Resuscitation in the "Gray Zone" of Viability: Determining Physician Preferences and Predicting Infant Outcomes (original) (raw)
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Decision-making in the delivery room: a survey of neonatologists
Journal of Perinatology, 2007
Objective: To examine influences on neonatologists' decision-making regarding resuscitation of extremely premature infants. Study Design: A mailed survey of Illinois neonatologists evaluated influences on resuscitation. Personal and parentally opposed (that is, acting against parental wishes) gray zones of resuscitation were defined, with the lower limit (LL) the gestational age at or below which resuscitation would be consistently withheld and the upper limit (UL) above which resuscitation was mandatory. Result: Among the 85 respondents, LL and UL of the personal and parentally opposed gray zones were median 22 and 25 weeks, respectively. Neonatologists with an UL personal gray zone <25 completed weeks were significantly more fearful of litigation, more likely to have received didactic/continuing medical education teaching, and less likely to always consider parents' opinions in resuscitation decisions. Neonatologists with an UL parentally opposed gray zone <25 completed weeks were more fearful of litigation. Conclusion: Neonatologists perceive a 'gray zone' of resuscitative practices and should understand that external influences may affect their delivery room resuscitation practices.
The ethics of delivery-room resuscitation
Seminars in Fetal and Neonatal Medicine, 2008
Perinatal care continues to improve and the number of extremely preterm babies delivered increases. What is the outcome for those babies? Under what circumstances should we not initiate resuscitation or under what circumstances should we discontinue support? How accurate and predictive are the data we have and how can these be improved? Who should make the decisions and how should they be made? Should we follow different guidelines in different settings? The following narrative will examine some of these questions but cannot answer them all. ª
What We Do When We Resuscitate Extremely Preterm Infants
The American journal of bioethics : AJOB, 2017
Children's Mercy Kansas City Neonatal intensive care is one of the most successful medical innovations of the last half century. Every year, in the United States alone, nearly 500,000 babies are born prematurely. Before neonatal intensive care, most of those babies died, and those who survived often suffered significant life-limiting impairments. Today, most preemies survive without impairments. In spite of this success, neonatal intensive care unit (NICU) care has always been viewed as ethically problematic. The objections to this care have taken different forms at different times. Economists questioned whether neonatal intensive care was cost-effective (Meadow et al. 2012; Rogowski 1998). Careful studies showed that it was more cost-effective than any other form of intensive care (Lantos and Meadow 2011), and even more cost-effective than many modalities of preventive care (including, for example, Pap smears) (Cutler and McClellan 2001). Some parents claimed that doctors were not honestly informing them of the potential long-term sequelae of NICU care, and that, if honestly informed, many parents would choose palliative care (Harrison 2001). Careful studies showed that these parents were unusual. Most parents want more intensive care than even doctors and nurses think is appropriate, and they want it even when informed that survivors might be left with significant disabilities (Lam et al. 2009; Streiner et al. 2001,). Bioethicists and doctors argued that neonatologists were playing God (Drane 1989), that premature babies were not full-fledged persons (Christoffersen-Deb 2012), and that saving disabled babies was like an ill-conceived military mission (Duff 1981). Each of these attempts to undermine the commitment made by parents, doctors, and society to saving preemies has been met with hard questions and strong rebuttals. But people just keep trying to find reasons why we shouldn't offer treatment that might save the lives of tiny babies.
Risk factors for advanced resuscitation in term and near-term infants: a case–control study
Archives of Disease in Childhood - Fetal and Neonatal Edition, 2016
Objective (1) To determine which antepartum and/or intrapartum factors are associated with the need for advanced neonatal resuscitation (ANR) at birth in infants with gestational age (GA) ≥34 weeks. (2) To develop a risk score for the need for ANR in neonates with GA ≥34 weeks. Design Prospective multicentre, case-control study. In total, 16 centres participated in this study: 10 in Argentina, 1 in Chile, 3 in Brazil and 2 in the USA. Results A case-control study conducted from December 2011 to April 2013. Of a total of 61 593 births, 58 429 were reported as an GA ≥34 weeks, and of these, only 219 (0.37%) received ANR. After excluding 23 cases, 196 cases and 784 consecutive birth controls were included in the analysis. The final model was generated with three antepartum and seven intrapartum factors, which correctly classified 88.9% of the observations. The area under the receiver operating characteristic (AROC) performed to evaluate discrimination was 0.88, 95% CI 0.62 to 0.91. The AROC performed for external validity testing of the model in the validation sample was 0.87 with 95% CI 0.58 to 0.92. Conclusions We identified 10 risk factors significantly associated with the need for ANR in newborns ≥34 weeks. We developed a validated risk score that allows the identification of newborns at higher risk of need for ANR. Using this tool, the presence of specialised personnel in the delivery room may be designated more appropriately.
PEDIATRICS, 2006
OBJECTIVES. The objective of this study was to determine the attitudes of a variety of health care providers toward the recommendations that should be made to parents regarding the resuscitation of infants who are born at the margins of viability. METHODS. A written questionnaire was distributed to the medical and nursing staff at 4 tertiary perinatal centers. For each of 5 weekly gestational age intervals from 22 weeks to 26 weeks, 6 days, the health care providers were asked to describe on a scale from 1 to 5 whether they would strongly discourage through strongly encourage resuscitation. They also were queried regarding their comfort with counseling regarding these issues. The attitudes of various groups of providers were compared across weekly intervals. RESULTS. A total of 204 physicians and 539 nurses completed the survey. The majority would strongly discourage, either discourage or strongly discourage, be neutral or recommend, recommend or strongly recommend, and strongly rec...