The ethics of delivery-room resuscitation

Decision-making at the border of viability: determining the best interests of extremely preterm infants

This paper proposes and employs a framework for determining whether life-saving treatment at birth is in the best interests of extremely preterm infants, given uncertainty about the outcome of such a choice. It argues that given relevant data and plausible assumptions about the well-being of babies with various outcomes, it is typically in the best interests of even the youngest preterm infants-those born at 22 weeks gestational age-to receive life-saving treatment at birth.

Ethics of resuscitation for extremely premature infants: a systematic review of argument-based literature

OBJECTIVE

To present (1) the ethical concepts related to the debate on resuscitation of extremely premature infants (EPIs) as they are described in the ethical literature; and (2) the ethical arguments based on these concepts.

DESIGN

We conducted a systematic review of the ethical literature. We selected articles based on the following predefined inclusion/exclusion criteria: (1) English language articles (2) presenting fully elaborated ethical arguments (3) on resuscitation (4) of EPIs, that is, infants born before 28 weeks of gestation.

ANALYSIS

After repeated reading of articles, we developed individual summaries, conceptual schemes and an overall conceptual scheme. Ethical arguments and concepts were identified and analysed.

RESULTS

Forty articles were included out of 4709 screened. Personhood, best interest, autonomy and justice were concepts grounding the various arguments. Regarding these concepts, included authors agreed that the best interest principle should guide resuscitation decisions, whereas justice seemed the least important concept. The arguments addressed two questions: Should we resuscitate EPIs? Who should decide? Included authors agreed that not all EPIs should be resuscitated but disagreed on what criteria should ground this decision. Overall, included authors agreed that both parents and physicians should contribute to the decision.

CONCLUSIONS

The included publications suggest that while the best interest is the main concept guiding resuscitation decisions, justice is the least important. The included authors also agree that both parents and physicians should be actively involved in resuscitation decisions for EPIs. However, our results suggest that parents' decision should be over-ridden when in contrast with the EPI's best interest.

Outcomes of infants born at borderline viability (23-25 weeks gestation) who received cardiopulmonary resuscitation at birth

AIM

The practice of providing advanced resuscitative measures to infants born at borderline viability (23-25⁺⁶ weeks gestation) varies among clinicians due to perception of futility. The aim of our study was to compare mortality and major morbidities in infants born at borderline viability who did not receive cardiopulmonary resuscitation (CPR) in the delivery room (No DR-CPR) as compared to those who did (DR-CPR).

METHODS

A retrospective analysis of prospectively collected data of infants born between 23 and 25⁺⁶ weeks gestation who were resuscitated at birth at the study centre or admitted to neonatal intensive care unit from peripheral hospitals, over 8 years (2007-2014). The primary outcome was survival, free of disability at 2 years corrected age and secondary outcomes were survival at discharge and neonatal morbidities.

RESULTS

Of 123 infants in the study cohort, 21 received DR-CPR. In unadjusted analysis, there was increased mortality rate in the DR-CPR group which was statistically insignificant (26.5 vs. 42.9%, P = 0.15). After adjustment for potential confounders, there was no significant difference in the mortality rate with odds ratio of 1.10 (confidence interval: 0.34-3.53, P = 0.86). Among infants who received DR-CPR for >2 min, the mortality rate was significantly higher (25.2 vs. 56.3%, P = 0.01). Survival free of disability was similar in two groups (50.9 vs. 47.6%, P = 0.78).

CONCLUSIONS

Among infants born at borderline viability, the vast majority of infants did not receive CPR and, if CPR was prolonged for >2 min, mortality was increased. Among survivors of the small DR-CPR group, early neurodevelopmental outcomes were comparable to the No DR-CPR group.

Population-based estimates of in-unit survival for very preterm infants

BACKGROUND

Estimates of the probability of survival of very preterm infants admitted to NICU care are vital for counseling parents, informing care, and planning services. In 1999, easy-to-use charts of survival according to gestation, birth weight, and gender were published in the United Kingdom. These charts are widely used in clinical care and for benchmarking survival, and they form the core of the Clinical Risk Index for Babies II score. Since their publication, the survival of preterm infants has improved, and the charts therefore need updating.

