The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective

Professional Guidelines for the Care of Extremely Premature Neonates: Clinical Reasoning versus Ethical Theory

AbstractProfessional statements guide neonatal resuscitation thresholds at the border of viability. A 2015 systematic review of international guidelines by Guillen et al. found considerable variability between statements' clinical recommendations for infants at 23-24 weeks gestational age (GA). The authors concluded that differences in the type of data included were one potential source for differing resuscitation thresholds within this "ethical gray zone." How statements present ethical considerations that support their recommendations, and how this may account for variability, has not been as rigorously explored. We performed a mixed-methods exploratory analysis of 25 current international guidelines for neonatal resuscitation at 22+0-25+0 weeks GA. Qualitative analysis using a modified grounded theory yielded 34 distinct codes, eight categories, and four overarching themes. Three themes, consequentialism, principlism, and rights-based, consisted of concepts central to these ethical frameworks. The fourth theme, clinical reasoning, described counseling practices, medical management, outcomes data, and prognostic uncertainty, without any ethical context. The theme of clinical reasoning appeared in 22 of 25 guidelines. Ten guidelines lacked any ethical theme. Guidelines with an identified ethical theme were more likely to recommend comfort care than guidelines without an identified ethical theme, and recommended it at a higher average GA (22.7 weeks vs. 22.0 weeks, p = 0.03). Thus, how ethical concepts are incorporated into guidelines potentially impacts resuscitation thresholds. We argue that inclusion of explicit discussion of ethical considerations surrounding resuscitation in the "gray zone" would clarify values that inform recommendations and facilitate discussions about how neonatology ought to approach periviability as outcomes continue to evolve.

Extremely low gestational age neonates and resuscitation: survey on perspectives of Canadian neonatologists

OBJECTIVES

Resuscitation care planning for extremely low gestational age neonates (ELGANs) is complex and ethically charged. Increasing survival at lower gestational ages has had a significant impact on this complexity. It also has an impact on healthcare resource utilization and policy development in Canada. This study sought to determine the current attitudes and practices of neonatologists in Canada, and to assess moral distress associated with resuscitation decisions in the ELGAN population. It also aimed to explore the perspectives of adopting a shared decision-making approach where further data with regard to best interests and prognosis are gathered in an individualized manner after birth.

METHODS

Neonatologists in Canadian level III NICUs were surveyed in 2020.

RESULTS

Amongst the 65 responses, 78% expressed moral distress when parents request non-resuscitation at 24 weeks. Uncertainty around long-term outcomes in an era with improved chances of morbidity-free survival was the most prominent factor contributing to moral distress. 70% felt less moral distress deciding goals of care after the baby's initial resuscitation and preferred an individualized approach to palliation decisions based on postnatal course and assessment.

CONCLUSIONS

While most current guidelines still support the option of non-resuscitation for infants born at less than 25 weeks, we show evidence of moral distress among Canadian neonatologists that suggests the consideration of routine resuscitation from 24 weeks and above is a more ethical approach in the current era of improved outcomes. Canadian neonatologists identified less moral distress when goals of care are developed postnatally, with availability of more evidence for prognostication, instead of antenatally based primarily on gestational age.

Digital decision aid for prenatal counseling in imminent extreme premature labor: development and pilot testing

Background

In case of extreme premature delivery at 24 weeks of gestation, both early intensive care and palliative comfort care for the neonate are considered treatment options. Prenatal counseling, preferably using shared decision making, is needed to agree on the treatment option in case labor progresses. This article described the development of a digital decision aid (DA) to support pregnant women, partners and clinicians in prenatal counseling for imminent extreme premature labor.

Methods

This DA is developed following the International Patient Decision Aid Standards. The Dutch treatment guideline and the Dutch recommendations for prenatal counseling in extreme prematurity were used as basis. Development of the first prototype was done by expert clinicians and patients, further improvements were done after alpha testing with involved clinicians, patients and other experts (n = 12), and beta testing with non-involved clinicians and patients (n = 15).

Results

The final version includes information, probabilities and figures depending on users’ preferences. Furthermore, it elicits patient values and provides guidance to aid parents and professionals in making a decision for either early intensive care or palliative comfort care in threatening extreme premature delivery.

