, USA. Open Access – This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. First, we used a thematic discourse analysis to interpret the recurring patterns of meaning within the transcribed antenatal consultations, and second, we theorized the subsequent effects of these discourses on shaping the context of SDM in antenatal encounters. Results. In this qualitative study, that included discourse analysis of real-time audio conversations in 25 antenatal consults, neonatologists used language that creates projected autonomy through (i) descriptions of fetal physiology (ii) development of the fetus’s presence, and (iii) fetal role in decision-making. Conclusion. Discourse analysis of real-time audio conversations in antenatal consultations was revelatory of how various discursive patterns brought the fetus into decision-making, thus changing who is considered the key actor in SDM.