Delivery room resuscitation decisions for extremely premature infants

Antenatal Consultations at Extreme Prematurity: A Systematic Review of Parent Communication Needs

OBJECTIVE

To synthesize and describe parental expectations on how healthcare professionals should interact with them during a peripartum, antenatal consultation for extremely preterm infants.

STUDY DESIGN

For this systematic literature review with textual narrative synthesis, we included studies that explored parental perspectives regarding the antenatal consultation for an extremely preterm infant. Electronic searches of Medline, CINAHL, PsycInfo, and Embase were conducted, along with a search of the grey literature. Quality appraisal was conducted using the guide by Walsh and Downe. Two independent reviewers reviewed 783 titles, of which 130 abstracts then 40 full-text articles were reviewed. Final data abstraction includes 19 studies. We predetermined 6 topics of interest (setting, timing, preferred healthcare professional, information, resources, and parents-physician interaction) to facilitate thematic analysis.

RESULTS

In consideration of the variability of parents' specific desires, six predetermined topics and additional overarching themes such as perception of support, degree of understanding, hope, spirituality, and decision-making influences emerged. Studies suggest the quality of the antenatal consultation is not purely about information content, but also the manner in which it is provided. Limitations include thematic analysis that can potentially lead to the exclusion of important nuances. Relevant studies may have been missed if published outside the healthcare literature.

CONCLUSIONS

The findings may inform clinical practice guidelines. This paper includes suggested strategies related to parents' perspectives that may facilitate communication during antenatal consultation for an extremely preterm infant. These strategies may also support parental engagement and satisfaction.

Caring for Families at the Limits of Viability: The Education of Dr Green

Resuscitation decisions for infants born at the edges of viability are complicated moral dilemmas, and the process of making these decisions is emotionally exhausting and morally distressful for families and physicians alike. An ethical approach to making these decisions requires input from physicians and parents; individuals tasked with facilitating such decisions must possess the communication and counseling skills needed to assist families with these painful and life-altering decisions. It is incumbent on all of us to continue our investigation into how we can better assist families in this process while providing care that is in their best interest.

Personalized Decision Making: Practical Recommendations for Antenatal Counseling for Fragile Neonates

Emphasis has been placed on engaging parents in processes of shared decision making for delivery room management decisions of critically ill neonates whose outcomes are uncertain and unpredictable. The goal of antenatal consultation should rather be to adapt to parental needs and empower them through a personalized decision-making process. This can be done by acknowledging individuality and diversity while respecting the best interests of neonates. The goal is for parents to feel like they have agency and ability and are good parents, before birth, at birth, and after, either in the NICU or until the death of their child.

Morbidity and mortality trends in very-very low birth weight premature infants in light of recent changes in obstetric care

OBJECTIVE

In this study, we describe trends in morbidity and mortality of preterm infants with less than 500mg birth weight in the changing landscape of obstetric and neonatal care.

STUDY DESIGN

During a ten year study period between 2006 and 2016 we assessed outcome data for all neonates with less than 500mg birth weight born at our Neonatal Intensive Care Unit. We divided study subjects into two groups based on whether their birth date fell in the first half (2006-2010; n=39) versus the second half (2011-2015; n=27) of the study period comparing clinical outcomes in the two groups. We also assessed several clinical parameters for association with postnatal survival by comparing relative frequencies for each clinical parameter among surviving infants versus mortality cases.

RESULTS

Survival rate for preterm neonates with less than 500mg birth weight born between 2006 and 2010 was 30.8%. This survival rate rose to 70.4% in the second half of the study period between 2011 and 2015 (p<0.05). Among surviving babies premature birth was found to be predominantly associated with maternal hypertension or intrauterine growth restriction while in those who died premature birth due to premature rupture of membranes and spontaneous preterm labor were significantly more common. All surviving infants with less than 500mg birth weight were born via cesarean section whereas among those who died cesarean section had been performed in only 80% and vaginal delivery in 20% representing a significant difference between the groups (p<0.05). The majority (90.3%) of surviving infants with less than 500mg birth weight had received surfactant therapy while the proportion of neonates receiving surfactant therapy among mortality cases was significantly lower (65.2%; p<0.05).

DISCUSSION

Our findings suggest that among premature neonates with less than 500mg birth weight preterm delivery due to premature rupture of membranes and intrauterine infections represents the worse mortality risk. Steroid prophylaxis and measures to prevent and treat intrauterine infections with appropriate use of antibiotics can markedly improve survival in these cases. In premature neonates with less than 500mg birth weight survival is more favorable after cesarean section compared to vaginal delivery.

Analyzing video recorded support of postnatal transition in preterm infants following a c-section

Background

Over the past years, research on neonatal resuscitation has focused on single interventions. The present study was performed to analyze the process quality of delivery room management of preterm infants born by c-section in our institution.

Methods

We performed a cross-sectional study of videos of preterm infants born by c-section. Videos were analyzed according to time point, duration and number of performed medical interventions. The study period occurred between January 2012 and December 2013. Infants were caterogized in 3 groups according to their gestational age.

Results

One hundred eleven videos were analyzed. 100 (90 %) of the infants were transferred to NICU and 91 (83 %) received respiratory support after a median of 0.5 min. All infants were auscultated after 8 (5–16) seconds median (IQR) and an oxygen saturation sensor was placed after 37 (28–52) seconds. 23 infants were intubated after 9 (6–17) minutes and 17 received exogenous surfactant; 29 % according to INSURE (intubation-surfactant-extubation) technique. The duration of intubation attempts was 47 (25–60) seconds. 51 % of the newborns received a sustained inflation for 8 (6–9) seconds. A successful IV-line placement occurred after 15 (12–20) minutes. 4 % of the infants were transported to the NICU without an IV-line after 3 (difference range: 2–5) unsuccessful attempts.

Conclusions

Using video analysis as a tool to study process quality, we conclude that interventions differ not only between but also within similar age groups. This data can be used for benchmarking with current guidelines and practice in other centers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1045-2) contains supplementary material, which is available to authorized users.

Palliative care for extremely premature infants and their families

Extremely premature infants face multiple acute and chronic life-threatening conditions. In addition, the treatments to ameliorate or cure these conditions often entail pain and discomfort. Integrating palliative care from the moment that extremely premature labor is diagnosed offers families and clinicians support through the process of defining goals of care and making decisions about life support. For both the extremely premature infant who dies soon after birth and the extremely premature infant who experiences multiple complications over weeks and months in the neonatal intensive care unit, palliative care can maintain a focus on infant comfort and family support. This article highlights the ways in which palliative care can be incorporated into intensive care for all critically ill infants.

Palliative care in neonatal neurology: robust support for infants, families and clinicians

Infants with neurological injury and their families face unique challenges in the neonatal intensive care unit. As specialty palliative care support becomes increasingly available, we must consider how to intentionally incorporate palliative care principles into the care of infants with neurological injury. Here, we review data regarding neonatal symptom management, prognostic uncertainty, decision making, communication and parental support for neonatal neurology patients and their families.