Conclusion

A decision aid was developed to support prenatal counseling regarding the decision on early intensive care versus palliative comfort care in case of extreme premature delivery at 24 weeks gestation. It was well accepted by parents and healthcare professionals. Our multimedia, digital DA is openly available online to support prenatal counseling and personalized, shared decision-making in imminent extreme premature labor.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01735-z.

Ethical issues in treatment of babies born at 22 weeks of gestation

Many centres now report that more than half of babies born at 22 weeks survive and most survivors are neurocognitively intact. Still, many centres do not offer life-sustaining treatment to babies born this prematurely. Arguments for not offering active treatment reflect concerns about survival rates, rates of neurodevelopmental impairment and cost. In this essay, I examine each of these arguments and find them ethically problematic. I suggest that current data ought to lead to two changes. First, institutional culture should change at institutions that do not offer treatment to babies born at 22 weeks. Second, we need more research to understand best practices for these tiny babies.

Decision-making in imminent extreme premature births: perceived shared decision-making, parental decisional conflict and decision regret

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.

Neonatal End-of-Life Decision Making: The Possible Behavior of Greek Physicians, Midwives, and Nurses in Clinical Scenarios

Background: This study investigates the acceptability, bioethical justification, and determinants of the provision of intensive care to extremely preterm or ill neonates among healthcare professionals serving in NICUs in Greek hospitals. Methods: Healthcare professionals (71 physicians, 98 midwives, and 82 nurses) employed full-time at all public Neonatal Intensive Care Units (NICUs) (n = 17) in Greece were asked to report their potential behavior in three clinical scenarios. Results: The majority of healthcare professionals would start and continue intensive care to (a) an extremely preterm neonate, (b) a full-term neonate with an unfavorable prognosis, and (c) a neonate with complete phocomelia. In cases (a) and (b), midwives and nurses compared to physicians (p = 0.009 and p = 0.004 in scenarios (a) and (b), respectively) and health professionals ascribing to the quality-of-life principle compared to those ascribing to the intrinsic value of life (p = 0.001 and p = 0.01 scenarios (a) and (b) respectively), tend towards withholding or withdrawing care. Religion plays an important role in all three scenarios (p = 0.005, p = 0.017 and p = 0.043, respectively). Conclusions: Understanding healthcare professionals’ therapeutic intensiveness in the face of NICU ethical dilemmas can improve NICU policies, support strategies, and, consequently, the quality of neonatal intensive care.

2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

The Prognosis of Preterm Infants Born at the Threshold of Viability: Fog Over the Gray Zone - Population-Based Studies of Extremely Preterm Infants

The limit of viability for premature newborns has changed in recent decades, but whether to initiate or withhold active care for periviable infants remains a subject of debate because the chances of survival and the extent of severe neurological impairment can be unclear. In our review, we analyzed large population-based studies of periviable infants from the past 2 decades. We compared survival rates and the incidence of early complications among survivors, including bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, and necrotizing enterocolitis. Moreover, we assessed the perinatal factors that may affect the survival of preterm infants. We analyzed 15 studies reporting data on preterm infants born between 22 and 28 gestational weeks. None of these studies reported survival of an infant born before 22 gestational weeks. Survival rates of infants born at 24 weeks’ gestation were above 50% in most studies. The incidence of each complication was also higher among infants born at ≤24 weeks. Of the analyzed perinatal factors, antenatal corticosteroid therapy, birth weight, female sex, cesarean delivery, singleton pregnancy, and birth in a tertiary-level Neonatal Intensive Care Unit were found to be associated with improved survival in some studies. The different methodologies of the studies limited comparison of the results. Further investigations are needed to gain up-to-date information on the limit of viability, and standardized methods in future studies would enable more accurate comparisons of findings.

