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Dave E, Kohari KS, Cross SN. Periviability for the Ob-Gyn Hospitalist. Obstet Gynecol Clin North Am 2024; 51:567-583. [PMID: 39098782 DOI: 10.1016/j.ogc.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Abstract
Periviable birth refers to births occurring between 20 0/7 and 25 6/7 weeks gestational age. Management of pregnant people and neonates during this fragile time depends on the clinical status, as well as the patient's wishes. Providers should be prepared to counsel patients at the cusp of viability, being mindful of the uncertainty of outcomes for these neonates. While it is important to incorporate the data on projected morbidity and mortality into one's counseling, shared-decision making is most essential to caring for these patients and optimizing outcomes for all.
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Affiliation(s)
- Eesha Dave
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Katherine S Kohari
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Sarah N Cross
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.
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2
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de Boer A, van Beek PE, Andriessen P, Groenendaal F, Hogeveen M, Meijer JS, Obermann-Borst SA, Onland W, Scheepers L(HCJ, Vermeulen MJ, Verweij EJT(J, De Proost L, Geurtzen R. Opportunities and Challenges of Prognostic Models for Extremely Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1712. [PMID: 37892375 PMCID: PMC10605480 DOI: 10.3390/children10101712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/06/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
Predicting the short- and long-term outcomes of extremely preterm infants remains a challenge. Multivariable prognostic models might be valuable tools for clinicians, parents, and policymakers for providing accurate outcome estimates. In this perspective, we discuss the opportunities and challenges of using prognostic models in extremely preterm infants at population and individual levels. At a population level, these models could support the development of guidelines for decisions about treatment limits and may support policy processes such as benchmarking and resource allocation. At an individual level, these models may enhance prenatal counselling conversations by considering multiple variables and improving transparency about expected outcomes. Furthermore, they may improve consistency in projections shared with parents. For the development of prognostic models, we discuss important considerations such as predictor and outcome measure selection, clinical impact assessment, and generalizability. Lastly, future recommendations for developing and using prognostic models are suggested. Importantly, the purpose of a prognostic model should be clearly defined, and integrating these models into prenatal counselling requires thoughtful consideration.
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Affiliation(s)
- Angret de Boer
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Pauline E. van Beek
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 EA Utrecht, The Netherlands;
| | - Marije Hogeveen
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
| | - Julia S. Meijer
- Department of Neonatology, Máxima Medical Center, 5504 DB Veldhoven, The Netherlands; (P.A.); (J.S.M.)
| | - Sylvia A. Obermann-Borst
- Care4Neo, Dutch Neonatal Patient and Parent Advocacy Organization, 3068 JN Rotterdam, The Netherlands; (S.A.O.-B.); (M.J.V.)
| | - Wes Onland
- Department of Neonatology, Emma Children’s Hospital, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands;
- Amsterdam Reproduction & Development, 1105 AZ Amsterdam, The Netherlands
| | | | - Marijn J. Vermeulen
- Care4Neo, Dutch Neonatal Patient and Parent Advocacy Organization, 3068 JN Rotterdam, The Netherlands; (S.A.O.-B.); (M.J.V.)
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Sophia Children’s Hospital, Erasmus Medical Center, 3015 CN Rotterdam, The Netherlands
| | - E. J. T. (Joanne) Verweij
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Lien De Proost
- Department of Ethics and Law, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands;
| | - Rosa Geurtzen
- Department of Neonatology, Amalia Children’s Hospital, Radboud University Medical Center, Geert Grooteplein Zuid 32, 6525 GA Nijmegen, The Netherlands; (P.E.v.B.); (M.H.); (R.G.)
