Kain, V. J. (2006). Neonatal Network, 25, 387-392.

Despite a well-established and universally accepted protocol (Catlin & Carter, 2002) and support for neonatal palliative care by the World Health Organization (Maginnes, 2002) and the American Academy of Pediatrics (2000), it is rarely and certainly inconsistently practiced in most NICUs today. This interesting article presented an extensive and systematic review of the literature on barriers for neonatal nurses to providing palliative care. The author systematically searched several databases (CINAHL, Medline, PsychINFO, and PsychArticles) and reference lists of several significant articles for a total of 35 articles. The author was surprised to find few articles that specifically related to neonatal nursing. Several themes emerged from the literature indicating that barriers for neonatal nurses may be attitudinal, clinical, educational, institutional, regulatory, and financial. The author discussed literature that spoke to the perception that neonatal death is often viewed as "unnatural" to both nurses and families, who often have unrealistic expectations for medical intervention with sick and dying neonates. These unrealistic expectations are further exploited by the media and, in combination with providing what is perceived as futile aggressive treatment, may result in a sense of moral distress for the nurse. Ethical dilemmas also exist for the nurse because there is little, if any, consensus in the research literature as to what neonatal outcomes should be considered beneficial versus detrimental. The literature also revealed that neonatal nurses with more experience and advanced education experienced less moral distress during and after the death of a patient. Other significant barriers to providing neonatal palliative care include the NICU environment, which offers little or no privacy and comfort for the family, and a lack of formal training in palliative care and palliative care skills. The author, a doctoral candidate at Queensland University of Technology in Australia, has developed a survey instrument that explores both barriers and facilitators to palliative care practice by neonatal nurses. She plans to administer this instrument to NICU nurses in Australia and eventually-after testing for validity and reliability-to an international sample of NICU nurses. The Neonatal Palliative Care Attitude Scale (NPCAS) surveys the following key barriers: (a) neonatal death viewed as a failure, (b) adjustment from a curative to palliative care approach, (c) difficult communication with parents of dying neonates, (d) previous and traumatic exposure to neonatal death, (e) conflicts among providers around end-of-life decision making, (f) NICU environment, (g) lack of support for nurses providing end-of-life care, and (h) lack of formal training for nurses. The NPCAS is included in a sidebar of the article and would be useful for neonatal nurses exploring their own attitudes on palliative care. As a start in the development of a more formalized approach to the education of neonatal nurses on this topic, the palliative care protocol (Catlin & Carter, 2002) is a must read!!

Judy Beal

References