Delivery room decision-making at the threshold of viability

doi:10.1016/j.jpeds.2004.06.018

The Journal of Pediatrics

Volume 145, Issue 4, October 2004, Pages 492-498

https://doi.org/10.1016/j.jpeds.2004.06.018 Get rights and content

Objectives

To assess attitudes of neonatologists toward parental wishes in delivery room resuscitation decisions at the threshold of viability.

Study design

Cross-sectional survey of the 175 practicing level II/III neonatologists in six New England states.

Results

Response rate was 85% (149/175). At 24 1/7-6/7 weeks' gestation, 41% of neonatologists considered treatment clearly beneficial, and at 25 1/7-6/7 weeks' gestation, 84% considered treatment clearly beneficial. When respondents consider treatment clearly beneficial, 91% reported that they would resuscitate in the delivery room despite parental requests to withhold. At or below 23 0/7 weeks' gestation, 93% of neonatologists considered treatment futile. Thirty-three percent reported that they would provide what they consider futile treatment at parental request. When respondents consider treatment to be of uncertain benefit, all reported that they would resuscitate when parents request it, 98% reported that they would resuscitate when parents are unsure, and 76% reported that they would follow parental requests to withhold.

Conclusions

Variation in neonatologists' beliefs about the gestational age bounds of clearly beneficial treatment and attitudes toward parental wishes in the context of uncertainty is likely to impact the manner in which they discuss options with parents before delivery. This supports the importance of transparency in neonatal decision-making.

Section snippets

Methods

From May to September 2002, an anonymous, self-administered survey was mailed to all practicing level II and III neonatologists in six New England states (Mass, NH, Conn, RI, Vt, and Me) using names and addresses obtained from the American Academy of Pediatrics (AAP) Directory of Neonatologists, Perinatal Section District 1. Every level II and III neonatal intensive care unit (NICU) in the six states was contacted to verify the names of all neonatologists practicing in their departments.

Results

Surveys were mailed to 178 neonatologists. Three were ineligible to participate because of retirement or relocation. Of the remaining 175, 149 returned completed surveys for an 85% response rate. Of the respondents, 44% reported more than 15 years of clinical experience in neonatology, approximately one quarter each were Catholic, Protestant, and Jewish, and 50% reported religion/spirituality to be important or very important (Table II).

Discussion

A notable finding of this study was that a large majority of neonatologists reported attitudes toward parental wishes regarding treatment for their extremely preterm infants in accordance with a decision-making framework for critically ill children put forth by a President's Commission more than 20 years ago. That is, the majority of respondents said that they would provide treatment that they consider clearly beneficial, withhold treatment that they consider futile, and defer to parental

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Supported by Grant No. T32 PE 10018 from the Health Resources and Services Administration.

The opinions expressed are those of the authors and do not necessarily reflect the position or policy of the National Institutes of Health, the Public Health Service, or the Department of Health and Human Services.

The first author is now affiliated with The Department of Clinical Bioethics, National Institutes of Health. However, the study was undertaken and completed while the author was affiliated with Children's Hospital Boston.

^∗: Deceased.

View full text

Original ArticleDelivery room decision-making at the threshold of viability

Objectives

Study design

Results

Conclusions

Section snippets

Methods

Results

Discussion

Semin Neonatol

Am J Perinatol

Semin Perinatol

Semin Neonatol

Clin Perinatol

J Pediatr

J Pediatr

Clin Perinatol

Clin Perinatol

J Pediatr

Lancet

Trends in mortality and morbidity for very low birth weight infants, 1991-1999

Pediatrics

A quantitative review of mortality and developmental disability in extremely premature newborns

Arch Pediatr Adolesc Med

Do the “Baby Doe” rules ignore suffering?

Second Opin

Limiting treatment for extremely premature, low-birth-weight infants (500 to 750 g)

Am J Dis Child

From how small is too small to how much is too much. Ethical issues at the limits of neonatal viability

Clin Perinatol

Treatment decisions for newborns at the threshold of viability: an ethical dilemma

J Perinatol

Parental rights at the birth of a near-viable infant: conflicting perspectives

Am J Obstet Gynecol

Bad cases make bad law: HCA v Miller is not a guide for resuscitation of extremely premature newborns

J Perinatol

Decisions regarding resuscitation of the extremely premature infant and models of best interest

J Perinatol

Withholding and withdrawing life sustaining treatment in neonatal intensive care: issues for the 1990s

Arch Dis Child Fetal Neonatal Ed

Deciding to forego life-sustaining treatment: a report on the ethical, medical, and legal issues in treatment decisions

Treating Baby Doe: the ethics of uncertainty

Hastings Cent Rep

Original Article
Delivery room decision-making at the threshold of viability