The ethical dilemma of when and when not to resuscitate a severely premature infant at birth has plagued the health care profession for decades. The dual phenomena of increased medical litigation and advances in the care of sick babies have, unfortunately, blurred rather than clarified this problem for the provider faced with a critically ill neonate. On May 15, 2006 the American Heart Association/American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee provided some guidance in this area with its 5th Edition of the Textbook of Neonatal Resuscitation.
The textbook’s guidelines have been used since the 1980s by practitioners dealing with the tragic situation of an infant who needs resuscitation at birth. The latest edition of the guidelines provides several critical updates derived from evidence based medicine. Among these updates are suggestions as to when it may be considered reasonable to withhold resuscitative efforts.
It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been opportunity for parental agreement.
The guidelines cite severe prematurity, i.e. gestational age of less than 23 weeks, as an example of such a condition. Conversely, the guidelines identify gestational age of 25 weeks or greater as a situation where resuscitation is almost always indicated. In the remainder of situations, where there is an uncertain prognosis with a relatively high risk of death or severe impairment, and which presumably includes gestational ages of 23 and 24 weeks, the guidelines suggest that parental desires concerning the initiation of resuscitation should be supported. The committee stresses that morbidity and mortality of newborns varies according to region and availability of resources and that the guidelines should be interpreted according to current regional outcomes.
Unfortunately, the uncommon medical calamities which strike during the prenatal and perinatal period, and the ethical dilemmas they generate, do not show any reassuring signs of abating. The latest edition of the Textbook of Neonatal Resuscitation prepares the practitioner with general suggestions of how to respond in certain of these situations. The practitioner should not use these guidelines as a substitute for personal clinical judgment based on the circumstances at hand and meaningful consultation with the parent.
The Health Care Team at Sheehy, Serpe & Ware, P.C. is committed to providing high quality services across the broad spectrum of legal issues facing health care providers. The firm, most notably, John Serpe, has developed special expertise in dealing with the legal issues surrounding obstetrical complications, including care of very premature infants.