Perinatal care at the threshold of viability

Maternal brain death and somatic support

Brain death is a concept used in situations in which life-support equipment obscures the conventional cardiopulmonary criteria of death, and it is legally recognized in most countries worldwide. Brain death during pregnancy is an occasional and tragic occurrence. The mother and fetus are two distinct organisms, and the death of the mother mandates consideration of the well-being of the fetus. Where maternal brain death occurs after the onset of fetal viability, the benefits of prolonging the pregnancy to allow further fetal maturation must be weighed against the risks of continued time in utero, and preparations must be made to facilitate urgent cesarean section and fetal resuscitation at short notice. Where the fetus is nonviable, one must consider whether continuation of maternal organ supportive measures in an attempt to attain fetal viability is appropriate, or whether it constitutes futile care. Although the gestational age of the fetus is central to resolving this issue, there is no clear upper physiological limit to the prolongation of somatic function after brain death. Furthermore, medical experience regarding prolonged somatic support is limited and can be considered experimental therapy. This article explores these issues by considering the concept of brain death and how it relates to somatic death. The current limits of fetal viability are then discussed. The complex ethical issues and the important variations in the legal context worldwide are considered. Finally, the likelihood of successfully sustaining maternal somatic function for prolonged periods and the medical and obstetric issues that are likely to arise are examined.

End-of-life after birth: death and dying in a neonatal intensive care unit

OBJECTIVE

In canonical modern bioethics, withholding and withdrawing medical interventions for dying patients are considered morally equivalent. However, electing not to administer cardiopulmonary resuscitation (CPR) struck us as easily distinguishable from withdrawing mechanical ventilation. Moreover, withdrawing mechanical ventilation from a moribund infant "feels" different from withdrawing mechanical ventilation from a hemodynamically stable child with a severe neurologic insult. Most previous descriptions of withdrawing and withholding intervention in the neonatal intensive care unit (NICU) have blurred many of these distinctions. We hypothesized that clarifying them would more accurately portray the process of end-of-life decision-making in the NICU.

METHODS

We reviewed the charts of all newborn infants who had birth weight >400 g and died in our hospital in 1988, 1993, and 1998 and extracted potential ethical issues (resuscitation, withdrawal, withholding, CPR, do-not-resuscitate orders, neurologic prognosis, ethics consult) surrounding each infant's death.

RESULTS

Using traditional definitions, roughly half of all deaths in our NICU in 1993 and 1998 were associated with "withholding or withdrawing." In addition, by 1998, >40% of our NICU deaths could be labeled "active withdrawal," reflecting the extubation of infants regardless of their physiologic instability. This practice is growing over time. However, 2 important conclusions arise from our more richly elaborated descriptions of death in the NICU. First, when CPR was withheld, it most commonly occurred in the context of moribund infants who were already receiving ventilation and dopamine. Physiologically stable infants who were removed from mechanical ventilation for quality-of-life reasons accounted for only 3% of NICU deaths in 1988, 16% of NICU deaths in 1993, and 13% of NICU deaths in 1998. Moreover, virtually none of these active withdrawals took place in premature infants. Second, by 1998 infants, who died without CPR almost always had mechanical ventilation withdrawn. Finally, the median and average day of death for 100 nonsurvivors who received full intervention did not differ significantly from the 78 nonsurvivors for whom intervention was withheld.

CONCLUSIONS

In our unit, a greater and greater percentage of doomed infants die without ever receiving chest compressions or epinephrine boluses. Rather, we have adopted a nuanced approach to withdrawing/withholding NICU intervention, providing what we hope is a humane approach to end-of-life decisions for doomed NICU infants. We suggest that ethical descriptions that reflect these nuances, distinguishing between withholding and withdrawing interventions from physiologically moribund infants or physiologically stable infants with morbid neurologic prognoses, provide a more accurate reflection of the circumstances of dying in the NICU.

Ethical dilemmas in extreme prematurity: recent answers; more questions

Advances in perinatal care allow survival of more extremely premature infants, but the implementation and continuation of intensive care may itself constitute an ethical dilemma, given the limited chances of intact survival among the patients most at risk. This paper discusses several key issues raised by the options that are under general consideration with reference to births of infants at the threshold of viability, in particular: the implications of making a distinction between extreme prematurity and other general medical situations that may involve decisions on ending support; the concrete nature of the restrictions on therapy in such patients interactions and the need for feedback between parents, medical staff and society.

Care of very premature infants: looking to the future

Advances in prenatal care have improved survival rates in extremely preterm newborns, but cerebral palsy rates have not decreased in developed countries over the past 30 years. During the next 10 years we will probably not observe a dramatic improvement in intensive care such as that observed over the last 15 years. The man goal for the coming years will be to improve the quality of neonatal and postdischarge care in order to improve the long-term outcomes of very preterm infants.

