Viability and thresholds for treatment of extremely preterm infants: survey of UK neonatal professionals.

BACKGROUND: Decisions about treatments for extremely preterm infants (EPIs) born in the 'grey zone' of viability can be ethically complex. This 2020 survey aimed to determine views of UK neonatal staff about thresholds for treatment of EPIs given a recently revised national Framework for Practice from the British Association of Perinatal Medicine. METHODS: The online survey requested participants indicate the lowest gestation at which they would be willing to offer active treatment and the highest gestation at which they would withhold active treatment of an EPI at parental request (their lower and upper thresholds). Relative risks were used to compare respondents' views based on profession and neonatal unit designation. Further questions explored respondents' conceptual understanding of viability. RESULTS: 336 respondents included 167 consultants, 127 registrars/fellows and 42 advanced neonatal nurse practitioners (ANNPs). Respondents reported a median grey zone for neonatal resuscitation between 22+1 and 24+0 weeks' gestation. Registrars/fellows were more likely to select a lower threshold at 22+0 weeks compared with consultants (Relative Risk (RR)=1.37 (95% CI 1.07 to 1.74)) and ANNPs (RR=2.68 (95% CI 1.42 to 5.06)). Those working in neonatal intensive care units compared with other units were also more likely to offer active treatment at 22+0 weeks (RR=1.86 (95% CI 1.18 to 2.94)). Most participants understood a fetus/newborn to be 'viable' if it was possible to survive, regardless of disability, with medical interventions accessible to the treating team. CONCLUSION: Compared with previous studies, we found a shift in the reported lower threshold for resuscitation in the UK, with greater acceptance of active treatment for infants <23 weeks' gestation.

Regional ethics of surgeon resuscitation for organ transplantation after lethal injury.

BACKGROUND: Trauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of deciding whether, when, and how to resuscitate a patient who will not directly benefit from it. As there are no established guidelines to follow, we aimed to describe resuscitation practices for organ transplantation; we hypothesized that resuscitation practices vary regionally. METHOD: Over a 3-month period, we surveyed trauma surgeons practicing in Levels I and II trauma centers within a single state using an instrument to measure resuscitation attitudes and practices for organ preservation. Descriptive statistics were calculated for practice patterns. RESULTS: The survey response rate was 51% (31/60). Many (81%) had experience with resuscitations where the primary goal was to preserve potential for organ transplantation. Many (90%) said they encountered this dilemma at least monthly. All respondents were willing to intubate; most were willing to start vasopressors (94%) and to transfuse blood (84%) (range, 1 unit to >10 units). Of respondents, 29% would resuscitate for ≥24 hours, and 6% would perform a resuscitative thoracotomy. Respect for patients' dying process and future organ quality were the factors most frequently considered very important or important when deciding to stop or forgo resuscitation, followed closely by concerns about excessive resource use. CONCLUSION: Trauma surgeons' regional resuscitation practices vary widely for this patient population. This variation implies a lack of professional consensus regarding initiation and extent of resuscitations in this setting. These data suggest this is a common clinical challenge, which would benefit from further study to determine national variability, areas of equipoise, and features amenable to practice guidelines.

Rally the Troops: Interdisciplinary Response to a Veteran Who Attempted Suicide on a Veterans Affairs Hospice Unit.

Requests for hastened death and suicidal ideation may be more prevalent in populations approaching the end of life. Often these wishes and thoughts occur in the context of concurrent psychiatric disorders and emotional suffering. We discuss the case of a veteran with terminal lung cancer and comorbid psychiatric illness who attempted suicide while under the care of an inpatient interdisciplinary hospice team and describe our team's response to this suicide attempt. We review risk factors for suicidality at end of life, challenges of distinguishing desire for hastened death from suicidality, and the ethics of resuscitation of a dying patient after a suicide attempt.

Is treatment futile for an extremely premature infant with giant omphalocele?

Doctors have no ethical obligation to provide futile treatment. This has been true since the time of Hippocrates who warned physicians not to treat patients who were "overmastered by their disease." This principle remains valid today but, as the Society for Critical Care Medicine notes, it is difficult to identify treatment as absolutely futile in all but a few clinical situations. Far more common, they note, are "treatments that are extremely unlikely to be beneficial, are extremely costly, or are of uncertain benefit." These, they say, "may be considered inappropriate and hence inadvisable, but should not be labeled futile." So what should doctors do when they have a case that seems close to the futility threshold but does not, perhaps, quite cross it? In such cases, is it appropriate to make unilateral decisions to withhold life-sustaining treatment even if the family objects? Or should treatment be provided knowing that it might cause pain and suffering to an infant with no likelihood of benefit? To address these questions, we present a case of an extremely premature infant with a giant omphalocele and ask 3 neonatologists, Dr Dalia Feltman of Evanston Hospital, Dr Theophil Stokes of the Walter Reed Medical Center, and Dr Jennifer Kett, a neonatologist and fellow in bioethics at Seattle Children's Hospital, to comment.

Rights of the newborn and end-of-life decisions.

