Viability and thresholds for treatment of extremely preterm infants: survey of UK neonatal professionals

Abstract

BackgroundDecisions about treatments for extremely preterm infants (EPIs) born in the ‘grey zone’ of viability can be ethically complex. This 2020 survey aimed to determine views of UK neonatal staff about thresholds for treatment of EPIs given a recently revised national Framework for Practice from the British Association of Perinatal Medicine.MethodsThe online survey requested participants indicate the lowest gestation at which they would be willing to offer active treatment and the highest gestation at which they would withhold active treatment of an EPI at parental request (their lower and upper thresholds). Relative risks were used to compare respondents’ views based on profession and neonatal unit designation. Further questions explored respondents’ conceptual understanding of viability.Results336 respondents included 167 consultants, 127 registrars/fellows and 42 advanced neonatal nurse practitioners (ANNPs). Respondents reported a median grey zone for neonatal resuscitation between 22+1 and 24+0 weeks’ gestation. Registrars/fellows were more likely to select a lower threshold at 22+0 weeks compared with consultants (Relative Risk (RR)=1.37 (95% CI 1.07 to 1.74)) and ANNPs (RR=2.68 (95% CI 1.42 to 5.06)). Those working in neonatal intensive care units compared with other units were also more likely to offer active treatment at 22+0 weeks (RR=1.86 (95% CI 1.18 to 2.94)). Most participants understood a fetus/newborn to be ‘viable’ if it was possible to survive, regardless of disability, with medical interventions accessible to the treating team.ConclusionCompared with previous studies, we found a shift in the reported lower threshold for resuscitation in the UK, with greater acceptance of active treatment for infants <23 weeks’ gestation.

Individualised decision making: interpretation of risk for extremely preterm infants—a survey of UK neonatal professionals

“…Sixty-eight per cent were female and 40% had more than 16 years’ experience working with EPI ( online supplemental table 2 ). 5 Ninety-five per cent reported having read the revised BAPM framework and 89% indicated that they were currently using it in their clinical practice.…”

“…The methods of the wider survey have been described previously. 5 Participants were three groups of UK neonatal professionals involved in antenatal decision making around management of EPIs; consultants, middle grade trainee doctors (‘registrars’) and advance neonatal nurse practitioners (ANNPs).…”

“…We have previously reported a shift in the approach of UK neonatal professionals to EPI since the publication of the revised framework, with a widening of the ‘grey zone’ for decision making. 5 It is not known how UK neonatal professionals interpret the framework’s risk assessment, nor how consistent are their estimates of the chances of survival and/or severe disability.…”

Gestation-Based Viability–Difficult Decisions with Far-Reaching Consequences

“…The attitudes of care providers towards the outcomes of babies born at the margins of viability were shown to influence the perinatal care of pregnancies at 22-24 weeks gestation and subsequent neonatal outcomes [8][9][10][11][12][13][14][15][16][17]. These attitudes are however changing, as outcome data from recent publications suggest survival and outcome data for babies born at 22 weeks gestation-similar to what was achieved in the early 1990s with babies born at 24 weeks gestation [18].…”

Parent-centered ethical decision making for preterm infants born near the limit of viability—reflection on the significance of probabilistic prognoses as a basis for shared decision making

“…Dieser Ansatz wird von anderen Autoren kritisiert und international unterschiedlich gehandhabt (Cummings und Committee on Fetus and Newborn 2015; Lantos 2019). Festzuhalten bleibt, dass Ärztinnen und Ärzte sehr unterschiedliche und sich ändernde Ansichten darüber haben, welche kindliche Prognose ausreichend ist, um lebenserhaltende Maßnahmen nach einer frühen Frühgeburt zu rechtfertigen (Wilkinson et al 2018;Di Stefano et al 2021). Manchmal wird angeführt, Eltern befänden sich in einer Art Ausnahmesituation, die schwerwiegende und weitreichende Entscheidungen zu sehr erschwere, oder, dass Eltern die Bürde der Verantwortung dieser schweren Entscheidungen nicht tragen können oder wollen.…”