Conventional revolution: the ethical implications of the natural progress of neonatal intensive care to artificial wombs

Research teams have used extra-uterine systems (Biobags) to support premature fetal lambs and to bring them to maturation in a way not previously possible. The researchers have called attention to possible implications of these systems for sustaining premature human fetuses in a similar way. Some commentators have pointed out that perfecting these systems for human fetuses might alter a standard expectation in abortion practices: that the termination of a pregnancy also (inevitably) entails the death of the fetus. With Biobags, it might be possible, some argue, that no woman has the right to expect that outcome if the technology is able to sustain fetal life after an abortion. In order to protect the expectation that the termination of a pregnancy always entails the death of the fetus, Elizabeth Romanis has argued that fetuses sustained in Biobags have a status different than otherwise 'born' children. In support of that view, she argues that these 'gestatelings' are incapable of independent life. This argument involves a misunderstanding of the gestational support involved, as well as a misapprehension of neonatology practice. Here, we argue that any human fetus sustained in a Biobag would be as 'independent' as any other premature infant, and just as 'born'. Neonatologists would seem to have certain presumptive moral responsibilities toward any human fetus gestating in a Biobag. It remains a separate question whether the perfection and widespread application of Biobags for premature human beings would or should alter the expectation that ending a pregnancy also entails fetal death.

Survival and early complications of preterm infants with birthweight less than 500 grams during a 10-year period in Hungary

BACKGROUND

There are limited data available on the survival and early complications of preterm infants with less than 500 g birthweight. To estimate the outcomes for these infants, it is important for caregivers to be aware of perinatal factors that may affect survival.

OBJECTIVES

We assessed the mortality and certain early complications of preterm infants born with less than 500 g in Hungary between 2006 and 2015.

METHODS

We reviewed data of 486 infants from the database of the Hungarian Central Statistical Office and in parallel of 407 infants from the "NICU database." The study period was divided into two epochs: 2006-2010 and 2011-2015.

RESULTS

The survival was 27.1% in the first epoch and 39.1% in the second epoch, and the incidence of early complications was slightly higher in the second epoch. In the surviving group (first and second epoch combined), gestational age (25.1 vs 23.7 weeks), birthweight (458 vs 447 g) antenatal steroid treatment (66.3% vs 52.3%), surfactant therapy (95.1% vs 84.3%), median Apgar scores (6 vs 3 and 8 vs 5 at 1 and 5 minutes, respectively) and proportion of caesarean delivery (89.3% versus 68.5%) were higher than in the non-surviving group (first and second epoch combined). The proportion of multiple births was lower in the surviving group (15.7% vs 33.4%).

CONCLUSIONS

Survival of infants with less than 500 g improved between 2006-2010 and 2011-2015 in Hungary. The slightly higher occurrence of early complications might be associated with improving survival.

Perinatal palliative care: a dedicated care pathway

OBJECTIVE

Ensure access to perinatal palliative care (PnPC) to all eligible fetuses/infants/parents.

DESIGN

During 12 meetings in 2016, a multidisciplinary work-group (WG) performed literature review (Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method was applied), including the ethical and legal references, in order to propose shared care pathway.

SETTING

Maternal-Infant Department of Padua's University Hospital.

PATIENTS

PnPC eligible population has been divided into three main groups: extremely preterm newborns (first group), newborns with prenatal/postnatal diagnosis of life-limiting and/or life-threatening disease and poor prognosis (second group) and newborns for whom a shift to PnPC is appropriate after the initial intensive care (third group).

INTERVENTIONS

The multidisciplinary WG has shared care pathway for these three groups and defined roles and responsibilities.

MAIN OUTCOME MEASURES

Prenatal and postnatal management, symptom's treatment, end-of-life care.

RESULTS

The best care setting and the best practice for PnPC have been defined, as well as the indications for family support, corpse management and postmortem counselling, as well suggestion for conflicts' mediation.

CONCLUSIONS

PnPC represents an emerging field within the paediatric palliative care and calls for the development of dedicated shared pathways, in order to ensure accessibility and quality of care to this specific population of newborns.

Active care of infants born between 22 and 26 weeks of gestation does not follow consensus expert recommendations

AIM

To determine the relationship between clinical practice and publication of an Australian consensus statement for management of extremely preterm infants in 2006.

METHODS

A population-based study using linked data from New South Wales, Australia for births between 22 + 0 and 26 + 6 weeks of gestation between 2000 and 2011.

