What do doctors record in the medical notes following discussion with the parents of sick premature infants?

• Published in: European journal of pediatrics Vol. 157; no. 1; pp. 63 - 65
• Main Authors: FOWLIE, P. W, DELAHUNTY, C, TARNOW-MORDI, W. O
• Format: Journal Article
• Language: English
• Published: Heidelberg Springer 01-01-1998; Berlin Springer Nature B.V
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Babies; Bioethics; Biological and medical sciences; Birth weight; Emergency and intensive care: neonates and children. Prematurity. Sudden death; Ethics; Ethics, Medical; Female; Gestational age; Humans; Hypotheses; Infant, Newborn; Infant, Premature, Diseases - diagnosis; Infant, Premature, Diseases - mortality; Infant, Premature, Diseases - therapy; Infant, Very Low Birth Weight; Infants; Intensive care medicine; Intensive Care Units, Neonatal - statistics & numerical data; Low-birth-weight; Male; Medical records; Medical Records - statistics & numerical data; Medical sciences; Neonates; Parents; Parents & parenting; Patient Education as Topic - methods; Physician-Patient Relations; Premature babies; Premature birth; Prognosis; Retrospective Studies; Risk Assessment; Sampling Studies; Severity of Illness Index; Survival Rate; Treatment Refusal; Truth Disclosure; United Kingdom; Withholding Treatment; United Kingdom > UK; Human; Premature; Pregnancy disorders; Parent; Physician; Intensive care unit; Very low birthweight; Health staff family relation; Newborn diseases; Newborn; Clinical interview; Medical record; Recording; Empirical Approach; Professional Patient Relationship
• ISSN: 0340-6199; 1432-1076
• DOI: 10.1007/s004310050768

In a retrospective review of medical notes we determined: (1) how often doctors record discussions with the parents of very low birth weight (VLBW) infants during the neonatal period; (2) what details of any discussion they actually record and; (3) if they are more likely to record discussion with the parents of sicker infants. A random sample (30%) of all VLBW infants admitted between 1989 and 1993 to a regional NICU was reviewed, n = 87. No discussion was documented in 47 cases, one of whom died, 24 had a single episode of discussion recorded and 16 had two or more episodes recorded. Specific discussion about prognosis was only recorded in the notes of 27 babies. Discussion was more likely to be documented in sicker infants as measured by CRIB (clinical risk index for babies) score, t = -3.9, P < 0.001.
A record of discussion between medical staff and parents is found in the medical notes of less than half of all VLBW infants. These findings may have practical, ethical and legal implications.