Ethics in the Neonatal Intensive Care Unit

Chapter 105 Ethics in the Neonatal Intensive Care Unit


The Limits of Viability



Helen M. Towers, MD




Medical Knowledge and Patient Care


The limits of viability encompass three different groups of infants in the neonatal intensive care unit (NICU). Some infants are born with evidence of congenital anomalies that are incompatible with life. These infants are generally identified in the antenatal period by ultrasound or chromosome analysis or by physical examination very shortly after delivery. In these unfortunate cases, there may be no medical interventions available to correct the underlying problem. No ethical dilemma regarding the provision of care exists, and the infants are offered comfort care. The families are generally provided with social support, and palliative support services as available. Other infants reach the limit of medical viability by virtue of congenital or acquired illnesses that lead to death despite extensive resuscitation efforts. These cases also generally do not generate ethical dilemmas, because all available resources have been used. The third group of infants consists of infants born at the gestational limit of viability, which is generally accepted as that time period between 22 and 25 completed weeks of gestation. Infants with birth weight less than 700 g make up approximately 5% of NICU admissions but account for almost one third of the deaths in the NICU. Because of the uncertainty of outcome at this gestational age, the decisions regarding the provision of medical care to these infants are laden with medical, social, and bioethical implications and remain some of the most difficult decisions that neonatal practitioners and the families of these tiny infants face together. The following areas are helpful in gathering the information required to make an informed and ethical decision in these situations.



Gestational Age


In vitro fertilization is clearly associated with an accurate date of conception. The accuracy of gestational dating in spontaneous pregnancies is greatest in the first trimester, approaching ±5 days, and has been greatly enhanced by early prenatal care and ultrasound evaluation. Gestational age based on a composite of menstrual history, early pregnancy examination, laboratory data, and ultrasound examination has been seen to predict survival better than estimated fetal weight. Fetal weight estimates may vary as much as 15% to 20%. Postnatal examination generally underestimates gestational age in infants less than 28 weeks.



Birth Weight2


Most infants with birth weight above 800 grams who receive optimal neonatal intensive care survive. There are few survivors with birth weight less than 400 grams. In the past two decades improvements in neonatal care have led to greater numbers of infants with birth weights ranging from 450 to 700 grams surviving at least the first day of life, but the success rate has reached a plateau in the last 10 years. Interestingly, one report suggests that if the infant survives until the fourth day of life, the likelihood of survival to discharge approaches 80% for this group of extremely low-birth-weight (ELBW) infants and was greater than 50% for those infants weighing less than 600 grams. Therefore most tiny infants who die in the NICU do so within the first 72 hours of life. This observation may counteract arguments that scarce health-care dollars invested in NICU care are spent on infants who do not survive.



Medical Outcomes


The two questions most commonly proposed to physicians during antenatal counseling at the gestational limit of viability are generally “Will my baby survive?” and “Will my baby survive neurologically intact?” The outcome figures from national and local sources should be used when counseling because these outcome data may differ significantly. Reported data suggest highest survival levels of approximately 25% for infants born at 23 completed weeks, 60% at 24 completed weeks, and 70% at 25 weeks. Data from individual units may vary considerably, and the prediction for intact survival for any individual infant is impossible. Reported outcomes on infants born under 26 weeks completed gestation reveal a high prevalence of neurologic and developmental disabilities, including cerebral palsy, deafness, blindness, and mental retardation. One study of surviving infants less than 26 weeks gestation reported 46% of infants had moderate or severe disability at 6 years of age, and 34% had mild disability. Surviving male infants were seen to have an increased risk for disability.



Condition at Birth3,4,7


Because of the nonuniformity in application of resuscitation measures to infants at the threshold of viability, there are insufficient data indicating that the condition at birth is predictive of outcome. Scores of illness severity have been developed to attempt to predict survival or nonsurvival of infants admitted to intensive care units. These scores include the APACHE, PRISM, and SNAP scoring systems and are based on physiologic parameters that include respiratory support, heart rate, blood pressure, oxygenation status, and other measures. The predictive power for nonsurvival using these score systems is rarely greater than 50%. Clinical experience and intuition of the health-care providers are also inaccurate predictors of nonsurvival.

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Ethics in the Neonatal Intensive Care Unit

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