Outcomes of neonates with birth weight⩽500 g: a 20-year experience

OBJECTIVE

Ethical dilemmas continue regarding resuscitation versus comfort care in extremely preterm infants. Counseling parents and making decisions regarding the care of these neonates should be based on reliable, unbiased and representative data drawn from geographically defined populations. We reviewed survival and morbidity data for our population at the edge of viability.

STUDY DESIGN

A retrospective review of our perinatal database was carried out to identify all infants born alive and admitted to the neonatal intensive care unit (NICU) with BW⩽500 g between 1989 and 2009. Data from the initial hospital stay and follow-up at 24 months were collected.

RESULT

Out of 22 672 NICU admissions, 273 were eligible: 212 neonates were reviewed after excluding infants with comfort care. BW ranged from 285 to 500 g (mean 448 g) and gestational age range 22 to 28 weeks (median 24 week). Sixty-one (28.8%) survived until discharge. Only 13.8% males survived compared with 39.2% females (P<0.05). Half (49%) were discharged with home oxygen/monitor. Fifty (82%) patients' charts were available to review at the 24-month follow-up. Thirty-three percent of surviving infants had a normal neurodevelopmental assessment at 24 months. Forty-three percent had weight/head circumference<5th percentile at 24 months.

CONCLUSION

About a third of neonates admitted to NICU with ⩽500 g BW survived, with 33% of those surviving, demonstrating age-appropriate development at a 24-month follow-up visit.

A national survey of obstetricians' attitudes toward and practice of periviable intervention

OBJECTIVE

Test the association between provider characteristics and antenatal interventions offered for periviable delivery.

STUDY DESIGN

Six hundred surveys mailed to members of the College's Collaborative Ambulatory Research Network. Items queried physicians' practices regarding administering steroids, recommending cesarean (for breech) and offering induction (for ruptured membranes) at 23 weeks.

RESULT

Three hundred and ten (52%) obstetricians (OBs) responded. Respondents reported institutional cutoffs of 23 weeks for resuscitation (34%) and 24 weeks for cesarean (35%), whereas personal preferences for cesarean were ⩾25 weeks (44%). At 23 weeks, two-thirds ordered steroids, 43% recommended cesarean and 23% offered induction. In multivariable analyses, institutional cutoffs and providers' personal preferences predicted steroid administration (odds ratio, OR=4.37; 95% confidence interval, CI=1.73 to 11.00; OR=0.30, 95% CI=0.13 to 0.70); institutional cutoffs and the impression that cesarean decreases neurodevelopmental disability predicted recommending cesarean (OR=3.09, 95% CI=1.13 to 8.44; OR=6.41, 95% CI=2.06 to 19.91). For offering induction, practice location and religious service attendance approached, but did not meet, statistical significance (P=0.06 and P=0.05).

CONCLUSION

OBs' willingness to intervene can impact periviable outcomes. These findings suggest that personal and institutional factors may influence obstetrical counseling and decision-making.

Comparing obstetricians' and neonatologists' approaches to periviable counseling

OBJECTIVE

To compare the management options, risks and thematic content that obstetricians and neonatologists discuss in periviable counseling.

STUDY DESIGN

Sixteen obstetricians and 15 neonatologists counseled simulated patients portraying a pregnant woman with ruptured membranes at 23 weeks of gestation. Transcripts from video-recorded encounters were qualitatively and quantitatively analyzed for informational content and decision-making themes.

RESULT

Obstetricians more frequently discussed antibiotics (P=0.005), maternal risks (<0.001) and cesarean risks (<0.005). Neonatologists more frequently discussed neonatal complications (P=0.044), resuscitation (P=0.015) and palliative options (P=0.023). Obstetricians and neonatologists often deferred questions about steroid administration to the other specialty. Both specialties organized decision making around medical information, survival, quality of life, time and support. Neonatologists also introduced themes of values, comfort or suffering, and uncertainty.

CONCLUSION

Obstetricians and neonatologists provided complementary counseling content to patients, yet neither specialty took ownership of steroid discussions. Joint counseling and/or family meetings may minimize observed redundancy and inconsistencies in counseling.

The influence of resuscitation preferences on obstetrical management of periviable deliveries

OBJECTIVE

To determine the relative influence of patients' resuscitation preferences on periviable delivery management.

STUDY DESIGN

Surveyed 295 obstetrician-gynecologists about managing periviable preterm premature rupture of membranes. Across 10 vignettes, we systematically varied gestational age, occupation, method of conception and resuscitation preference. Physicians rated their likelihood (0 to 10) of proceeding with induction, steroids and cesarean. Data were analyzed via conjoint analysis.

RESULT

Two hundred and five physician responses were included. Median ratings for management decisions were: induction 1.89; steroids 5.00; cesarean for labor 3.89; and cesarean for distress 4.11. Gestational age had the greatest influence on physician ratings across all decisions (importance values ranging from 72.6 to 86.6), followed by patient's resuscitation preference (range=9.3 to 21.4).

CONCLUSION

Gestational age is weighted more heavily than patients' resuscitation preferences in obstetricians' decision making for periviable delivery management. Misalignment of antenatal management with parental resuscitation preferences may adversely affect periviable outcomes. Interventions are needed to facilitate more patient-centered decision making in periviable care.

Comparing neonatal morbidity and mortality estimates across specialty in periviable counseling

OBJECTIVE

To describe and compare estimates of neonatal morbidity and mortality communicated by neonatologists and obstetricians in simulated periviable counseling encounters.

METHODS

A simulation-based study of 16 obstetricians (OBs) and 15 neonatologists counseling standardized patients portraying pregnant women with ruptured membranes at 23 weeks gestation. Two investigators tabulated all instances of numerically-described risk estimates across individuals and by specialty.

RESULTS

Overall, 12/15 (80%) neonatologists utilized numeric estimates of survival; 6/16 (38%) OBs did. OBs frequently deferred the discussion of "exact numbers" to neonatologists. The 12 neonatologists provided 13 unique numeric estimates, ranging from 3% to 50% survival. Half of those neonatologists provided two to three different estimates in a single encounter. By comparison, six OBs provided four unique survival estimates ("50%", "30-40%", "1/3-1/2", "<10%"). Only 2/15 (13%) neonatologists provided numeric estimates of survival without impairment. None of the neonatologists used the term "intact" survival, while five OBs did. Three neonatologists gave numeric estimates of long-term disability and one OB did.

CONCLUSION

We found substantial variation in estimates and noteworthy omissions of discussions related to long-term morbidity. Across specialties, we noted inconsistencies in the use and meaning of terms like "intact survival." More tools and training are needed to improve the quality and consistency of periviable risk-communication.

Perspectives on anticipated quality-of-life and recommendations for neonatal intensive care: a survey of neonatal providers

OBJECTIVE

Explore associations between neonatal providers' perspectives on survival, quality of life (QOL) and treatment recommendations.

