Treatment Decisions for Newborns at the Threshold of Viability: An Ethical Dilemma

Abstract

The major ethical issues involved in decision-making in the care of extremely low birth weight newborns are analyzed here. We propose a schema for assessment and management of these infants that is consistent with ethical principles broadly accepted by the pediatric community, and which takes into account mortality risk at any given institution rather than arbitrary weight limits, with a major decision-making role for the infant's parents. When possible, the decision of whether or not to resuscitate should be made before delivery; when not possible, delivery room resuscitation is recommended, and the decision to continue or withdraw care should be made subsequently based on likelihood of survival and the wishes of the parents.

Improved Survival Rates With Increased Neurodevelopmental Disability for Extremely Low Birth Weight Infants in the 1990s

“…[4][5][6]45 The ethical debate pertains mainly to the resuscitation of infants with birth weights of Ͻ750 g; however, in our experience, the worsened neurodevelopmental outcomes associated with the increased survival rates in the 1990s were attributable mainly to the survival of infants with birth weights of 750 to 999 g. Although we cannot fully explain this finding, we speculate that, although active resuscitation was used nearly universally for the larger infants, selective resuscitation and support were offered only to the most vigorous infants who were Ͻ750 g, who thus represented a select group. Our data suggest that all prospective parents of extremely low birth weight infants should be advised of the substantial risk for neurodevelopmental problems and should consider the risks and benefits of various approaches to their care.…”

“…[1][2][3] The medical, ethical, and economic implications of providing care for such extremely low birth weight infants have been the subject of much debate. [4][5][6] As infants of increasingly lower birth weight and gestational age have been resuscitated, questions have arisen regarding whether the improved survival rates have been accompanied by increased impairment rates, with a worsened quality of life, for the tiniest survivors. [7][8][9] We sought to compare the rates of survival, neonatal morbidity, and neurodevelopmental impairment at 20 months of corrected age among children of 500-to 999-g birth weight who were born at our perinatal center during 2 periods, ie, 1982-1989 and 1990 -1998; the latter period was associated with increased prenatal steroid therapy, cesarean section delivery, assisted ventilation in the delivery room, surfactant therapy, and postnatal steroid use.…”

Delivery room decision-making at the threshold of viability

“…[4][5][6][7] Moreover, the circumstances under which parental wishes regarding resuscitation should be elicited prior to delivery and then followed at birth are unclear. Although there are many articles in the medical literature that discuss these ethical issues, [8][9][10][11][12][13][14][15] there are few empirical studies of physician attitudes and practices. Our study aims to provide current data from New England on management at the threshold of viability, with an emphasis on neonatologists' responses to parental wishes in decision-making.…”

Prenatal Consultation Practices at the Border of Viability: A Regional Survey

“…Compelling claims have been made in support of both parents and physicians as guardians of the child's best interests. [6][7][8][9][10][11][12][13][14][15][16][17] The ethical and clinical dilemmas inherent in making these choices are complex and deserve careful consideration from all involved. A large amount of medical and personal information must be shared inorder for both parties to assess what course of action is in the best interest of the infant.…”