PEDIATRICS Vol. 117 No. 6 June 2006, pp. 2276 (doi:10.1542/peds.2005-3199)
COMMENTARY |
500-Gram Infants—and 800-Pound Gorillas—in the Delivery Room
Department of Pediatrics, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
Peerzada et al,1 like most authors of similarly excellent surveys around the world, conclude that "[d]elivery room resuscitation decisions for extremely preterm infants (<26 weeks of gestation) continue to be controversial." I agree, but not for the reasons that they, or most others, cite.
Indeed, as I review the world's literature on this topic, delivery room decision-making for this group of infants is remarkably noncontroversial, at least if homogeneity of response is a measure of noncontroversy. There is a certain gestational age/birth weight (
25 weeks' gestation/650 g) above which neonatologists around the world believe that outcomes are so good that resuscitation is obligatory, independent of parental wishes, on the ethical grounds of the "best interests" of the infant. At the other end of a surprisingly narrow spectrum (22 weeks' gestation/400 g), almost all neonatologists in almost every country surveyed refuse to resuscitate such an infant, again overriding parental wishes, this time on the grounds of "futility."
It is the behavior (or behaviour in many countries) in between that interests me. One might have assumed that for infants born at 23 to 24 weeks' gestation and 450 to 600 g, physicians are in a state of what ethicists pretentiously call "equipoise"; that is, it is simply unclear in these cases whether resuscitation or comfort care should be the preferred medical response. In those cases, one might further assume, parental preferences should dominate. However, they do not. In almost all cases, neonatologists surveyed say that they would "see how the infant looks" or "watch how the infant responds to resuscitation" before informing the parents of what should be done. I believe that these neonatologists are both honest and well-intentioned in responding in this way.
Unfortunately (here is the first 800-lb gorilla), I do not know of any data to suggest that neonatologists can accurately foretell which infants will "do well" from anything they can observe in the delivery room (indeed, if forced, or even gently nudged, I would advance that claim for many ventilated infants outside the delivery room, but that is a commentary for another day). Stipulating (as our legal and philosophical brethren would have it) that the infant comes out looking appropriate for the gestational age of 23 to 24 weeks, I would raise 2 points. First, without data supporting a claim that prognostication in the delivery room has any predictive power at all, how can we ever ethically override parental preferences for either resuscitation or comfort care? Second, we should be searching for such data. If they can be developed, let's do it. If (here is the second gorilla), as I would bet, we will never have sufficient predictive power in this arena, let's admit it and restore decision-making authority to the parents to either provide or withhold resuscitation for their prematurely born infant as they see fit.
 |
FOOTNOTES |
|---|
Accepted Dec 29, 2005.
Address correspondence to William Meadow, MD, PhD, Department of Pediatrics, MacLean Center for Clinical Medical Ethics, University of Chicago, 5841 S Maryland Ave, Chicago IL 60637. E-mail: wlm1{at}uchicago.edu
The author has indicated he has no financial relationships relevant to this article to disclose.
|
REFERENCE |
|---|
 TOP REFERENCE |
|---|
- Peerzada JM, Schollin J, Håkansson S. Delivery room decision-making for extremely preterm infants in Sweden.
Pediatrics. 2006;117
:1988
–1995
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