METHODS

Providers attending a workshop on neonatal viability were surveyed about survival, perceived QOL and treatment recommendations for marginally viable infants. We assessed associations between estimated survival and perceived QOL and treatment recommendations.

RESULTS

In the 44 included surveys, estimates of survival and QOL varied widely. Maximum care was recommended 80% of the time when anticipated QOL was high, versus 20% when anticipated QOL was low (p < 0.001). Adjusted for confounders, odds of recommending maximum intervention were 4.4 times higher when anticipated QOL was high (95% CI 1.9 - 10.2, p = 0.001).

CONCLUSIONS

The perspectives of practitioners who provide care to critically ill neonates regarding potential survival and QOL vary dramatically and are associated with the treatments those practitioners recommend. Practitioners should take care to avoid basing treatment recommendations on their own perspectives if they are not well aligned with those of the parents.

Resuscitation of neonates at 23 weeks' gestational age: a cost-effectiveness analysis

OBJECTIVE

Resuscitation of infants at 23 weeks' gestation remains controversial; clinical practices vary. We sought to investigate the cost effectiveness of resuscitation of infants born 23 0/7-23 6/7 weeks' gestation.

DESIGN

Decision-analytic modeling comparing universal and selective resuscitation to non-resuscitation for 5176 live births at 23 weeks in a theoretic U.S. cohort. Estimates of death (77%) and disability (64-86%) were taken from the literature. Maternal and combined maternal-neonatal utilities were applied to discounted life expectancy to generate QALYs. Incremental cost-effectiveness ratios were calculated, discounting costs and QALYs. Main outcomes included number of survivors, their outcome status and incremental cost-effectiveness ratios for the three strategies. A cost-effectiveness threshold of $100 000/QALY was utilized.

RESULTS

Universal resuscitation would save 1059 infants: 138 severely disabled, 413 moderately impaired and 508 without significant sequelae. Selective resuscitation would save 717 infants: 93 severely disabled, 279 moderately impaired and 343 without significant sequelae. For mothers, non-resuscitation is less expensive ($19.9 million) and more effective (127 844 mQALYs) than universal resuscitation ($1.2 billion; 126 574 mQALYs) or selective resuscitation ($845 million; 125 966 mQALYs). For neonates, both universal and selective resuscitation were cost-effective, resulting in 22 256 and 15 134 nQALYS, respectively, versus 247 nQALYs for non-resuscitation. In sensitivity analyses, universal resuscitation was cost-effective from a maternal perspective only at utilities for neonatal death <0.42. When analyzed from a maternal-neonatal perspective, universal resuscitation was cost-effective when the probability of neonatal death was <0.95.

CONCLUSIONS

Over wide ranges of probabilities for survival and disability, universal and selective resuscitation strategies were not cost-effective from a maternal perspective. Both strategies were cost-effective from a maternal-neonatal perspective. This study offers a metric for counseling and decision-making for extreme prematurity. Our results could support a more permissive response to parental requests for aggressive intervention at 23 weeks' gestation.

Survival at the threshold of viability: a nationwide survey of the opinions and attitudes of physicians in a developing country

BACKGROUND

To explore physicians' opinions and attitudes regarding resuscitation of extremely premature infants (EPIs) in a developing country with suboptimal resources.

METHODS

A survey was developed, revised, and pilot-tested. All 964 paediatricians registered in the Lebanese Order of Physicians were contacted; physicians involved in resuscitation of EPIs were eligible. Between February and April of 2009, anonymous surveys were mailed to consenting participants.

RESULTS

Three hundred twenty-eight eligible physicians agreed to participate. One hundred twenty (36%) returned the survey, 45.3% of which were neonatologists. The vast majority agreed that parents would like to be informed and to participate in the resuscitation decision of an EPI. The majority of physicians considered infants at gestational age of ≤25 weeks (78%) or ≤800 g (89%) as non-viable. Physician's age, years of practice, and practising neonatal intensive care unit level were significantly associated with the choice of birthweight at which infants were considered non-viable.

CONCLUSIONS

The majority of surveyed physicians consider infants at gestational age less than or equal to 25 weeks gestation or 800 g at birth as non-viable, and therefore would not attempt their resuscitation. Factors influencing threshold of viability in developing countries need to be addressed and explored further.

On ethical (in)decisions experienced by parents of infants in neonatal intensive care

This study was a phenomenological investigation of ethical decisions experienced by parents of newborns in neonatal intensive care. I explore the lived meanings of thematic events that speak to the variable ways that ethical situations may be experienced: a decision that was never a choice; a decision as looking for a way out; a decision as thinking and feeling oneself through the consequences; a decision as indecision; and a decision as something that one falls into. The concluding recommendations spell out the need for understanding the experiences of parents whose children require medical care and underscore the tactful sensitivities required of the health care team during moral-ethical decision making.

A qualitative study of predelivery counselling for extreme prematurity

OBJECTIVE

To ascertain from parents of neonates born before 27 weeks' gestational age how to improve predelivery counselling for delivery room resuscitation.

METHODS

Qualitative ethnographic study using semistructured, face-to-face interviews of 10 families. Data were analyzed using a constant comparative method.

RESULTS

Parents had no previous knowledge about prematurity. They would have preferred prioritized information during predelivery counselling focused on the immediate risks to their child. Resuscitation wishes were inconsistently sought. Opportunities for repeat discussions involving both parents were often missed. Parents agreed that the opportunity to explicitly state resuscitation wishes should be offered. Additional materials, such as pamphlets or videos, would improve counselling.

CONCLUSIONS

Information about prematurity should be offered when the pregnancy is deemed high risk, with repeat counselling opportunities for both parents to discuss options. Once the decision is made to resuscitate, parents want the neonatal team to convey a message of hope and compassion.

Obstetric decision-making and counseling at the limits of viability

OBJECTIVE

The purpose of this study was to examine factors that influence obstetric decision-making and counseling for periviable deliveries and to describe counseling challenges.

STUDY DESIGN

Twenty-one semistructured interviews were conducted with obstetricians who were recruited from 5 academic medical centers in Philadelphia. Two trained reviewers independently coded transcripts using grounded theory methods. Research software facilitated qualitative analysis.

RESULTS

Circumscribed by institutional norms and clinical acuity, obstetric decision-making and counseling were influenced primarily by patient preferences. Perspectives on patient autonomy guided approaches to counseling. Thresholds for intervention varied from "attending to attending" and "institution to institution." Sociodemographic factors were not believed to influence clinical decision-making. However, obstetricians admittedly managed in vitro fertilization pregnancies more aggressively. Communicating uncertainty, managing expectations, assessing understanding, and relaying consistent messages across specialties were frequently described counseling challenges for obstetricians.

CONCLUSION

The impact of institutional variation and in vitro fertilization on periviable decision-making warrants further consideration. Interventions to train and support obstetricians in communicating uncertainty, managing expectations, and assessing values and understanding are needed.