METHODS

A logistic model was fitted with gestational age, birth weight, and gender. Nonlinear functions were estimated by using fractional polynomials. Bootstrap methods were used to assess the internal validity of the final model. The final model was assessed both overall and for subgroups of infants by using Farrington's statistic, the c-statistic, Cox regression coefficients, and the Brier score.

RESULTS

A total of 2995 white singleton infants born at 23(+0) to 32(+6) weeks' gestation in 2008 through 2010 were identified; 2751 (91.9%) infants survived to discharge. A prediction model was estimated and good model fit confirmed (area under receiver-operating characteristics curve = 0.86). Survival ranged from 27.7% (23 weeks) to 99.1% (32 weeks) for boys and from 34.5% (23 weeks) to 99.3% (32 weeks) for girls. Updated charts were produced showing estimated survival according to gestation, birth weight and gender, together with contour plots displaying points of equal survival.

CONCLUSIONS

These survival charts have been updated and will be of use to clinicians, parents, and managers.

Prediction of death for extremely premature infants in a population-based cohort

OBJECTIVE

Although gestational age (GA) is often used as the primary basis for counseling and decision-making for extremely premature infants, a study of tertiary care centers showed that additional factors could improve prediction of outcomes. Our objective was to determine how such a model could improve predictions for a population-based cohort.

METHODS

From 2005 to 2008, data were collected prospectively for the California Perinatal Quality Care Collaborative, which encompasses 90% of NICUs in California. For infants born at GAs of 22 to 25 weeks, we assessed the ability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development 5-factor model to predict survival rates, compared with a model using GA alone.

RESULTS

In the study cohort of 4527 infants, 3647 received intensive care. Survival rates were 53% for the whole cohort and 66% for infants who received intensive care. In multivariate analyses of data for infants who received intensive care, prenatal steroid exposure, female sex, singleton birth, and higher birth weight (per 100-g increment) were each associated with a reduction in the risk of death before discharge similar to that for a 1-week increase in GA. The multivariate model increased the ability to group infants in the highest and lowest risk categories (mortality rates of >80% and <20%, respectively).

CONCLUSIONS

In a population-based cohort, the addition of prenatal steroid exposure, sex, singleton or multiple birth, and birth weight to GA allowed for improved prediction of rates of survival to discharge for extremely premature infants.

Clinical assessment of extremely premature infants in the delivery room is a poor predictor of survival

BACKGROUND

Some neonatologists state that at the delivery of extremely premature infants they rely on "how the baby looks" when deciding whether to initiate resuscitation. Previous studies have reported poor correlation between early clinical signs and prognosis.

OBJECTIVE

To determine if neonatologists can accurately predict survival to discharge of extremely premature infants on the basis of observations in the first minutes after birth.

METHODS

We showed videos of the resuscitation of 10 extremely premature infants (<26 weeks' gestation) to attending neonatologists and fellows from the 3 major perinatal centers in Melbourne, Australia. Antenatal information was available to the observers. A monitor visible in each video displayed the heart rate and oxygen saturation of the infant. Observers were asked to estimate the likelihood of survival to discharge for each infant at 3 time points: 20 seconds, 2 minutes, and 5 minutes after birth. The predictive ability of observers was expressed as the area (95% confidence interval [CI]) under the receiver-operating-characteristic curve.

RESULTS

Seventeen attending neonatologists and 17 neonatal fellows completed the study. Receiver-operating-characteristic curves were generated for the combined and individual groups. Observers' ability to predict survival was poor (combined results): 0.61 (95% CI: 0.54-0.67) at 20 seconds, 0.59 (95% CI: 0.52-0.64) at 2 minutes, and 0.61 (95% CI: 0.55-0.67) at 5 minutes. Level of experience did not affect the observers' accuracy of predicting survival.

CONCLUSION

Neonatologists' reliance on initial appearance and early response to resuscitation in predicting survival for extremely premature infants is misplaced.