On the limits of viability: toward an individualized prognosis-based approach

Proost, Lien De; M’hamdi, Hafez Ismaili; Verhagen, Eduard; Geurtzen, Rosa; Verweij, E. J.

doi:10.1038/s41372-020-00793-x

Cited by 10 publications

(10 citation statements)

References 12 publications

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“…The current validation study provides up‐to‐date information and can be of additional value in decision‐making in individual cases. It is important to provide parents and clinicians with useful prognostic information enabling them to make informed, well‐considered decisions 29 . Although this model was developed for postnatal application, it can be a helpful tool to support decisions when counselling parents prenatally, e.g.…”

Section: Discussionmentioning

confidence: 99%

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Prognostic model for predicting survival in very preterm infants: an external validation study

Beek

Groenendaal

Onland

et al. 2021

BJOG

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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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Section: Discussionmentioning

confidence: 99%

“…It is important to provide parents and clinicians with useful prognostic information enabling them to make informed, well-considered decisions. 29 Although this model was developed for postnatal application, it can be a helpful tool to support decisions when counselling parents prenatally, e.g. using estimated fetal birthweight.…”

Section: Discussionmentioning

confidence: 99%

Prognostic model for predicting survival in very preterm infants: an external validation study

Beek

Groenendaal

Onland

et al. 2021

BJOG

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“…For many years, clinicians have used a series of gestational age thresholds to guide practice of "active neonatal intervention", although they vary widely around the world. [24 25] The use of such thresholds is always controversial and may remove both clinician and parental discretion from the decision making, [12] whereas other recommendations suggest a "grey" zone where discretion may be used. [14] Some may point to a lack of cost effectiveness but there are few data to support such a view.…”

Section: The Ethical Basis For Survival-focused Management At Extreme...mentioning

confidence: 99%

Refining regional organization of services in the UK to improve outcomes of pregnancies delivering at extremely low gestational age

Marlow

Adams

David

2022

Seminars in Perinatology

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“…One could wonder how much technological interference is "allowed" to still label a certain GA as threshold of viability. In practice, a set GA is actually always an estimated (e-)GA (32). Moreover, because of differences between countries in availability of technological and medical support, thresholds of viability may differ from country to country (7,24).…”

Section: The Threshold Of Viabilitymentioning

confidence: 99%

“…The problem is that changing the threshold alone can be considered an outdated measure. There is a lot of current literature stating that GA is not sufficient to come to a prognosis, and that GA is always an estimated (e-)GA (32,38,39). Besides, by lowering the threshold to provide active care, the ethical challenges of a strictly GA-based guideline will merely be shifted, not solved.…”

Section: Ga-based Guidelinementioning

confidence: 99%

The Edge of Perinatal Viability: Understanding the Dutch Position

Proost¹,

Verweij

M’hamdi³

et al. 2021

Front. Pediatr.

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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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On the limits of viability: toward an individualized prognosis-based approach

Cited by 10 publications

References 12 publications

Prognostic model for predicting survival in very preterm infants: an external validation study

Prognostic model for predicting survival in very preterm infants: an external validation study

Refining regional organization of services in the UK to improve outcomes of pregnancies delivering at extremely low gestational age

The Edge of Perinatal Viability: Understanding the Dutch Position

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