Resuscitation of likely nonviable infants: a cost-utility analysis after the Born-Alive Infant Protection Act

OBJECTIVE

The purpose of this study was to compare the effects of universal vs selective resuscitation on maternal utilities, perinatal costs, and outcomes of preterm delivery and termination of pregnancy at 20-23 weeks 6 days' gestation.

STUDY DESIGN

We used studies on medical practices, prematurity outcomes, costs, and maternal utilities to construct decision-analytic models for a cohort of annual US deliveries after preterm delivery or induced termination. Outcome measures were (1) the numbers of infants who survived intact or with mild, moderate, or severe sequelae; (2) maternal quality-adjusted life years (QALYs); and (3) incremental cost-effectiveness ratios.

RESULTS

Universal resuscitation of spontaneously delivered infants between 20-23 weeks 6 days' gestation increases costs by $313.1 million and decreases QALYs by 329.3 QALYs; after a termination, universal resuscitation increases costs by $15.6 million and decreases QALYs by 19.2 QALYs. With universal resuscitation, 153 more infants survive: 44 infants are intact or mildly affected; 36 infants are moderately impaired, and 73 infants are severely disabled.

CONCLUSION

Selective intervention constitutes the highest utility and least costly treatment for infants at the margin of viability.

Decision-making at the border of viability by means of values clarification: a case study to achieve distinct communication by ordinary language approach

OBJECTIVES

We set out to investigate the major obstacles in achieving a sensitive and supportive communication between parents and clinicians in ethical dilemma situations. We focused on discussions in emergency situations by means of values clarification.

METHODS

The study population (n=141) covers four samples of clinical staff (n(1)=72) from different specialties and parents of preterm and term infants (n(2)=69). Because of the vulnerability of parents and the virulence of the topic, the descriptive qualitative case study comprises standardized questionnaires and half-standardized interviews. Data were analyzed graphically and statistically, comparing parents and professionals for the justification of acting using values clarification in this context.

RESULTS

Our study indicated that the use of a critically reconsidered and less personalized language has to be a major goal in the care of preterm infants at the edge of viability. Furthermore we found that acting ethically means making decisions individually by using open-context terms sensitively in consideration of diverging action-guiding principles.

CONCLUSIONS

Decisions in medicine concern different people - experts as well as patients and their representatives. The present study is an attempt to establish more awareness for improved communication, which is a part of professionalism, as well as coping strategies for all involved.

Care at the edge of viability: medical and ethical issues

Decision-making for extremely immature preterm infants at the margins of viability is ethically, professionally, and emotionally complicated. A standard for prenatal consultation should be developed incorporating assessment of parental decision-making preferences and styles, a communication process involving a reciprocal exchange of information, and effective strategies for decisional deliberation, guided by and consistent with parental moral framework. Professional caregivers providing perinatal consultations or end-of-life counseling for extremely preterm infants should be sensitive to these issues and be taught flexibility in counseling techniques adhering to consistent guidelines. Emphasis must shift away from physician beliefs and behaviors about the boundaries of viability.

Racial and ethnic differences in use of intubation for periviable neonates

OBJECTIVE

Racial/ethnic minorities report preferences for resuscitative care at the end of life. The main objective of this study was to determine if there are racial/ethnic differences in use of intubation for periviable neonates. We hypothesized that infants born to black and Hispanic women are more likely to be resuscitated compared with infants born to white women.

METHODS

We conducted a retrospective cohort study of state-level maternal and infant hospital discharge data of women who delivered between 23.0 and 24.6 weeks' gestation linked to birth and death certificate data for California, Missouri, and Pennsylvania from 1995 to 2005 (N = 9632).

RESULTS

Overall, 78.9% of the population was aged 18 to 35 years, and almost half were nulliparous; 19.4% of the women were black, 36.6% were Hispanic, and 33.4% were white. Approximately 30% had less than a high school education, and 49.2% were federally insured. Overall, 44.7% of periviable neonates were intubated. In multivariable analyses adjusting for sociodemographic characteristics, black and Hispanic race/ethnicity was significantly associated with neonatal intubation (odds ratios [ORs]: 1.14 [95% confidence interval (CI): 1.01-1.29] and 1.22 [95% CI: 1.10-1.36], respectively). In models controlling for clustering at the level of the delivery hospital, black race remained a predictor of neonatal intubation (OR: 1.25 [95% CI: 1.07-1.46]), but differences among Hispanics dissipated (OR: 1.12 [95% CI: 0.98-1.27]).

CONCLUSIONS

Racial/ethnic differences exist in patterns of periviable resuscitation, which may reflect underlying differences in patient preference. Alternatively, institutional practices or resources may account for these differences. These findings have important implications for patient care and institutional practice. Our results lay the foundation for additional work to investigate how social, cultural, and institutional factors influence patient-provider decision-making regarding periviable care.

Day-by-day postnatal survival in very low birth weight infants

OBJECTIVES

Postnatal survival rates of very low birth weight (VLBW) infants are well established for each birth weight or gestational age category. These figures do not differentiate viable infants who survive the first few days of life from extremely immature ones who die shortly after birth. This study aimed to develop standardized curves for day-by-day postnatal survival rates of VLBW infants.

METHODS

National Inpatient Sample Database and its pediatrics-only subportion were analyzed for the years 1997-2004. Infants with birth weight <1500 g were included in the study. Infants were classified according to their birth weight into 4 groups: <500, 500 to 749, 750 to 999, and 1000 to 1499 g. Postnatal survival rates were calculated for each group at birth and at 1, 2, 3, 4 to 5, 6 to 7, 14, 21, 28, and >28 postnatal days.

RESULTS

Overall survival for infants with birth weight <500 g was 8%. Those who lived through the first 3 days of life had a chance of survival up to 50%. Infants in the 500- to 749-g group had overall survival rate of 50% that increased to 70% if they survived through the third day and 80% by the end of the first week. There was no improvement in the overall survival of any birth weight category over the years of the study.

CONCLUSIONS

VLBW infants who survive the first few postnatal days have a considerably better chance for life. We can predict postnatal survival chances for each birth weight category on a day-by-day basis until discharge.

An evidence-based overview of prenatal consultation with a focus on infants born at the limits of viability

Before the delivery of a premature infant, a prenatal consultation between parents and physicians provides the opportunity to establish a trusting relationship and create a supportive environment for decision-making concerning neonatal resuscitation. The ideal consult enables physicians to educate parents about preterm delivery and potential outcomes for their infant while providing parents with the time to ask questions and express their values. The uncertainty that surrounds many decisions in the treatment and resuscitation of infants born at the limits of viability creates a situation in which joint responsibility for decision-making between parents and physicians is vital. In this review we examine ethical considerations regarding the resuscitation of infants born at the limits of viability and present the current policies established by the Neonatal Resuscitation Program and the American Academy of Pediatrics. The parental and physician perspectives regarding the consultation experience are presented also. Finally, a model for the prenatal consultation is introduced with suggestions for the incorporation of morbidity and mortality data as well as the structure and approach to discussion with parents with threatened preterm delivery.