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3
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De Proost L, de Boer A, Reiss IKM, Steegers EAP, Verhagen AAE, Hogeveen M, Geurtzen R, Verweij EJJ. Adults born prematurely prefer a periviability guideline that considers multiple prognostic factors beyond gestational age. Acta Paediatr 2023; 112:1926-1935. [PMID: 37272253 DOI: 10.1111/apa.16866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/22/2023] [Accepted: 06/02/2023] [Indexed: 06/06/2023]
Abstract
AIM The aim of the study was to explore the perspectives of adults born prematurely on guidelines for management at extreme premature birth and personalisation at the limit of viability. METHODS We conducted four 2-h online focus group interviews in the Netherlands. RESULTS Twenty-three participants born prematurely were included in this study, ranging in age from 19 to 56 years and representing a variety of health outcomes. Participants shared their perspectives on different types of guidelines for managing extremely premature birth. They agreed that a guideline was necessary to prevent arbitrary treatment decisions and to avoid physician bias. All participants favoured a guideline that is based upon multiple prognostic factors beyond gestational age. They emphasised the importance of discretion, regardless of the type of guideline used. Discussions centred mainly on the heterogeneity of value judgements about outcomes after extreme premature birth. Participants defined personalisation as 'not just looking at numbers and statistics'. They associated personalisation mainly with information provision and decision-making. Participants stressed the importance of involving families in decision-making and taking their care needs seriously. CONCLUSION Adults born prematurely prefer a periviability guideline that considers multiple prognostic factors and allows for discretion.
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Affiliation(s)
- L De Proost
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Neonatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Obstetrics, Leids University Medical Center, Leiden, The Netherlands
| | - A de Boer
- Department of Obstetrics, Leids University Medical Center, Leiden, The Netherlands
- Department of Neonatology, Amalia Children's Hospital, Radboud UMC, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - I K M Reiss
- Department of Neonatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - E A P Steegers
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - A A E Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - M Hogeveen
- Department of Neonatology, Amalia Children's Hospital, Radboud UMC, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - R Geurtzen
- Department of Neonatology, Amalia Children's Hospital, Radboud UMC, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - E J Joanne Verweij
- Department of Obstetrics, Leids University Medical Center, Leiden, The Netherlands
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4
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Wilkinson DJ, Bertaud S. End of life care in the setting of extreme prematurity - practical challenges and ethical controversies. Semin Fetal Neonatal Med 2023; 28:101442. [PMID: 37121832 PMCID: PMC10914670 DOI: 10.1016/j.siny.2023.101442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
While the underlying principles are the same, there are differences in practice in end of life decisions and care for extremely preterm infants compared with other newborns and older children. In this paper, we review end of life care for extremely preterm infants in the delivery room and in the neonatal intensive care unit. We identify potential justifications for differences in the end of life care in this population as well as practical and ethical challenges.
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Affiliation(s)
- Dominic Jc Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK; John Radcliffe Hospital, Oxford, UK; Murdoch Children's Research Institute, Melbourne, Australia; Centre for Biomedical Ethics, National University of Singapore Yong Loo Lin School of Medicine, Singapore.
| | - Sophie Bertaud
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK
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5
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Verweij EJ, De Proost L, Hogeveen M, Reiss IKM, Verhagen AAE, Geurtzen R. Dutch guidelines on care for extremely premature infants: Navigating between personalisation and standardization. Semin Perinatol 2022; 46:151532. [PMID: 34839939 DOI: 10.1016/j.semperi.2021.151532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE There is no international consensus on what type of guideline is preferred for care at the limit of viability. We aimed to conceptualize what type of guideline is preferred by Dutch healthcare professionals: 1) none; 2) gestational-age-based; 3) gestational-age-based-plus; or 4) prognosis-based via a survey instrument. Additional questions were asked to explore the grey zone and attitudes towards treatment variation. FINDING 769 surveys were received. Most of the respondents (72.8%) preferred a gestational-age-based-plus guideline. Around 50% preferred 24+0/7 weeks gestational age as the lower limit of the grey zone, whereas 26+0/7 weeks was the most preferred upper limit. Professionals considered treatment variation acceptable when it is based upon parental values, but unacceptable when it is based upon the hospital's policy or the physician's opinion. CONCLUSION In contrast to the current Dutch guideline, our results suggest that there is a preference to take into account individual factors besides gestational age.