RESULTS

There were 4746 births of whom 2870 were liveborn and 1876 were stillborn. Of the live births, 2041 (71%) were resuscitated, 1914 (67%) were admitted into a neonatal intensive care unit (NICU) and 1310 (46%) survived to hospital discharge. Thirty-nine (2%) stillbirths were resuscitated but none survived. No 22-week infant survived to hospital discharge. Fewer 23-week gestation infants were resuscitated between 2004 (52%) and 2005 (20%) but resuscitation rates increased by 2008 (44%). There was no difference at other gestations. Adjusted odds ratio (OR) for resuscitation was increased by birthweight (OR: 1.01), tertiary hospital birth (OR: 3.4) and Caesarean delivery (OR: 11.3) and decreased by rural residence (OR: 0.4) and male gender (OR: 0.7).

CONCLUSION

Expert recommendations may be shaped by clinical practice rather than the converse, especially for 23-week gestation infants. Recommendations should be revised regularly to include clinical practice changes.

Cost is an important factor influencing active management of extremely preterm infants

AIM

The attitudes of neonatologists towards the active management of extremely premature infants in a developing country like China are uncertain.

METHODS

A web-based survey was sent to neonatologists from 16 provinces representing 59.6% (824.2 million) of the total population of China on October 2015 and December 2017.

RESULTS

A total of 117 and 219 responses were received in 2015 and 2017, respectively. Compared to 2015, respondents in 2017 were more likely to resuscitate infants <25 weeks of gestation (86% vs. 72%; p < 0.05), but few would resuscitate infants ≤23 weeks of gestation in either epoch (10% vs. 6%). In both epochs, parents were responsible for >50% of the costs of intensive care, but in 2017, significantly fewer clinicians would cease intensive care (75% vs. 88%; p < 0.05) and more would request for economic aid (40% vs. 20%; p < 0.05) if parents could not afford to pay. Resource availability (e.g. ventilators) was not an important factor in either initiation or continuation of intensive care (~60% in both epochs).

CONCLUSION

Cost is an important factor in the initiation and continuation of neonatal intensive care in a developing country like China. Such factors need to be taken into consideration when interpreting outcome data from these regions.

National guidelines for delivery room management

The following guideline is designed to give recommendations for the routine care of all neonates immediately after delivery, and the resuscitation and delivery room approach of all high-risk infants in light of recent literature. The guideline has been prepared as three different parts. The first part is about routine procedures that have to be performed to all healthy term and preterm infants in delivery room care. The second part summaries the basic principles of resusucitation including the latest changes that were mentioned in the International Liaison Committee on Resuscitation (ILCOR)-2015 guideline. Recommendations about the delivery room management of rare clinical conditions have been discussed in the last part. The social, medical conditions, and the resourses of Turkey have also been taken into consideration in its preparation. We hope it will be useful for all pediatricians and neonatologists for use as a essential guideline in delivery room care.

Opinions of Argentinean neonatologists on the initiation of life-sustaining treatment in preterm infants

BACKGROUND

In June 2014, the Argentinean Ministry of Health published guidelines for the management of neonates born at the limit of viability (≤25 weeks of gestation). We explored the opinion of neonatologists in Buenos Aires, Argentina, regarding the initiation of life-sustaining treatment (LST) in critically ill neonates, focusing on the effect of sociocultural factors on their opinion.

METHODS

An anonymous survey was designed to explore the opinions of Argentinean neonatologists on whether or not to initiate LST in newborns born prematurely. Five hundred eighty neonatologists from 36 neonatal units were invited to participate, and 315 specialists from 34 neonatal units completed the survey (response rate 54%). The survey was conducted between June 2014 and February 2015.

RESULTS

9.5% (30/315) of the neonatologists answered they would begin LST on neonates born at 22 weeks, 42.5% (134/315) at 23 weeks, 37% (117/315) at 24 weeks, 7% (22/315) at 25 weeks, and 4% (12/315) at ≥26 weeks. Cumulatively then, 96% of participants stated they would start LST at 25 weeks of gestation or less. On multivariate analysis, a "transcendent" value of life and lack of consideration of the local legal framework for making medical decisions in the delivery room were statistically associated with an opinion in favor of initiation of LST in neonates born at the limit of viability. More than 50% of the Argentinean neonatologists surveyed answered they would initiate treatment at a gestational age of less than 23 weeks, despite the fact that the recommendations of the Argentinean Ministry of Health are to only give comfort care for these neonates. The opinion of most Argentinean neonatologists surveyed thus differs from that recommended by the guidelines of Argentina.