Extensive cardiopulmonary resuscitation for VLBW and ELBW infants: a systematic review and meta-analyses

Studies of the outcomes of preterm infants after the receipt of extensive cardiopulmonary resuscitation (CPR) at birth or in the neonatal intensive care units (NICUs) have yielded varied results. A systematic review of the outcomes of very low birth weight (VLBW) and extremely low birth weight (ELBW) infants who received extensive resuscitation at birth or in the NICU was carried out. MEDLINE, EMBASE, CINAHL databases were searched for studies of extensive CPR in the delivery room (DR-CPR) and in NICU (NICU-CPR) that have reported neonatal or long-term outcomes. A total of 20 eligible studies were identified (11 of DR-CPR, 7 of NICU-CPR and 2 had combined data). DR-CPR was associated with an increased risk of mortality (odds ratio (OR) 2.83, 95% confidence interval (CI) 1.92, 4.16) and severe neurological injury (OR 2.27, 95% CI 1.40, 3.67) compared with infants who did not receive extensive CPR. NICU-CPR was associated with an increased risk of mortality (OR 55, 95% CI 15, 195) compared with infants who did not receive CPR; however, confidence limits were wide. The long-term outcome of survivors was reported in a limited number of studies. Extensive CPR at birth or in the NICU for VLBW or ELBW infants was associated with higher risk of mortality.

Supporting parents' decision making surrounding the anticipated birth of an extremely premature infant

Parents who are at risk for giving birth to an extremely premature infant, defined as 22 to 25 weeks' gestation, can find themselves faced with urgent treatment decisions for their unborn infant that have life-altering consequences. Despite the recommendation for involving parents in decision making for these infants, there is limited evidence regarding guidelines for involving parents. In this article, we describe a case from a larger collective case study that examines the decision making and the decision support needs of parents regarding life support decisions made over time (prenatally and postnatally) for extremely premature infants from the perceptions of parents, physicians, and nurses. For this case study, we describe decisions that were made during the antenatal hospitalization of the mother whose infant was stillborn, the support the parents received, and advice for healthcare professionals for improving care to families. For this case, the mother and father, a physician, and 2 nurses were interviewed before the birth of the infant. The findings in this case study demonstrate the importance of the nurse being present when information is given to parents, of informing with compassion, and helping parents to understand treatment options and decisions.

Message framing and perinatal decisions

OBJECTIVES

The purpose of this study was to explore the effect of information framing on parental decisions about resuscitation of extremely premature infants. Secondary outcomes focused on elucidating the impact of other variables on treatment choices and determining whether those effects would take precedence over any framing effects.

METHODS

This confidential survey study was administered to adult volunteers via the Internet. The surveys depicted a hypothetical vignette of a threatened delivery at gestational age of 23 weeks, with prognostic outcome information framed as either survival with lack of disability (positive frame) or chance of dying and likelihood of disability among survivors (negative frame). Participants were randomly assigned to receive either the positively or negatively framed vignette. They were then asked to choose whether they would prefer resuscitation or comfort care. After completing the survey vignette, participants were directed to a questionnaire designed to test the secondary hypothesis and to explore possible factors associated with treatment decisions.

RESULTS

A total of 146 subjects received prognostic information framed as survival data and 146 subjects received prognostic information framed as mortality data. Overall, 24% of the sample population chose comfort care and 76% chose resuscitation. A strong trend was detected toward a framing effect on treatment preference; respondents for whom prognosis was framed as survival data were more likely to elect resuscitation. This framing effect was significant in a multivariate analysis controlling for religiousness, parental status, and beliefs regarding the sanctity of life. Of these covariates, only religiousness modified susceptibility to framing; participants who were not highly religious were significantly more likely to be influenced to opt for resuscitation by the positive frame than were participants who were highly religious.

CONCLUSIONS

Framing bias may compromise efforts to approach prenatal counseling in a nondirective manner. This is especially true for subsets of participants who are not highly religious.

Attitudes of neonatologists toward delivery room management of confirmed trisomy 18: potential factors influencing a changing dynamic

OBJECTIVE

The objective of this study was to determine the attitude of neonatal providers toward delivery room resuscitation of an infant with confirmed trisomy 18 with known congenital heart disease at >/=36 weeks of gestation.

METHODS

A multiple-choice questionnaire listing this clinical scenario was completed by neonatologists and fellows staffing level III NICUs. Potential factors influencing the decision to initiate resuscitation included maternal preference, neonatal condition at birth, obstetric care, and legal concerns.

RESULTS

Fifty-four (76%) of 71 surveys were completed. Of respondents, 44% indicated that they would be willing to initiate resuscitation. Maternal preference (70%) was the primary reason to initiate resuscitation, with the appearance of the neonate in the delivery room (46%) and legal concerns (25%) as additional factors.

CONCLUSIONS

Until recently, there was universal consensus that trisomy 18 was a lethal anomaly for which resuscitation in the delivery room was not indicated. These data indicate that more providers (44%) than anticipated would consider initiation of resuscitation for an infant with trisomy 18 even with congenital heart disease. We speculate that support for the best-interest standard for neonates is diminishing in favor of ceding without question to parental autonomy. This shift may have profound implications for ethical decisions in the NICU.

Ethical issues for parents of extremely premature infants

Evidence suggests that NICU (neonatal intensive care unit) parents with an baby born at the threshold of viability do not always receive sufficient counselling during an emergency admission and as a consequence, are not well-informed to accept withdrawal of treatment or quality of life decisions. As prospective parents are not educated earlier in pregnancy about extreme premature delivery, crucial information and counselling explaining neonatal issues is only offered to labouring women during their emergency admission. As a result, most have difficulty understanding the risks and benefits of baby's treatment and therefore rely heavily on the perinatal physician to take responsibility for the initial treatment. However, this lack of understanding often leaves parents disadvantaged, as many are left unprepared to participate objectively in quality of life decisions. According to recent research, morbidity figures remain relatively high with one in five survivors at risk of a long-term disability. This shows that some parents will still be confronted by ethical decision of whether or not to continue treatment, and this may not be apparent until days after treatment has been established. As recent research has shown, parents do, in fact, want increased involvement in the decision-making process regarding their child's treatment. Therefore, it has been argued, that parents should be provided with information earlier in pregnancy to familiarise themselves with quality of life issues which they may encounter as the NICU parents of an extremely premature infant.

Attitudes of Canadian neonatologists in delivery room resuscitation of newborns at threshold of viability

OBJECTIVE

There is great debate regarding the extent of intensive care interventions for extremely premature newborns. In this report, we describe Canadian neonatologists' attitudes towards delivery room resuscitation decisions in neonates at the threshold of viability.

METHODS

We interviewed neonatologists (N = 121) practising in Canadian tertiary care neonatal units between June 2004 and April 2005, and asked whether they would support a parental request not to initiate resuscitation for newborns of 23 to 26 weeks' gestation. Bivariate analyses were performed to identify sociodemographic or cultural factors that might affect resuscitation decisions.