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Affiliation(s)
- E J Verweij
- Department of Obstetrics, LUMC, Albinusdreef 2, Leiden ZA 2333, the Netherlands; Department of Obstetrics and Gynaecology, Erasmus MC, the Netherlands.
| | - Lien De Proost
- Department of Obstetrics and Gynaecology, Erasmus MC, the Netherlands; Department of Neonatology, Erasmus MC, the Netherlands; Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, the Netherlands
| | - Marije Hogeveen
- Department of Neonatology, Radboud University Medical Centre, Amalia Children's Hospital, the Netherlands
| | - I K M Reiss
- Department of Neonatology, Erasmus MC, the Netherlands
| | - A A E Verhagen
- Department of Paediatrics, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - Rosa Geurtzen
- Department of Neonatology, Radboud University Medical Centre, Amalia Children's Hospital, the Netherlands
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6
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Marlow N, Adams E, David AL. Refining regional organization of services in the UK to improve outcomes of pregnancies delivering at extremely low gestational age. Semin Perinatol 2022; 46:151534. [PMID: 34879981 DOI: 10.1016/j.semperi.2021.151534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Care for pregnant women and their infants at extremely low gestational ages challenges clinical teams. The continuing rise in survival at gestational ages below 25 weeks has prompted re-evaluation of practice guidelines within the UK and other countries. This paper describes the background data that have guided our practice, the approach that has been taken to deliver optimal outcomes for pregnancies delivering at extremely low gestational age in the UK, mainly through centralising care, and discusses the research and audit data that support our practice. In particular, we emphasize the importance of a coordinated perinatal approach to both mother and infant, and careful assessment of the risks to both, to ensure that we develop the highest quality personalized care for each family, supported by national quality improvement and research evidence.
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Affiliation(s)
- Neil Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, 74 Huntley Street, London WC1E 6AU, UK.
| | - Eleri Adams
- Getting it Right First Tim (GIRFT) Clinical Lead for Neonatology and Consultant Neonatologist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anna L David
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, 74 Huntley Street, London WC1E 6AU, UK
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7
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van Beek PE, Groenendaal F, Onland W, Koole S, Dijk PH, Dijkman KP, van den Dungen F, van Heijst A, Kornelisse RF, Schuerman F, van Westering-Kroon E, Witlox R, Andriessen P, Schuit E. Prognostic model for predicting survival in very preterm infants: an external validation study. BJOG 2021; 129:529-538. [PMID: 34779118 DOI: 10.1111/1471-0528.17010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To perform a temporal and geographical validation of a prognostic model, considered of highest methodological quality in a recently published systematic review, for predicting survival in very preterm infants admitted to the neonatal intensive care unit. The original model was developed in the UK and included gestational age, birthweight and gender. DESIGN External validation study in a population-based cohort. SETTING Dutch neonatal wards. POPULATION OR SAMPLE All admitted white, singleton infants born between 23+0 and 32+6 weeks of gestation between 1 January 2015 and 31 December 2019. Additionally, the model's performance was assessed in four populations of admitted infants born between 24+0 and 31+6 weeks of gestation: white singletons, non-white singletons, all singletons and all multiples. METHODS The original model was applied in all five validation sets. Model performance was assessed in terms of calibration and discrimination and, if indicated, it was updated. MAIN OUTCOME MEASURES Calibration (calibration-in-the-large and calibration slope) and discrimination (c statistic). RESULTS Out of 6092 infants, 5659 (92.9%) survived. The model showed good external validity as indicated by good discrimination (c statistic 0.82, 95% CI 0.79-0.84) and calibration (calibration-in-the-large 0.003, calibration slope 0.92, 95% CI 0.84-1.00). The model also showed good external validity in the other singleton populations, but required a small intercept update in the multiples population. CONCLUSIONS A high-quality prognostic model predicting survival in very preterm infants had good external validity in an independent, nationwide cohort. The accurate performance of the model indicates that after impact assessment, implementation of the model in clinical practice in the neonatal intensive care unit could be considered. TWEETABLE ABSTRACT A high-quality model predicting survival in very preterm infants is externally valid in an independent cohort.
