Published online June 1, 2007
PEDIATRICS Vol. 119 No. 6 June 2007, pp. 1267 (doi:10.1542/peds.2007-0748)

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LETTER TO THE EDITOR

Noninitiation or Withdrawal of Intensive Care for High-Risk Newborns

Hugh Whittall, BA
Nuffield Council on Bioethics
London WC1B 3JS, United Kingdom

To the Editor.—

The recently published policy statement of the American Academy of Pediatrics Committee on Fetus and Newborn tackles the difficult decisions that parents and health care professionals have to make about the treatment and care of extremely premature or very ill infants.¹ Being prepared simultaneously was a report of the Nuffield Council on Bioethics titled "Critical Care Decisions in Fetal and Neonatal Medicine: Ethical Issues,"² which was published in November 2006. The council's recommendations on withdrawing and withholding treatment have much in common with those of the American Academy of Pediatrics committee. Both bodies concluded that it is not always right to put an infant through the stress and pain of invasive treatment if he or she is unlikely to improve and death is inevitable, and both recommended that every effort should be made to secure consensus about treatment between the parents and the health care team.

The Nuffield Council on Bioethics also went on to propose, as the basis for professional discussion, week-by-week guidelines to assist decisions on when to initiate intensive care for extremely premature infants. The aim of the guidelines was to help parents and doctors make more informed decisions in a way that would be more open and consistent. They are not intended to be rigid rules, and each case will always need to be considered individually. The guidelines should be reviewed regularly to reflect any changes in outcome for premature infants.

The proposed guidelines include the following:

• Infants born before 22 weeks’ gestation should only be given intensive care as part of a research study.
  
• Between 22 weeks, 0 days, and 22 weeks, 6 days, standard practice should be to not resuscitate the infant. Resuscitation should only be attempted and intensive care offered if the parents request resuscitation, and reiterate this request, after thorough discussion with an experienced pediatrician about the risks and long-term outcomes and if the clinicians agree that it is in the infant's best interests.
  
• Between 23 weeks, 0 days, and 23 weeks, 6 days, it is very difficult to predict the future outcome for an individual infant. Precedence should be given to the wishes of the parents. However, when the condition of the infant indicates that he or she will not survive for long, clinicians should not be obliged to proceed with treatment wholly contrary to their clinical judgment, if they judge that treatment would be futile.
  
• Between 24 weeks, 0 days, and 24 weeks, 6 days, normal practice should be to provide full invasive intensive care and support from birth and to admit the infant to a NICU unless the parents and clinicians are agreed that the infant's condition is such that it is not in his or her best interests to start intensive care.
  
• At 25 weeks’ gestation, the relatively high rate of survival and the relatively low risk of severe disability are such that intensive care should be initiated and the infant admitted to a NICU unless he or she is known to be affected by some severe abnormality that is incompatible with any significant period of survival.
  

Professional bodies in the United Kingdom are currently considering the council's recommendations. For additional information or to download a copy of the report, see www.nuffieldbioethics.org.

REFERENCES

1. American Academy of Pediatrics, Committee on Fetus and Newborn. Noninitiation or withdrawal of intensive care for high-risk newborns. Pediatrics. 2007;119 :401 –403[Abstract/Free Full Text]
2. Nuffield Council on Bioethics. Critical care decisions in fetal and neonatal medicine: ethical issues. Available at: www.nuffieldbioethics.org/fileLibrary/pdf/CCD_web_version_8_November.pdf. Accessed April 11, 2007

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Whittall, H. Search for Related Content PubMed Articles by Whittall, H. Related Collections Emergency Medicine Social Bookmarking                         What's this?