RESULTS

Most Canadian neonatologists would support a parental request not to initiate resuscitation of an infant at 23 and 24 weeks' gestation (98% and 80%, respectively). However, we observed heterogeneity across the country in attitudes primarily at 25 weeks, but also at 24 weeks' gestation. At 24 weeks' gestation, decisions also appear to be significantly related to personal experience with a disabled close friend or relative. For newborns of 25 weeks' gestation, neonatologists are divided: a majority (76%) would strongly advocate resuscitation and/or resuscitate a "viable" fetus against parental wishes, and a minority (24%) would agree not to initiate treatment. At 26 weeks' gestation, more than 97% would not support a request not to initiate resuscitation.

CONCLUSION

Attitudes of Canadian neonatologists towards resuscitation of newborns at the threshold of viability primarily differ at 25 weeks and to a lesser extent at 24 weeks of gestation. Our findings highlight important nuances in relation to existing national guidelines.

Problèmes éthiques posés par l'extrême prématurité: résultats d'une étude qualitative auprès des obstétriciens et des sages-femmes

OBJECTIVE

Our objective was to explore the practices, attitudes and feelings of obstetricians and midwives in case of extreme prematurity.

POPULATION AND METHODS

A qualitative study was conducted as part of a European Concerted Action (EUROBS) in 1999 and 2000 in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France respectively. Semi-structured, tape-recorded interviews were conducted and were independently analysed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated.

RESULTS

Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the foetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as more inclined than the obstetrical team to initiate intensive care. If the child was born alive, intensive care was started, knowing that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, less frequently at birth or after birth.

DISCUSSION AND CONCLUSION

Compared with obstetricians, midwives tended to have a less favourable perception of the neonatologists' practices, and to deplore the lack of parental information and involvement in decision-making. Decisions about the obstetrical management and resuscitation of extremely preterm infants are essentially always made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

Moral distress and providing care to dying babies in neonatal nursing

Moral distress in nursing is a prevalent theme in the literature. Although this issue has been investigated in other nursing disciplines, it has not been investigated by empirical research in the emotionally and ethically sensitive area of providing care to dying babies. Moral distress occurs when nurses are prevented from translating moral choices into moral action. The response to moral distress is anger, resentment, guilt, frustration, sorrow and powerlessness. If not addressed, self-worth may be jeopardised, affecting personal and professional relationships. A review of the literature was conducted to explore moral distress in neonatal nursing when providing care to dying babies. This literature review provides a basis for the direction of further research and hypothesis testing. Further focused research is necessary in this under-theorised area of nursing practice to clarify the significance of moral distress for neonatal nurses caring for dying babies.

Estudo seccional descritivo de crianças com deficiência auditiva atendidas no Instituto Nacional de Educação de Surdos, Rio de Janeiro, Brasil

O estudo das deficiências múltiplas em geral e da surdez em especial é escasso em nosso país. Os pesquisadores iniciaram estudo pioneiro desde 1992, avaliando alunos da educação especial das redes governamentais de ensino do Estado, estando atualmente focados na surdez. Avaliamos 232 alunos com idade variando de 1 a 39 anos, com média de 10,9 anos. O sexo masculino prevaleceu na amostra. A consangüinidade ocorreu 7,6% e a história familiar de surdez em 19% dos casos. Observamos 33% de intercorrências gestacionais. O parto normal foi utilizado em 59% de nossos casos, sendo a termo em 75%. As intercorrências neonatais estiveram presentes em 35% das vezes. As causas ambientais foram responsáveis por 58,5% da amostra, as causas genéticas por 20,7% dos casos. Sendo o restante considerado idiopático. Nossos achados corroboram os dados da literatura. Acreditamos que este estudo possa servir como o início de uma preocupação maior com esta população, e que através do melhor conhecimento de suas características seja possível implementar estratégias de intervenção facilitando a sua interação produtiva na sociedade.

Non-initiation and discontinuation of resuscitation

Whereas certain aspects of neonatal resuscitation may benefit from evidence evaluation using standard evaluation techniques, the ethical aspects of non-initiation and discontinuation of resuscitative efforts are more subjective and might certainly be influenced by the biases of the reviewers. The outcome data are relatively straightforward, although survival and morbidity data differ significantly by region and even among hospitals classified at similar levels in the same region. However, the interpretation of that data is necessarily somewhat subjective. Whereas certain aspects of neonatal resuscitation may benefit from evidence evaluation using standard evaluation techniques, the ethical aspects of non-initiation and discontinuation of resuscitative efforts are more subjective and might certainly be influenced by the biases of the reviewers. The outcome data are relatively straightforward, although survival and morbidity data differ significantly by region and even among hospitals classified at similar levels in the same region. However, the interpretation of that data is necessarily somewhat subjective. Does a survival rate of 1% of patients at a certain weight or gestational age warrant full resuscitative efforts? What about 20% or 49%? Similar questions could be posed regarding significant morbidity. However, as the science of neonatal resuscitation advances, it is important to review objective evidence-based outcome data in certain situations in which non-initiation or discontinuation of resuscitative efforts may be appropriate to determine if certain common themes can be elicited.

Life support decisions for extremely premature infants: report of a pilot study

The purpose of this pilot study was to describe decision making and the decision support needs of parents, physicians, and nurses regarding life support decisions made over time prenatally and postnatally for extremely premature infants. Using the collective case study method, one prenatal, one postnatal, and one postdeath, if the infant had died, tape-recorded interviews were conducted with each parent. With parents' permission, prenatal interviews were done with the physicians and nurses who talked to them about life support decisions for their infants. Twenty-five tape-recorded interviews were conducted with six cases (six mothers, two fathers, six physicians, and two nurses). Hospital records were reviewed for documentation of life support decisions. Results of this pilot study demonstrated that most parents wanted a model of shared decision making and perceived that they were informed and involved in making decisions. Parents felt that to be involved in decision making they needed information and recommendations from physicians. Parents also stressed the importance of encouragement and hope. In contrast, physicians informed parents but most physicians felt that parents were the decision makers. Physicians used parameters to offer options or involve parents in decisions and became very directive at certain gestational ages. Nurses reported that they believed that parents needed information from the physician first, then they would reinforce information. The results of this study offer an initial understanding of the decision support needs of parents.

Prenatal consultation practices at the border of viability: a regional survey

OBJECTIVE

We undertook a survey of all practicing neonatologists in New England to determine their attitudes and practices regarding prenatal consultations for infants at the border of viability.

METHODS

A self-administered anonymous survey, mailed to every practicing neonatologist in the 6 Northeast states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont, explored respondent attitudes and practices with respect to a hypothetical clinical scenario of a prenatal consultation for an infant at the border of viability.