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Affiliation(s)
- P E van Beek
- Department of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - F Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht and Utrecht University, Utrecht, The Netherlands
| | - W Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centres, VU University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - S Koole
- The Netherlands Perinatal Registry, Utrecht, The Netherlands
| | - P H Dijk
- Department of Neonatology, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - K P Dijkman
- Department of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Fam van den Dungen
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centres, VU University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Afj van Heijst
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - R F Kornelisse
- Department of Paediatrics, Division of Neonatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Faba Schuerman
- Department of Neonatology, Isala Clinics, Zwolle, The Netherlands
| | - E van Westering-Kroon
- Department of Neonatology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rsgm Witlox
- Department of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - P Andriessen
- Department of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands.,Department of Applied Physics, School of Medical Physics and Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - E Schuit
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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8
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Geurtzen R, van den Heuvel JFM, Huisman JJ, Lutke Holzik EM, Bekker MN, Hogeveen M. Decision-making in imminent extreme premature births: perceived shared decision-making, parental decisional conflict and decision regret. J Perinatol 2021; 41:2201-2207. [PMID: 34285357 DOI: 10.1038/s41372-021-01159-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 07/09/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To describe levels of perceived shared decision making (SDM), decisional conflict (DC), and decision regret (DR) in prenatal counseling by pregnant women, partners, neonatologists, and obstetricians regarding decision-making around imminent extreme premature birth in which a decision about palliative comfort care versus early intensive care had to be made. STUDY DESIGN Multicenter, cross-sectional study using surveys to determine perceived SDM at imminent extreme premature birth in parents and physicians, and to determine DC and DR in parents. RESULTS In total, 73 participants from 22 prenatal counseling sessions were included (21 pregnant women, 20 partners, 14 obstetricians, 18 neonatologists). High perceived levels of SDM were found (median 82,2), and low levels of DC (median 23,4) and DR at one month (median 12, 5). CONCLUSIONS Reported levels of self-perceived SDM in the setting of prenatal counseling in extreme prematurity were high, by both the parents and the physicians. Levels of DC and DR were low.
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Affiliation(s)
- R Geurtzen
- Amalia Children's Hospital, department of neonatology, Radboud university medical center, Nijmegen, The Netherlands.
| | - J F M van den Heuvel
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - J J Huisman
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - E M Lutke Holzik
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - M N Bekker
- Department of Obstetrics and Gynecology, University Medical Centre, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - M Hogeveen
- Amalia Children's Hospital, department of neonatology, Radboud university medical center, Nijmegen, The Netherlands
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9
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De Proost L, Verweij EJT, Ismaili M'hamdi H, Reiss IKM, Steegers EAP, Geurtzen R, Verhagen AAE. The Edge of Perinatal Viability: Understanding the Dutch Position. Front Pediatr 2021; 9:634290. [PMID: 33598441 PMCID: PMC7882530 DOI: 10.3389/fped.2021.634290] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/08/2021] [Indexed: 11/17/2022] Open
Abstract
The current Dutch guideline on care at the edge of perinatal viability advises to consider initiation of active care to infants born from 24 weeks of gestational age on. This, only after extensive counseling of and shared decision-making with the parents of the yet unborn infant. Compared to most other European guidelines on this matter, the Dutch guideline may be thought to stand out for its relatively high age threshold of initiating active care, its gray zone spanning weeks 24 and 25 in which active management is determined by parental discretion, and a slight reluctance to provide active care in case of extreme prematurity. In this article, we explore the Dutch position more thoroughly. First, we briefly look at the previous and current Dutch guidelines. Second, we position them within the Dutch socio-cultural context. We focus on the Dutch prioritization of individual freedom, the abortion law and the perinatal threshold of viability, and a culturally embedded aversion of suffering. Lastly, we explore two possible adaptations of the Dutch guideline; i.e., to only lower the age threshold to consider the initiation of active care, or to change the type of guideline.
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Affiliation(s)
- L. De Proost
- Department of Medical Ethics, Philosophy and History of Medicine, Rotterdam, Netherlands
- Department of Neonatology, Rotterdam, Netherlands
- Department of Obstetrics and Gynecology, Rotterdam, Netherlands
| | - E. J. T. Verweij
- Department of Obstetrics and Gynecology, Rotterdam, Netherlands
- Department of Obstetrics, Leiden University Medical Center (LUMC), Leiden, Netherlands
| | - H. Ismaili M'hamdi
- Department of Medical Ethics, Philosophy and History of Medicine, Rotterdam, Netherlands
| | | | | | - R. Geurtzen
- Department of Neonatology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, Netherlands
| | - A. A. E. Verhagen
- Department of Pediatrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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10
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Resuscitation policies for extremely preterm newborns: finally moving beyond gestational age. J Perinatol 2020; 40:1731-1733. [PMID: 33009493 DOI: 10.1038/s41372-020-00843-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/24/2020] [Accepted: 09/18/2020] [Indexed: 11/08/2022]
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