Advances in perinatal medicine have dramatically improved neonatal survival. End-of-life decision making for newborns with adverse prognosis is an ethical challenge and the ethical issues are controversial. The newborn is a person with specific rights which he cannot claim, due to his physical and mental immaturity. These rights impose to the society obligations and responsibilities, which health professionals and institutions of all countries must enforce. Every newborn has the right to life with dignity. Providing compassionate family-centered end-of-life care to infants and their families in the NICU should be a mandatory component of an optimally neonatal palliative care.

Do-not-resuscitate decisions in a large tertiary hospital: differences between wards and results of a hospital-wide intervention.

BACKGROUND: Despite the advent of palliative care, the quality of dying in the hospital remains poor. Differences in quality of end-of-life practice between hospital wards are well known in clinical practice but rarely have been investigated. METHODS: A prospective observation of do-not-resuscitate (DNR) decisions was conducted in patients dying in a Belgian university hospital before (115 patients) and after (113 patients) a hospital-wide intervention consisting in informing hospital staff on the law on Patient's Rights and the introduction of a new DNR form.The new DNR form puts more emphasis on the motivation of the DNR decision and on the description of the participants in the decision-making process. RESULTS: The completion of DNR forms improved after the intervention: physicians better documented who participated in DNR decisions (for participation of family: 63% after the intervention vs. 44% before the intervention, p = 0.022, for nurses: 27% vs. 14%, p = 0.047) and the motivation for these decisions (59% vs. 32%, p = 0.001). However, there was no difference in referral to the intensive care unit (ICU) at the end of life (in 40% of patients after and 37% before the intervention). Furthermore, the number of patients dying without DNR form on the wards was similar (13% and 8%). Surgical patients and patients with non-malignant diseases were more often referred to ICU at the end of life (71% in surgical vs. 35% in medical patients, p < 0.001 and 49% in patients with non-malignant diseases vs. 23% in patients with malignancy, p < 0.001). Moreover, surgical patients less frequently received a DNR order (56% in surgical vs. 92% in medical patients, p = 0.007). CONCLUSIONS: The introduction of a new DNR form and informing hospital staff on patients' right to information did not improve physicians' end-of-life practice.Transition from life-prolonging treatment to a more palliative approach was less anticipated in surgical patients and patients with non-malignant diseases.

[Save life--allow death. Collation of emergency missions for terminally ill patients]. / Leben retten--sterben zulassen. Erfassung notärztlicher Einsätze bei Patienten in der Terminalphase.

BACKGROUND: Emergency missions can also be necessary for patients in the terminal phase of a progressive incurable disease. The emergency physician, accustomed to acting under strict procedures and whose training focuses on the restoration and stabilization of acutely threatened vital functions, can face severe difficulties when treating incurably ill patients in the terminal phase. This study investigates the number of such cases, patient symptoms and the events occurring during life-threatening emergencies of terminally ill patients. METHOD: All cases of emergency events involving terminally ill patients were analyzed prospectively. In addition to the standardized protocol (following DIVI/Mind 2) an enquiry sheet was used, which contained an 8-item checklist specifically for terminally ill patients, to be filled out by the responding physician. RESULTS: The total number of patients in the terminal phase identified by the emergency physician was 55 (0.72% of total cases) and of these patients 30 (55%) were tumor patients. The most frequent complaint observed was dyspnea (30 patients, 55%), followed by relatives of the patients experiencing the stress of caring for a terminally ill person (19 patients, 35%). The leading symptom of 6 patients (11%) was pain. Only 17 cases (30.9%) required transport of the patient to hospital for further treatment. CONCLUSION: Every emergency physician can be confronted with an emergency involving a patient with a progressive incurable disease. The condition of each patient must be assessed for each medical decision. Not only medical, but also psychosocial, ethical and legal aspects have to be considered.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Première partie : pronostic des naissances avant 28 semaines, identification d'une zone grise.

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

[Very premature births: Dilemmas and management. Second part: Ethical aspects and recommendations]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Seconde partie : enjeux éthiques, principes de prise en charge et recommandations.

In the first part of this work, the outcome following very premature birth was assessed. This enabled a gray zone to be defined, with inherent major prognostic uncertainty. In France today, the gray zone corresponds to deliveries occurring at 24 and 25 weeks of postmenstrual age. The management of births occurring below and above the gray zone was described. Withholding intensive care at birth for babies born below or within the gray zone does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. Given the high level of uncertainty, making good decisions within the gray zone is problematic. Decisions should be based on the infant's best interests. Decisions should be reached with the parents, who are entitled to receive clear and comprehensive information. Possible decisions to withhold intensive care should be made following the procedures described in the French law of April 2005. Guidelines, based on gestational age and the other prognostic elements, are proposed to the parents before birth. They are applied in an individualized fashion, in order to take into account the individual features of each case. At 25 weeks, resuscitation and/or full intensive care are usually proposed, unless unfavorable factors, such as severe growth restriction, are associated. A senior neonatologist will attend the delivery and will make decisions based on both the baby's condition at birth and the parents' wishes. At 24 weeks, in the absence of unfavorable associated factors, the parents' wishes should be followed in deciding between initiating full intensive care or palliative care. Below 24 weeks, palliative care is the only option to be offered in France at the present time.

