Borderline Viability

Leuthner, Steven R.

doi:10.1016/j.clp.2014.08.005

Cited by 40 publications

(19 citation statements)

References 69 publications

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“…Rates of mechanical ventilation for surviving preterm ≥24 weeks’ gestation in this study and mortality among ventilated preterm infants were both consistent with reports from the NICHD Neonatal Research Network,( 29 ) suggesting reasonable capture of mechanical ventilation by ICD-9 codes. Given the significant healthcare provider distress that occurs around a perceived inappropriate provision of ICU resources at the extremes of age,( 8 ) these data should provide reassurance that on a population level, most ICU resources at the extremes of age are not directed toward non-surviving patients.…”

Section: Discussionmentioning

confidence: 99%

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Cost comparison of mechanically ventilated patients across the age span

et al. 2015

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Objectiveto compare use of mechanical ventilation and hospital costs across ventilated patients of all ages, preterm through adults, in a nationally-representative sample.Study Designsecondary analysis of the 2009 Agency for Healthcare Research and Quality National Inpatient Sample.Results1,107,563 (2.8%) patients received mechanical ventilation. For surviving ventilated patients, median costs for infants ≤32 weeks’ gestation were $51,000–$209,000, whereas median costs for older patients were lower, from $17,000–$25,000. For non-surviving ventilated patients, median costs were $27,000–$39,000 except at the extremes of age; the median cost was $10,000 for <24 week newborns, and $14,000 for 91+ year adults. Newborns of all gestational ages had a disproportionate share of hospital costs relative to their total volume.ConclusionsMost ICU resources at the extremes of age are not directed toward non-surviving patients. From a perinatal perspective, attention should be directed toward improving outcomes and reducing costs for all infants, not just at the earliest gestational ages.

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Section: Discussionmentioning

confidence: 99%

“…( 3 – 7 ) For premature neonates, resource allocation and quality of life discussions center around gestational-age-based discretionary resuscitation guidelines. ( 8 – 11 )…”

Section: Introductionmentioning

confidence: 99%

Cost comparison of mechanically ventilated patients across the age span

et al. 2015

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“…Foetal weight can vary as much as 15% and GA estimates vary depending on the assessment tools used (Kett 2015 ). Maternal dating based upon last menstrual period rarely underestimates the GA, whereas crown to rump measurements have an accuracy of ± 3 days, and the New Ballard Exam was shown to overestimate GA by 2 weeks, with range of ± 4 weeks (Leuthner 2014 ). Also, the neonatologist’s ability to predict survival based on baseline appearance data and early response is argued to be poor (Brett 2010 ).…”

Section: Uncertaintymentioning

confidence: 99%

“…Uncertainties about baseline and outcome data couple with the empirical uncertainly. It is unclear what it is like to live through the experience of comfort care, active treatment that leads to death, or active treatment that leads to neurodevelopmental impairment (NDI) (Leuthner 2014 ). This is further coupled with ethical uncertainty.…”

Section: Uncertaintymentioning

confidence: 99%

“…When deciding within the grey zone , parents as well as NICU professionals are expected to regard the best interest of their newborn child in the first place. But, this distinction between the best interest of the newborn and the best interest of the family is overly individualistic and hence questionable (Leuthner 2014 ). The best interest principle calls for negating all other interests except for the infant’s self-regarding interest.…”

Section: Best Interestmentioning

confidence: 99%

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Professional ethics: the case of neonatology

Stanak

2018

Med Health Care and Philos

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Neonatal professionals encounter many ethical challenges especially when it comes to interventions at the limit of viability (weeks 22-25 of gestation). At times, these challenges make the moral dilemmas in neonatology tragic and they require a particular set of intellectual and moral virtues. Intellectual virtues of episteme and phronesis, together with moral virtues of courage, compassion, keeping fidelity to trust, and integrity were highlighted as key virtues of the neonatal professional. Recognition of the role of ethics requires a recognition that answering the obvious question (what shall we do?) does not always suffice. Acknowledging the tragic question (is any of the alternatives open to us free from serious moral wrongdoing) and recognizing the ethical dilemmas, where the lines between right and wrong are blurred, leads to actions taken towards establishing ethics frameworks to support decision-making. In neonatology units, such organizational support can help in allowing the team members to recognize the ethical dilemmas, avoid moral distress, and improve team cohesion and the quality of care provided. Only when the organizational structure allows ethical dilemmas to be recognized, adequate decisions can be made.

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The ethics and practice of perinatal care at the limit of viability: FIGO recommendations

Vidaeff,

Capito,

Gupte

et al. 2024

Intl J Gynecology & Obste

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An arbitrary gestational age limit of viability cannot be set, and in clinical practice the focus should be on a periviability interval—the so‐called “gray zone” of prognostic uncertainty. For cases within this interval, the most appropriate decision‐making process remains debatable and periviability has emerged as one of the greatest challenges in bioethics. Universally recognized ethical principles may be interpreted differently due to socioeconomic, cultural, and religious aspects. In the case of periviability, there is considerable uncertainty over whether interventions result in a greater balance of clinical good over harm. Furthermore, the fetus or neonate is unable to exercise autonomy and the physicians and parents will act as patient surrogates. When parents and physicians disagree about the infant's best interest, a dialogue without paternalistic attitudes is essential, whereby physicians should only offer, but not recommend, perinatal interventions. Parental choice, based on thorough information, should be respected within the limits of what is medically feasible and appropriate. When disagreements between parents and physicians occur, how is consensus to be achieved? Professional guidelines can be helpful as a framework and starting point for discussion. In reality, however, guidelines only rarely draw categorical lines and in many cases remain vague and ambiguously worded. Local ethics committees can provide counseling and function as moderators during discussions, but ethics committees do not have decision precedence. Counseling assumes the most significant role in periviability discussions, taking into consideration the particular fetal and maternal characteristics, as well as parental values. Several caveats should be observed relative to counseling: message fragmentation or inconsistence should be minimized, prognosis should preferably be presented in a positive framing, and overreliance on statistics should be avoided. It is recommended that decisions regarding neonatal resuscitation in the periviability interval be made before birth and not conditional on the newborn's appearance at birth. Regardless of decision, it is important to assure pre‐ and postnatal coherence. The present article describes how individual physicians, centers, and countries differ in the approach to the decision to initiate or forgo intensive care in the periviability interval. It is impossible to provide a global consensus view and there can be no unifying ethical, moral, or practical strategy. Nevertheless, ethically justified, quality care comprises early involvement of the obstetric and neonatal team to enable a coherent, comprehensible, nonpaternalistic, and balanced plan of care. Ultimately, physicians will need to adjust the expectations to the local standards, local outcome data, and local neonatal support availability.

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Borderline Viability

Cited by 40 publications

References 69 publications

Cost comparison of mechanically ventilated patients across the age span

Cost comparison of mechanically ventilated patients across the age span

Professional ethics: the case of neonatology

The ethics and practice of perinatal care at the limit of viability: FIGO recommendations

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