The EPIBEL study: outcomes to discharge from hospital for extremely preterm infants in Belgium

OBJECTIVE

To determine mortality and morbidity at discharge from the hospital of a large population-based cohort of infants who were born at <or=26 weeks' gestation.

METHODS

Perinatal data were collected on extremely preterm infants who were alive at the onset of labor and born between January 1, 1999, and December 31, 2000, in all 19 Belgian perinatal centers.

RESULTS

A total of 525 infants were recorded. Life-supporting care was provided to 322 liveborn infants, 303 of whom were admitted for intensive care. The overall survival rate of liveborn infants was 54%. Of the infants who were alive at the age of 7 days, 82% survived to discharge. Vaginal delivery, shorter gestation, air leak, longer ventilator dependence, and higher initial oxygen need all were independently associated with death; gender, plurality, and surfactant therapy were not. Among the 175 survivors, 63% had 1 or more of the 3 major adverse outcome variables at the time of discharge (serious neuromorbidity, chronic lung disease at 36 weeks' postmenstrual age, or treated retinopathy of prematurity). The chance of survival free from serious neonatal morbidity at the time of hospital discharge was <15% (21 of 158) for the admitted infants with a gestation <26 weeks.

CONCLUSIONS

If for the time being prolongation of pregnancy is unsuccessful, then outcome perspectives should be discussed and treatment options including nonintervention explicitly be made available to parents of infants of <26 weeks' gestation within the limits of medical feasibility and appropriateness.

Deaths in a neonatal intensive care unit: a 10-year perspective

OBJECTIVE

To examine changes in the characteristics and management of infants dying in a regional neonatal intensive care unit in 1987-1988 vs. 1997-1998.

SETTING

The level III Neonatal Intensive Care Unit (NICU) at Rikshospitalet, Oslo, Norway, handles both regional and national referrals.

DESIGN/METHODS

The study was retrospective and observational. Patients who died in the neonatal intensive care unit were identified using our own and the hospital's data records. Charts were reviewed by the principal author.

RESULTS

The mortality rate relative to admissions decreased significantly from 1987-1988 to 1997-1998 (6.9% vs. 3.4%, p <.0001). Infants who died in 1997-1998 were more mature and had higher birth weights than those who died in 1987-1988 (34.0 +/- 5.5 vs. 32 +/- 6.0 wks gestational age [mean +/- sd], p <.05; and 2,186 +/- 1,207 vs. 1,699 +/- 1,038 g, p <.05). There was a significantly higher proportion of infants with complex congenital malformations among those who died in 1997-1998 (54% vs. 28%, p <.005). Forgoing intensive care treatment was more commonly associated with the process of dying in 1997-1998 than 10 yrs earlier (63.5% vs. 22.8%, p <.0001). Parental involvement in the process leading to a decision to forgo life support was more frequently described in the charts from 1997-1998 (72.7% vs. 23.8%, p <.001). During the last time period, parents were also present at the time of death significantly more often.

CONCLUSIONS

The mortality rate of sick infants decreased significantly between 1987-1988 and 1997-1998, showing the improvements in neonatal intensive care during that decade. In 1997-1998, congenital malformations had become the leading cause of death. Parental involvement in life-and-death questions seems to have become the rule, and almost two thirds of neonatal intensive care unit deaths followed a decision to forgo life support.

Fetal palliative care

Efforts in advance palliative care planning for the fetus at risk of dying are as meaningful and should be as clinically and socially acceptable as the provision of continued life-extending endeavors. The diagnosis of a fetus at risk of dying because of a lethal anomaly or prematurity is a monumental moment in a family's life. It requires not only extensive team counseling about complex neonatal and obstetric medical management but also acknowledgment, counseling, and support of complex mental health, ethical, spiritual issues. To participate in the care of these families during a tremendously personal time is sad but also rewarding personally and professionally.

[Ethical dilemmas of extreme prematurity]

Caring for extremely premature babies is difficult and costly. Mortality has been reduced with recent medical progress, but at the price of an increased number of surviving infants with handicaps. Should we then fix firm limits (gestational age and/or birthweight) for deciding on whether or not to take medical action? There is however the question of whether it is ethically acceptable to define human life solely on the basis of the length of gestation or birthweight. Moreover, what risk level for death or handicap is legitimate for treating or not a premature baby? The issue thus comes to the worthiness of trying first to save life, then accepting an interruption of curative treatments later on if severe cerebral injuries become evident. Who should make the decisions? Guidelines have been published by medical associations to help professionals to answer these important and puzzling questions.

Views of bereaved multiple-birth parents on life support decisions, the dying process, and discussions surrounding death

OBJECTIVE

This study assessed the experiences of bereaved parents of multiples with resuscitation and life-support discussions, the death process, and conversations with health-care professionals about death.