Límite de viabilidad en prematuros extremos: aspectos éticos / Survival deadline in premature infant: ethical issues

El concepto "límite de la viabilidad" no está claramente definido, originando dilemas éticos, esta "zona gris gestacional" la sitúan los expertos entre las 23 y 25 semanas. Reanimar y someter a tratamiento intensivo a prematuros tan inmaduros con altas tasas de mortalidad y secuelas graves, implica ofrecer un óptimo manejo perinatológico y neonatal con fuerte sentido humanitario, y además involucrar los aspectos médicos, sociales, culturales, éticos, legales, espirituales y económicos; adquiriendo así cada vida humana un valor único. Aplicando los principios éticos de autonomía, beneficencia, no maleficencia y justicia es posible tomar las decisiones más beneficiosas o del "mejor interés" para el niño. Ello puede incluir reanimación, tratamiento intensivo o limitación de esfuerzo terapéutico, evitar el encarnizamiento y proveer cuidados paliativos. Existen pautas clínicas propuestas basadas en edad gestacional, evidencia científica y opinión de los padres. Los prematuros al límite de la viabilidad plantean grandes desafíos a la medicina, a la sociedad y a la ética, por lo cual deben tomarse decisiones compartidas entre el equipo de salud y los padres o instituciones que representen los mejores intereses del niño.

"Survival deadline" is a not well defined concern, leading to ethical issues. Extremely immature infants, born at 23 -25 weeks of gestational age (WGA) are under discussion. Reanimation and Intensive Care on these so immature infants, having either high mortality or morbidity rates leading to severe sequels, must have an optimal perinatal and neonatal approach, involving humanitarian, social, ethic, legal, cultural, spiritual and economic features. Human life, in this way, is certainly worth. Best decisions on therapeutics on these infants, must follow certain principles of autonomy, beneficence, "damage avoidance" and justice. In this way, either proportional treatment or palliative care can be addressed. Decisions must involve not only health providers but parents as well.

Ethical issues in caring for people with carotid artery rupture.

Nurses working in the head and neck oncology field will be conscious of the possible risk of carotid artery rupture in their patients. This complication occurs swiftly and the patient requires the nurse to rapidly change focus from acute care and cure to palliative care and comfort. Prior decisions need to be made as to whether or not active resuscitation is to be undertaken. In this final article, the ethical issues surrounding this decision-making process are discussed, including patient autonomy, advocacy, beneficence and justice. The facts as they relate to each individual patient should be discussed truthfully and openly with them and their significant others. Each person should be assisted to come to his own decision, following discussion of the prognosis and risks that are pertinent to that individual. Respect for the autonomy of patients should be a guiding principle governing the conduct of decisions.

Breaking through the silence: illegality of performing resuscitation procedures on the "newly-dead".

Israeli author Daniel Sperling brings to a light a disturbing practice that is taking place in some teaching hospitals throughout the world--the practice of resuscitation procedures on newly dead patients without the consent of the next-of-kin. Mr. Sperling examines some of the policies and procedures in place to prevent such practice and also looks at the ethical principles that should guide such procedures. The paper also reviews the general issue of consent in the context of medical decision-making and discusses potential legal claims that might be available to persons who have not been consulted or informed before such procedures are performed. The evolving jurisprudence surrounding the treatment of the newly dead is analyzed and Mr. Sperling concludes by suggesting ways to improve upon the procedures currently in place at some teaching facilities.

Aspectos bioéticos da reanimação neonatal: quando não iniciar x quando interromper / Bioethical Aspects of Neonatal Resuscitation - When Not to Initiate vs. When to Stop

Não iniciar ou interromper a reanimação para os recém-nascidos pré-termos extremos, para os recém-nascidos que apresentam graves malformações é um dos maiores dilemas para o neonatologista. A Bioética não faz distinção entre não iniciar e interromper as manobras de reanimação (interromper é moralmente o mesmo que não iniciar). Eticamente é mais aceitável retirar a terapia do que não iniciá-la, pois se a terapia não for iniciada, o paciente nunca se beneficiará dela. Para os recém-nascidos pré-termos extremos, a decisão de não iniciar a reanimação na sala de parto deve ser baseada no conhecimento do limite de viabilidade do serviço, assim como o grau de seqüelas presumíveis. Esforços devem ser continuamente buscados no sentido de melhorar a sobrevivência e, sobretudo, a qualidade de vida dos recém-nascidos pré-termos extremos. O envolvimento dos pais é importante para evitar conflitos na reanimação. A extensão contínua do suporte vai depender das condições e prognóstico do bebê, que devem ser discutidas de forma clara e exaustiva com a família e a decisão final deve ser obtida em conjunto.

Action v inaction: a case history in ethics.

The motives behind the author's decision to resuscitate a patient are examined. This is prompted by the realisation that he ignored the man's apparent wish not to be saved for fear of criticism from both relatives and colleagues. The way in which decisions are made when the interests of the doctor and the patient clash are briefly explored. Self interest may play a more significant role than is commonly accepted.