The Initiation or Withdrawal of Treatment for High-Risk Newborns

Abstract

As medical technology has advanced, outcomes for high-risk newborns have greatly improved. With advanced technology such as assisted ventilation, it is now possible to keep some terminal, severely ill, or extremely premature infants alive for long periods of time. The result of such treatment is that dying may be prolonged or that the infant will survive with profound neurologic or other debilitating problems.¹ The medical treatment of infants should be based on what is in their best interest. However, because the infant's "best interest" is not always clear, parents and health care givers are often faced with difficult treatment decisions when faced with the situation of a severely ill, extremely premature, or terminally ill infant.

The Treatment Dilemma

If intensive treatment uniformly resulted in saving infants at risk, it would be the obvious choice for all severely ill infants. This outcome, of course, does not always occur. If intensive treatment is not provided to very ill infants, most of them will die, but some may survive with significant neurodevelopmental disability, in part because specific treatments were withheld. The following dilemma therefore exists: intensive treatment of all severely ill infants sometimes results in prolongation of dying or occasionally iatrogenic illness; nonintensive treatment results in increased mortality and unnecessary morbidity. The overall outcomes of either approach are disappointing.

Strategy for Care

A reasonably acceptable approach to this dilemma is an individualized prognostic strategy.^2,3 In this setting, care is provided for the individual infant at the appropriate level based on the expected outcome at the time care is initiated.