RESULTS

Our final sample included 149 surveys from 175 eligible neonatologists, giving a response rate of 85%. Seventy-seven percent of respondents indicated that they thought neonatologists and parents should make the decision jointly to withhold resuscitation. Only 40% indicated that the decision actually is made by both parties. A majority of neonatologists (58%) saw their primary role during the prenatal consultation as providing factual information to the parents. Far fewer (27%) thought that their main role was to assist the parents in weighing the risks and benefits of various management options. A majority of respondents indicated that parental understanding of the mother's current medical situation (96%), desired parental role (77%), and parental prior experience with premature or handicapped children (64%) were frequently or always discussed. However, far fewer respondents reported frequently or always asking about parental interpretations of a "good quality of life" (42%), parental prior experiences with death or dying (30%), and parental religious or spiritual beliefs (25%). Short-term outcomes and complications such as the need for surfactant/respiratory distress syndrome (89%) and the risk of intraventricular hemorrhage (81%) were discussed more extensively than long-term outcomes such as motor delays or cerebral palsy (68%), cognitive delays or learning disabilities (63%), and chronic lung disease (61%). Multivariate logistic regression analysis revealed 2 characteristics that were significant predictors of shared decision-making for the final decision regarding resuscitation in the delivery room for extremely premature infants, ie, believing that the main role of the neonatologist during prenatal consultations is to help parents weigh the risks and benefits of each resuscitation option (odds ratio: 4.1; 95% confidence interval: 1.6-10.9) and having >10 years of clinical experience (odds ratio: 3.6; 95% confidence interval: 1.5-8.8).

CONCLUSIONS

Overall, our results showed that neonatologists are quite consistent in discussing clinical issues but quite varied in discussing social and ethical issues. If neonatologists are to perform complete prenatal consultations for infants at the border of viability as described by the latest American Academy of Pediatrics guidelines, then they will be expected to address quality-of-life values more robustly, to explain long-term outcomes, and to incorporate parental preferences during their conversations. Potential barriers to shared decision-making have yet to be outlined.

International comparison of care for very low birth weight infants: parents' perceptions of counseling and decision-making

OBJECTIVE

To characterize parent perceptions and satisfaction with physician counseling and delivery-room resuscitation of very low birth weight infants in countries with neonatal intensive care capacity.

STUDY DESIGN

Convenience sample of 327 parents of 379 inborn very low birth weight infants (<1501 g) who had received resuscitation and neonatal intensive care in 9 neonatal intensive care units (NICUs) in 6 Pacific Rim countries and in 2 California hospitals. The sample comprised mostly parents whose infants survived, because in some centers interviews of parents of nonsurviving infants were culturally inappropriate. Of 359 survivors for whom outcome data were asked of parents, 29% were reported to have long-term sequelae. Half-hour structured interviews were performed, using trained interpreters as necessary, at an interval of 13.7 months after the infant's birth. We compared responses to interview questions that detailed counseling patterns, factors taken into consideration in decisions, and acceptance of parental decision-making.

RESULTS

Parents' recall of perinatal counseling differed among centers. The majority of parents assessed physician counseling on morbidity and mortality as adequate in most, but not all, centers. They less commonly perceived discussions of other issues as adequate to their needs. The majority (>65%) of parents in all centers felt that they understood their infant's prognosis after physician counseling. The proportion of parents who expected long-term sequelae in their infant varied from 15% (in Kuala Lumpur, Malaysia) to 64% (in Singapore). The majority (>70%) of parents in all centers, however, perceived their infant's outcome to be better than they expected from physician counseling. A majority of parents across all centers feared that their infant would die in the NICU, and approximately one third continued to fear that their infant might die at home after nursery discharge. The parents' regard for physicians' and, to a lesser extent, partners' opinions was important in decision-making. Less than one quarter of parents perceived that physicians had made actual life-support decisions on their own except in Melbourne, Australia, and Tokyo, Japan (where 74% and 45% of parents, respectively, reported sole physician decision-making). Parents would have preferred to play a more active, but not autonomous, role in decisions made for their infants. Counseling may heighten parents' anxiety during and after their infant's hospitalization, but that does not diminish their recalled satisfaction with counseling and the decision-making process.

CONCLUSIONS

Counseling differs by center among these centers in Australasia and California. Given that parents desire to play an active role in decision-making for their premature infant, physicians should strive to provide parents the medical information critical for informed decision-making. Given that parents do not seek sole decision-making capacity, physicians should foster parental involvement in life-support decisions to the extent appropriate for local cultural norms.

Comparison of mothers' and counselors' perceptions of predelivery counseling for extremely premature infants

OBJECTIVE

To understand mothers' and counselors' perceptions of their roles in decision-making about resuscitation of extremely premature infants at delivery and to assess mothers' and counselors' satisfaction with the counseling and decision-making process.

METHODS

Mothers who delivered an infant between 22 and 27 completed weeks of gestation and their self-identified counselor were interviewed using a structured interview format. Mothers' and counselors' perceptions of the content, tone, and directiveness of predelivery counseling and their satisfaction with the decision-making process were compared. Demographic data were collected for the mothers, infants, and counselors. Simple descriptive statistics described demographic characteristics of mothers, counselors, and infants. Pearson's correlation coefficient was used to determine agreement within individual mother-counselor pairs about the content and directiveness of counseling.

RESULTS

Thirty-three counselors and 15 mother-counselor pairs were interviewed. The majority (66.7%) of mothers stated that the counselor had made a treatment recommendation, and 60% stated that they had no choice in how their infant would be treated. Only 27.3% of counselors stated that they had made a recommendation, saying instead that they had described the treatment plan or offered options. Counselors believed that mothers were given a treatment choice in 57.6% of encounters. Specific mother-counselor pairs showed little correlation in their perceptions of whether a treatment recommendation had been made (R = 0.0) or a choice had been given about resuscitation (R = 0.07). Despite a lack of perceived choice, mothers generally believed that they were included in treatment decisions (66.7%) and were satisfied with the amount of influence that they had in the decision-making process (73.3%).

CONCLUSIONS

The decision-making process in this study conforms most closely to a model of informed assent. Mothers may have been satisfied with this type of counseling because they felt informed and included in the decision-making process. Physicians and nurses need to elicit mothers' preferences to incorporate them into the treatment plan, as counseling about the resuscitation of extremely premature infants at delivery is considered directive by mothers even when it is not intended to be directive.

Medical end-of-life decisions in neonates and infants in Flanders

BACKGROUND

Paediatricians are increasingly confronted with end-of-life decisions in critically ill neonates and infants. Little is known about the frequency and characteristics of end-of-life decisions in this population, nor about the relation with clinical and patients' characteristics.

METHODS

A death-certificate study was done for all deaths of neonates and infants in the whole of Flanders over a 12 month period (August, 1999, to July, 2000). We sent an anonymous questionnaire by mail to the attending physician for each of the 292 children who died under the age of 1 year. Information on patients was obtained from national registers. An attitude study was done for all physicians who attended at least one death during the study period.

