Acta Pædiatrica ISSN 0803-5253
The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective Jonathan M. Fanaroff ([email protected]
)1, Jean-Michel Hasco€et2, Thor Willy Ruud Hansen3,4, Malcolm Levene5, Mikael Norman6, Apostolos Papageorgiou7, Eric Shinwell8, Margot van de Bor9, David K. Stevenson10, on behalf of the International Perinatal Collegium (IPC) 1.Department of Pediatrics and the Rainbow Center for Pediatric Ethics, Case Western Reserve University School of Medicine, Cleveland, OH, USA Re gionale, Universite de Lorraine, Nancy, France 2.Department of Neonatology, Maternite 3.Women’s and Children’s Division, Department of Neonatology, Oslo University Hospital, Oslo, Norway 4.Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway 5.Division of Pediatrics and Child Health, University of Leeds, Leeds, UK 6.Department of Neonatal Medicine, Karolinska Institutet & University Hospital, Stockholm, Sweden 7.Department of Pediatrics, Jewish General Hospital, McGill University, Montreal, QC, Canada 8.Department of Neonatology, Ziv Medical Center, Bar-Ilan University, Tsfat, Israel 9.Department of Health and Life Sciences, VU University, Amsterdam, The Netherlands 10.Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
Keywords Ethics, Extremely premature infants, International perspectives, Neonatology, Resuscitation Correspondence J M Fanaroff, MD, JD, Department of Pediatrics, Rainbow Babies and Children’s Hospital/University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA. Tel: +216-844-3387 | Fax: +216-844-3380 | Email: [email protected]
ABSTRACT Premature infants at the limits of viability raise difficult ethical, legal, social and economic questions. Neonatologists attending an international Collegium were surveyed about delivery room behaviour, and the approach taken by selected countries practicing ‘modern’ medicine was explored. Conclusion: There were strong preferences for comfort care at 22 weeks and full resuscitation at 24 weeks. Resuscitation was a grey area at 23 weeks. Cultural, social and legal factors also had a considerable impact on decision-making.
Received 22 November 2013; revised 1 March 2014; accepted 12 March 2014. DOI:10.1111/apa.12633
INTRODUCTION The field of neonatology has made tremendous progress over the last few decades (1). Advances such as antenatal steroids, surfactant, parenteral nutrition and mechanical ventilation have made it possible for many premature infants to survive and thrive when they would not have done so in the past. However, a number of difficult ethical, legal, social and economic questions arise when infants are born extremely premature. Who gets to decide if an extremely premature infant will be resuscitated? What criteria should be used? Do parents have the right to insist on resuscitation even when the physicians believe that such care is futile? Or vice versa, can parents demand that physicians do not intervene when infants are born premature, but their medical judgement is that there are good expectations for both survival and eventual outcome? A unique opportunity to discuss these complex issues from a wider worldwide perspective arose during the 23rd International Perinatal Collegium (IPC), which took place from July 14, 2013, to July 18, 2013, in Banff, Alberta,
Canada. The IPC is a biannual meeting of neonatologists, mainly from European and North American countries, and in 2013, there were 42 participants from 14 countries: Austria, Belgium, Canada, Finland, France, Greece, Israel, Italy, the Netherlands, Norway, Sweden, Taiwan, the United Kingdom and the United States. While exact data were not collected, the participants were an experienced group of neonatologists, mostly from academic medical centres. Our purpose was to determine the current approach to delivery room management of extremely premature infants.
Abbreviations GA, Gestational age; IPC, International Perinatal Collegium.
©2014 Foundation Acta Pædiatrica. Published by John Wiley & Sons Ltd 2014 103, pp. 701–708
Premature infants at the limits of viability raise difficult ethical, legal, social and economic questions. Neonatologists attending an International Collegium were surveyed about delivery room behaviour, and the approach taken by selected countries was explored. The consensus ranged from comfort care at 22 weeks to full resuscitation at 24 weeks, and it was clear that cultural, social and legal factors had a considerable impact on decisions-making processes.
Resuscitation at the limits of viability
Fanaroff et al.
METHODS Part one: survey The survey was carried out after a presentation by Professor Levene, which compared changes in outcomes over the last decade and was followed by a discussion on antenatal consultations with parents facing delivery of an extremely premature infant. The group were asked about their behaviour in the delivery room when they were asked to attend the following deliveries: (i) a female infant whose mother had received antenatal steroids, (ii) a male infant whose mother had not received antenatal steroids, (iii) a premature infant who was active and crying with a heart rate of 130 and (iv) a nonreactive infant with poor tone and a heart rate of 60. Participants were asked to select their likely response at 22, 23 and 24 weeks of gestation for each of the following scenarios: (i) start resuscitation with full care (intubation with chest compressions), (ii) start pulmonary resuscitation only (intubation with no chest compressions), (iii) comfort care measures only (no intubation and no chest compressions) and (iv) other (none of the above options). Part two: ethical approach to resuscitation at the limits of viability in selected countries A more detailed discussion was carried out on the approaches adopted by clinicians from several of the participants’ countries towards decision-making in the delivery room when presented with an extremely premature infant. These countries were Canada, Norway, France, Israel, Sweden and the Netherlands.
RESULTS Part one: survey The results of the survey are presented in Figure 1. At 22 weeks of gestation, there was a preference for comfort
care in every scenario, except for a vigorous baby, where there was a preference for more support. At 23 weeks, responses varied considerably depending upon the circumstances. For a vigorous female baby who had received steroids, there was a preference towards more support, while for a male infant without steroids or a nonvigorous infant, there were more participants who would choose comfort care. At 24 weeks of gestation, there was a preference for full support in every scenario. Part two: ethical approach to resuscitation at the limits of viability in selected countries Canada We noted variations between countries, and even institutions in the same country, when it came to active intervention at the limits of viability, together with the definition of limits and the ethical implications. However, it has been possible to implement a very uniform approach in Canada because of universal medical coverage and the absence of private institutions. The provincial governments have assigned levels of care for perinatal care. For example, six tertiary care institutions in the Province of Quebec receive all the high-risk pregnancies below 33 weeks of gestation and there is a centralised electronic system, updated every 8 h, which details the availability of beds for high-risk mothers and neonates requiring NICU admission. An obstetrical perinatologist and a neonatologist coordinate the service and are available by phone 24-h-a-day to help obstetricians and paediatricians from Level I and II centres to manage emergencies and to direct admissions to the closest and most appropriate perinatal centre. The system appears to function well, as nearly 90% of infants weighing