In the neonatal intensive care unit, some of the most consequential medical decisions unfold in conversations where parents do not say exactly what they mean. A mother may ask whether continued treatment is “still helping.” A father may wonder aloud whether their baby is suffering. Parents may stop asking about the next procedure, or quietly acknowledge that the prognosis has not changed. These statements can signal a readiness to reconsider aggressive treatment, yet they do not necessarily constitute an explicit request to change the goals of care. A paper in the Journal of Perinatology argues that, in such moments, clinicians may have an underused option: informed nondissent.
Informed nondissent is a form of shared decision-making that reverses the usual expectation that parents must actively approve a clinician’s recommendation before care proceeds. Instead, the clinical team explains what it believes is medically appropriate, makes the reasoning transparent, and gives parents a clear opportunity to object. If parents understand the recommendation and do not dissent, the team may move forward while continuing to monitor whether their views remain consistent with the plan. The model is not designed to turn silence into consent. Its central premise is that parents should be informed, heard, and able to refuse or challenge the recommendation, while clinicians retain responsibility for offering professional judgment.
That distinction is particularly important in the NICU, where newborns may be unable to communicate and parents must make decisions under extreme emotional and cognitive strain. Critically ill infants can require mechanical ventilation, surgery, medications that support blood pressure, dialysis, or prolonged nutritional support. In some cases, clinicians conclude that the infant’s condition is unlikely to improve or that continued intervention may prolong suffering without achieving goals the family considers meaningful. The medical facts may be uncertain, but the ethical pressure is immediate. Parents are asked to interpret complex prognostic information while coping with fear, exhaustion, grief, and the possibility of losing their child.
Traditional shared decision-making generally emphasizes affirmative agreement. Clinicians describe the options, discuss benefits and burdens, and ask parents to select a path that reflects their values. This approach protects parental authority and can be essential when choices are closely balanced or when the consequences of an intervention are substantial. Yet affirmative decision-making can also place a heavy burden on parents who feel that they are personally causing a treatment to begin, continue, or stop. Some may repeatedly ask clinicians what they would do, hoping for guidance rather than a menu of options. Others may communicate indirectly because they are not ready to state openly that they want life-sustaining treatment withdrawn.
The authors describe informed nondissent as a way to respond to that communication without abandoning parental participation. A clinician might say that, based on the infant’s condition, the team recommends shifting from an escalation-focused plan to comfort-focused care. The clinician would then explain the medical reasoning, describe what the change would involve, and ask the parents whether they disagree or want more time, clarification, or another consultation. Parents would not be required to produce a formal declaration before their concerns could be addressed. At the same time, a lack of objection would not be treated as proof that they are unconcerned, emotionally prepared, or fully settled.
The technical and ethical work lies in distinguishing nondissent from passive acquiescence. Parents may remain silent because they are confused, intimidated, overwhelmed, or unable to process information. Language barriers, cultural differences, unequal power between families and medical teams, and previous negative experiences with healthcare can all affect how disagreement is expressed. A parent who nods may be acknowledging that they heard the recommendation rather than endorsing it. For that reason, informed nondissent requires clinicians to use plain language, check understanding, invite questions repeatedly, and make disagreement psychologically safe. It also requires attention to nonverbal cues and to changes in a family’s behavior, while avoiding the assumption that those cues have only one meaning.
Used carefully, the approach may reduce decisional conflict. Parents often experience distress when they believe they must choose between opposing medical options without sufficient expertise, or when different members of the clinical team appear to offer inconsistent recommendations. A clear professional recommendation can provide structure. It tells families how clinicians interpret the prognosis, what outcomes are considered realistically achievable, and why one plan may better fit the infant’s clinical situation and the family’s stated values. Informed nondissent preserves space for parental values while reducing the expectation that parents must independently determine the medically appropriate course.
The model may also help address moral distress among clinicians. Neonatal professionals can experience moral distress when they believe treatment is no longer beneficial but feel unable to recommend a change, or when they perceive that families are asking for interventions that impose significant burdens without a plausible path to the goals being pursued. Conversely, clinicians may feel distressed if they believe a family is moving toward limitation of treatment without fully understanding the prognosis. By making clinical recommendations explicit and inviting objection, informed nondissent can clarify professional responsibility while keeping the family’s perspective central. It does not eliminate disagreement, uncertainty, or grief, but it may make the decision process more coherent.
The paper nevertheless emphasizes that informed nondissent is not a shortcut around consent, and it must not become a mechanism for overriding parents. Parental authority includes the ability to disagree, request additional information, seek a second opinion, ask for more time, and express values that clinicians do not share. The approach is inappropriate when parents are actively objecting, when the decision is highly contested, when the medical recommendation is uncertain, or when parents lack a meaningful opportunity to understand and respond. Documentation should reflect what was explained, what questions were asked, how understanding was assessed, and whether parents expressed agreement, uncertainty, or dissent. Ethics consultation, palliative care involvement, interpreters, and repeated meetings may be necessary safeguards.
Informed nondissent is therefore best understood not as a replacement for shared decision-making but as a carefully bounded variation within it. Its success depends on the quality of communication before any recommendation is accepted: the accuracy of prognostic information, the clinician’s willingness to explain uncertainty, and the family’s confidence that objection will not jeopardize their relationship with the care team. In the NICU, where parents often communicate through tentative questions rather than definitive declarations, that distinction can be crucial. The authors’ message is both practical and cautionary: when clinicians believe a change in goals of care is appropriate, they should say so clearly, invite disagreement directly, and continue listening even after parents appear not to dissent. The goal is not to make decisions easier by making parents less involved, but to make difficult decisions more transparent, humane, and aligned with the values of the family and the needs of the infant.
Subject of Research: Informed nondissent as a shared decision-making approach for goals-of-care decisions in neonatal intensive care units.
Article Title: Informed nondissent: an underutilized tool for the NICU context
Article References: Wilson, S., Gregory, E., Kukora, S. et al. “Informed nondissent: an underutilized tool for the NICU context.” Journal of Perinatology (2026). https://doi.org/10.1038/s41372-026-02853-0
Image Credits: AI Generated
DOI: https://doi.org/10.1038/s41372-026-02853-0
Keywords: neonatal intensive care, informed nondissent, shared decision-making, goals of care, parental authority, neonatal ethics, moral distress, end-of-life care, clinician-family communication, critically ill newborns