FINDINGS

253 (87%) of the 292 questionnaires were returned, and 121 (69%) of the 175 physicians involved completed the attitude questions. An end-of-life decision was possible in 194 (77%; 95% CI 70.4-82.4) of the 253 deaths studied, and such a decision was made in 143 cases (57%; 48.9-64.0). Lethal drugs were administered in 15 cases among 117 early neonatal deaths and in two cases among 77 later deaths (13%vs 3%; p=0.018). The attitude study showed that 95 (79%; 70.1-85.5) of the 121 physicians thought that their professional duty sometimes includes the prevention of unnecessary suffering by hastening death and 69 (58%; 48.1-66.5) of 120 supported legalisation of life termination in some cases.

INTERPRETATION

Death of neonates and infants is commonly preceded by an end-of-life decision. The type of decision varied substantially according to the age of the child. Most physicians favour legalisation of the use of lethal drugs in some cases.

Ethical dilemmas in the care of the most premature infants: the waters are murkier than ever

PURPOSE OF REVIEW

Summarize the literature relevant to ethical issues surrounding decisions to provide intensive care to extremely premature newborns.

RECENT FINDINGS

A Texas Supreme Court decision and a position paper are noteworthy for health professionals participating in management decisions with families at risk for extremely preterm delivery.

SUMMARY

In Miller v HCA, the Millers sued the Hospital Corporation of America for resuscitating their approximately 23-week gestation daughter against their wishes. The baby survived with severe neurodevelopmental disabilities. They were awarded $59.9 million in a jury trial. However, the judgment was reversed by the court of appeals, which ruled that parents have no right to withhold urgently needed life-sustaining medical treatment from children with non-terminal impairments, deformities, or disabilities, regardless of their severity. The Supreme Court of Texas upheld that ruling, but reasoned that parents have no right to refuse resuscitation of extremely premature infants prior to birth because they cannot be fully evaluated until birth; therefore, decisions before birth could not be fully informed. Robertson (Hasting Center Report 2004) supports precluding parental refusal of resuscitation before birth. He argues that parents have a right to withhold or withdraw medical treatment from a non-terminally ill child, but only if the child will lack capacity for symbolic interaction. Such severe limitation of quality of life concerns in decision making for extremely premature newborns is inconsistent with current published guidelines, the positions of noted bioethicists, and the practice of many neonatologists. Further, the additional information attained by initiating intensive care in the most premature infants does not justify doing so without parental consent.

Delivery room decision-making at the threshold of viability

OBJECTIVES

To assess attitudes of neonatologists toward parental wishes in delivery room resuscitation decisions at the threshold of viability.

STUDY DESIGN

Cross-sectional survey of the 175 practicing level II/III neonatologists in six New England states.

RESULTS

Response rate was 85% (149/175). At 24 1/7-6/7 weeks' gestation, 41% of neonatologists considered treatment clearly beneficial, and at 25 1/7-6/7 weeks' gestation, 84% considered treatment clearly beneficial. When respondents consider treatment clearly beneficial, 91% reported that they would resuscitate in the delivery room despite parental requests to withhold. At or below 23 0/7 weeks' gestation, 93% of neonatologists considered treatment futile. Thirty-three percent reported that they would provide what they consider futile treatment at parental request. When respondents consider treatment to be of uncertain benefit, all reported that they would resuscitate when parents request it, 98% reported that they would resuscitate when parents are unsure, and 76% reported that they would follow parental requests to withhold.

CONCLUSIONS

Variation in neonatologists' beliefs about the gestational age bounds of clearly beneficial treatment and attitudes toward parental wishes in the context of uncertainty is likely to impact the manner in which they discuss options with parents before delivery. This supports the importance of transparency in neonatal decision-making.

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.

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.

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.

Perinatal care at the threshold of viability

In the United States, an increase in the number of births of extremely preterm infants and in their survival potential has occurred over the last decade. Determining the survival prognosis for the infant of a pregnancy with threatened preterm delivery between 22 and 25 completed weeks of gestation remains problematic. Many physicians and families encounter the difficulty of making decisions regarding the institution and continuation of life support for an infant born within this threshold period. This report addresses the process of counseling, assisting, and supporting families faced with the dilemma of an extremely preterm delivery.

Maternal characteristics associated with place of delivery and neonatal mortality rates among very-low-birthweight infants, Georgia

To determine whether the Healthy People 2000 objective to deliver very-low-birthweight (VLBW) infants at subspecialty perinatal care centres was met, and if improvements in the regional perinatal care system could reduce neonatal mortality further for 2010, we examined place of delivery for VLBW infants, associated maternal characteristics and the potential impact on neonatal mortality. We used linked birth and death records for the 1994-96 Georgia VLBW (i.e. 500-1499 g) birth cohorts. Among 4770 VLBW infants, 77% were delivered at hospitals providing subspecialty perinatal care. The strongest predictor of birth hospital level was the mother's county of residence, defined using three levels: residence in a county with a subspecialty hospital, residence in a county adjacent to one with such a hospital or residence in a non-adjacent county. Eighty-nine per cent of infants born to women who resided in counties with subspecialty care hospitals delivered at such hospitals, compared with 53% of infants born to women who resided in a non-adjacent county. Women were also more likely to deliver outside subspecialty care if they had less than adequate prenatal care [adjusted odds ratio (AOR) 1.5, P-value = 0.0001]. The neonatal mortality rate varied by level of perinatal care at the birth hospital from 132.1/1000 to 283/1000 live births, with the highest death rate for infants born at hospitals offering the lowest level of care. Assuming that the differences in mortality were due to care level of the birth hospital, potentially 16-23% of neonatal deaths among VLBW infants could have been prevented if 90% of infants born outside subspecialty care were delivered at the recommended level. These findings suggest that a state's support of strong, collaborative, regional perinatal care networks is required to ensure that high-risk women and infants receive optimal health care. Improved access to recommended care levels should further reduce neonatal mortality until interventions are identified to prevent VLBW births.

Fear of litigation may increase resuscitation of infants born near the limits of viability

OBJECTIVES

To explore how fear of litigation influences neonatal treatment decisions.

STUDY DESIGN

In a mailed survey, we presented a hypothetical vignette of a premature infant to 1000 neonatologists. We asked them to estimate prognosis, indicate appropriate intervention, and respond to parental treatment requests. Subjects were randomly assigned to receive one of two questionnaires, "litigious" or "nonlitigious," which differed only in the description of the infant's parents.

RESULTS

The response rate was 63.0%. The vast majority of respondents deferred to parental requests rather than adhering to their best judgment. They deferred whether or not parents requested treatment and whether or not parents were described as litigious (P <.0001). Among those respondents who shifted their resuscitation opinion after parental introduction, respondents to the nonlitigious version were more likely to shift their opinion from "treat" to "do not treat" after parental requests to "use your best judgment" (P <.042). The influence of parental litigiousness was primarily seen among neonatologists who thought that the infant's prognosis was dismal (P <.044).

CONCLUSIONS

There is a strong disposition among neonatologists toward respecting parental wishes. This disposition is stronger when neonatologists are given additional reason to be concerned about litigation.