STUDY DESIGN

In all, 71 bereaved parents of multiples recruited from Internet support groups completed a narrative e-mail survey assessing many facets of bereavement. Numeric data were analyzed using simple quantitative analysis, with a grounded theory approach used for qualitative data.

RESULTS

Most decisions were collaborative, with occasional directive comments. Some decisions were made during crises. Occasionally, parents initiated life-support discussions. Multidisciplinary meetings occurred with 30%, but were desired by more parents. A total of 18% of parents encountered criticism of choices. Most parents attended resuscitation, and found meaning in holding their dying children. Many desire privacy, availability of symptom management, and family or clergy involvement. Photographs of multiples together are valued. Parents offered many suggestions for compassionate death notification, which most felt should occur in person if parents are not present for the death. Respondents valued clear, prompt discussion of the cause of death, and clinician availability for later review of clinical events or decisions.

CONCLUSIONS

Multiple-birth parents' choices resemble those of singleton parents at the end of an infant's life.

Guidelines for resuscitation in the delivery room of extremely preterm infants

Ethical problems related to intensive care of extremely preterm newborns of < or = 25 weeks' gestational age and at risk of disability have been extensively debated. The Bioethical Committee of the Department of Paediatrics of the University Hospital of Padua organized and started a multidisciplinary group to release guidelines to help staff facing problems related to prematurity. The vitality limit, survival, outcome, and ethical aspects were analyzed. Consequently, we suggest the following: at 22 weeks' gestational age, the deliverance of comfort care only; at 23 weeks, in the presence of detectable vital signs, the practice of immediate intubation, respiratory support, and a reassessment of the neonatal conditions; and at 24 weeks, the provision of intubation, ventilatory support, and cardiovascular resuscitation. If the clinical age and anamnestic gestational age are different, we proceed according to the more advanced one. The importance of providing parents with correct information and the role of comfort care are outlined.

Ethical considerations in the management of infants born at extremely low gestational age

With ongoing improvements in technology and the understanding of neonatal physiology, there has been increasing debate regarding the gestational age and birth weight limits of an infants' capability of sustaining life outside the womb and how this is to be determined. The objective of this review was to address this issue with an analysis of current data (following the introduction of surfactant therapy in 1990) from published studies of survival in extremely low gestational age infants. We found that survival was possible at 22 completed weeks of gestation but only in < 4% of live births reported. Survival increased from 21% at 23 weeks gestational age to 46% at 24 weeks gestational age. Historically, despite continual advances in neonatology, the mortality at 22 weeks has not improved over the past three decades. Combining the data from studies on survival with evidence from developmental biology, we believe that it is not worthwhile to pursue aggressive support of infants born at < 23 weeks gestational age. Given the complicated issues related to morbidity and mortality in infants born at 22 to 25 weeks gestational age and the ethical implications of the available evidence, we propose the need for a consensus derived framework to help in decision-making.

Management decisions in extremely premature infants

Survival rates in excess of 25% at 23 weeks' gestation and in excess of 50% at 24 weeks' gestation have been reported among live births in the 1990s within tertiary perinatal care centres in the USA and Australia. Decisions about medical management at these gestational ages can no longer be based merely on whether survival is possible. Relevant moral considerations include the primacy of the newborn's best interests, parental autonomy, physicians' duties of beneficence and non-maleficence, and distributive justice. There is significant variability between developed nations in the survival of extremely premature infants among cohorts born within perinatal tertiary care centres. This is, at least to some degree, the result of differences in the aggressiveness of obstetrical and neonatal management at these gestational ages. There is also great variability in the prevalence of major neurodevelopmental disability among survivors. Moreover, the prevalence of major disabilities does not inform quality-of-life considerations adequately. Despite similar gestational age ranges over which the benefit:burden ratio of aggressive obstetric and neonatal care is questioned in developed countries, there is marked variation in the frequency with which it is provided within these ranges. This is understandable given the relevant moral values and the different ways in which competing values will be balanced by different individuals, cultures and societies; the increasing survival of extremely premature infants, but the persistence of high (but widely variable) prevalences of major disabilities reported among survivors and even higher prevalences of mild-to-moderate neurodevelopmental sequelae; our imperfect ability to estimate an individual extremely premature infant's prognosis; and the complexities of estimating the quality of life from the individual's own perspective.

Neonatal hand casting method

This article describes the methods used to make hand or foot molds of infants in the neonatal intensive care unit. Parents seem appreciative of the mementos of their infant's stay and infancy. These castings also have teaching as well as fund-raising value.

Evidence-based ethics and the care and outcome of extremely premature infants

The care of extremely premature infants involves a number of complex clinical and ethical issues. The ethical and scientific quality of decisions made in the care of these infants has profound long-term consequences for these infants and their families. In circumstances when it is unclear whether intensive care should be initiated or continued, evidence-based ethics provides an approach to facilitate treatment decisions that over time will be progressively better informed, better justified, and more broadly acceptable to parents, caregivers, and the general public.