CONCLUSION

The most frequent opinion of Argentinean neonatologists was to initiate LST in neonates at the limit of viability. Certain factors, in particular the sense of a transcendent meaning to life and lack of consideration of the local legal framework for making medical decisions in the delivery room, seem to influence the decision to start LST.

Decision-making at the limit of viability: differing perceptions and opinions between neonatal physicians and nurses

Background

In the last 20 years, the chances for intact survival for extremely preterm infants have increased in high income countries. Decisions about withholding or withdrawing intensive care remain a major challenge in infants born at the limits of viability. Shared decision-making regarding these fragile infants between health care professionals and parents has become the preferred model today. However, there is an ongoing ethical debate on how decisions regarding life-sustaining treatment should be reached and who should have the final word when health care professionals and parents do not agree. We designed a survey among neonatologists and neonatal nurses to analyze practices, difficulties and parental involvement in end-of-life decisions for extremely preterm infants.

Methods

All 552 physicians and nurses with at least 12 months work experience in level III neonatal intensive care units (NICU) in Switzerland were invited to participate in an online survey with 50 questions. Differences between neonatologists and NICU nurses and between language regions were explored.

Results

Ninety six of 121 (79%) physicians and 302 of 431(70%) nurses completed the online questionnaire. The following difficulties with end-of-life decision-making were reported more frequently by nurses than physicians: insufficient time for decision-making, legal constraints and lack of consistent unit policies. Nurses also mentioned a lack of solidarity in our society and shortage of services for disabled more often than physicians. In the context of limiting intensive care in selected circumstances, nurses considered withholding tube feedings and respiratory support less acceptable than physicians. Nurses were more reluctant to give parents full authority to decide on the course of action for their infant. In contrast to professional category (nurse or physician), language region, professional experience and religion had little influence if any on the answers given.

Conclusions

Physicians and nurses differ in many aspects of how and by whom end-of-life decisions should be made in extremely preterm infants. The divergencies between nurses and physicians may be due to differences in ethics education, varying focus in patient care and direct exposure to the patients. Acknowledging these differences is important to avoid potential conflicts within the neonatal team but also with parents in the process of end-of-life decision-making in preterm infants born at the limits of viability.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1040-z) contains supplementary material, which is available to authorized users.

The attitudes of neonatologists towards extremely preterm infants: a Q methodological study

OBJECTIVES

The attitudes and biases of doctors may affect decision making within Neonatal Intensive Care. We studied the attitudes of neonatologists in order to understand how they prioritise different factors contributing to decision making for extremely preterm babies.

DESIGN

Twenty-five neonatologists (11 consultants and 14 senior trainees) participated in a Q methodological study about decision making that involved the ranking of 53 statements from agree to disagree in a unimodal shaped grid. Results were explored by person factor analysis using principle component analysis.

RESULTS

The model of best fit comprised 23 participants contributing a three-factor model, which represented three different attitudes towards decision making and accounted for 59% of the variance. Fourteen statements were ranked in statistically significant similar positions by 23 participants; consensus statements included placing the baby and family at the centre of care, limitation of intervention based upon perceived risk and non-mandatory intervention at birth. Factor 1 participants (n=12) believed that treatment should not be limited based on gestational age and technology should be used to improve treatment. Five factor 2 participants identified strongly with a limit of 24 weeks for treatment, one of whom being polar opposite, believing in treatment at all costs at all gestations. The remaining six factor 3 participants identified strongly with statements that treatment should be withheld on quality of life grounds.

CONCLUSIONS

This study has identified differences in attitudes towards decision making between individual neonatologists and trainees that may impact how decisions are communicated to families.

Ethics of birth at the limits of viability: the risky business of prediction

Infants born at the limits of viability present neonatologists in particular and society in general with difficult challenges. Ethical and legal considerations establish a framework for action, although this varies between countries, departments and individuals and shows dynamic changes over time. This brief review includes a vignette telling a familiar story. In this case, the parents ask searching questions and the caring, knowledgeable neonatologist uses up-to-date information to offer empathic and thoughtful guidance - a challenge for all.