Limits of viability: dilemmas, decisions, and decision makers.

Decision-making about treatments for neonates at the threshold of viability is a complex process that must involve physicians, other health-care professionals, and families. Parents and families bring personal, ideological, cultural, and religious beliefs into their relationship with health-care professionals that have the potential to conflict with professional perceptions of good medical care and the interests of the patient. Neonatologists often find themselves criticized for overtreatment of these extremely premature infants. Yet, from the perspective of the health-care provider, perceived obligations in the face of an uncertain outcome, parental wishes as well as perceptions about legal mandates are often cited as the reasons for the provision of such extraordinary care. Recent reductions in perinatal mortality for premature infants born at the cusp of viability, in conjunction with emerging data on the substantial short- and long-term morbidities experienced by infants born between 23-25 weeks' gestation, have engendered a serious debate about professional and parental obligations in the face of extreme uncertainty. The fundamental questions are who ought to be permitted, under the present circumstances of rapidly evolving technologies and innovative therapies, to decide the best interests of the child, and how to achieve consensus regarding treatment goals when the outcome is uncertain and there are divergent views with regard to the infant's best interests. As survival for these infants increases and morbidity remains a significant likelihood, physicians must be cognizant of the power of their technology to impose undesired burdens on these infants. A reasonable, and reasoned, approach for these vulnerable infants requires collaborative decision making incorporating professional recommendations, with an openness, trust and willingness to work with parents to ascertain the best interests of an individual infant. Understanding of and respect for the differing views of the moral obligations of perinatal specialists and families can aid neonatal professionals in resolving interdisciplinary and physician-family conflicts as well as facilitating resolution of neonatal ethical dilemmas.

Development of a palliative education assessment tool for medical student education.

Studies assessing palliative care education in U.S. medical schools reveal that little attention is paid to this topic. Although core competencies have been defined, few schools have implemented effective means to incorporate formal palliative care education into undergraduate curricula. To promote reform, each school needs to conduct a thorough assessment to identify palliative care content throughout the four-year curriculum. The authors developed an innovative assessment instrument to facilitate curricular mapping of palliative care education. The Palliative Education Assessment Tool (PEAT) comprises seven palliative care domains: palliative medicine, pain, neuropsychologic symptoms, other symptoms, ethics and the law, patient/family/nonclinical caregiver perspectives on end-of-life care, and clinical communication skills. Each domain details specific curricular objectives of knowledge, skills, and attitudes. Designed as a flexible self-assessment tool, PEAT helps determine the existence of palliative care education, which usually is found in various formats throughout a medical school's curriculum and thus sometimes "hidden." PEAT enables educators to describe a specific, multidimensional aspect of the curriculum and use the information for strategic planning, educational reform, and evaluation. The curricular reform implications of such an instrument are broader than palliative care assessment. A modified version of PEAT can be used to assess systematically other topics that are taught in various formats in the curriculum and to develop collaborative approaches to fulfilling the educational objectives of those topics.

Physician participation in capital punishment: a question of professional integrity.

The death penalty is legal in 36 states, and physicians are expected to attend and participate in executions. Yet, every major medical and health-related organization opposes physician participation in capital punishment. This article argues that it is unethical for physicians within the role as medical professional to participate in capital punishment, and that such acts erode the foundation of trust at the heart of medical practice. We believe that it is important for professional groups and medical societies to impose sanctions on members who choose to participate in executions.

Planning for children whose parents are dying of HIV/AIDS. American Academy of Pediatrics. Committee on Pediatric AIDS, 1998-1999.

Although the character of acquired immunodeficiency syndrome is changing into a chronic illness, it is estimated that by the end of this century, 80 000 children and adolescents in the United States will be orphaned by parental death caused by human immunodeficiency virus infection. Plans for these children need to be made to ensure not only a stable, consistent environment that provides love and nurturing, but also the medical and social interventions necessary to cope with the tragic loss. Pediatricians should become aware of local laws and community resources and initiate discussion early in the course of parental illness to facilitate planning for the future care and custody of the children. States need to adopt laws and regulations that provide flexible approaches to guardianship and placement of children orphaned by acquired immunodeficiency syndrome.

The physician's moral obligations to the pregnant woman, the fetus, and the child.

The moral obligations and ethical duties of health care professionals responsible for the care of a pregnant woman, a fetus, and a child are complex and evolve with gestation and birth. Well-intentioned physicians and others concerned with the interests of pregnant women and their fetuses may disagree about the moral status of the fetus and ethical duties owed to both the woman and fetus. This article lays out a framework for thinking about these issues from several perspectives.

Factors affecting humidity of inspired gas in a neonatal lung model.

OBJECTIVE: The American National Standards Institute recommends an absolute humidity of > or = 30 mg/L of inspired gas in patients receiving mechanical ventilation. This study was designed to assess the absolute humidity of inspired gas in relation to humidifier settings and environmental conditions in a test lung. STUDY DESIGN: Measurements were obtained at the endotracheal tube manifold of an artificial lung in an isolette or radiant warmer with use of a nonheated wired system and two different ventilator circuit lengths. Temperature and relative humidity were measured at three environmental temperatures and various humidifier settings. RESULTS: We achieved adequate absolute humidity levels only at near maximum humidifier settings. When the artificial lung was placed in an isolette with a standard circuit length inside the isolette, adequate absolute humidity was never reached at an environmental temperature of 30 degrees C. Increasing the length of the ventilator circuit situated inside the isolette or using a radiant warmer improved absolute humidity compared with that obtained with use of a standard circuit length. CONCLUSION: Recommended absolute humidity levels may not be reached at the manifold even at high humidifier settings. Thus actual measurements of relative humidity and temperature at the endotracheal tube site are necessary to optimize humidity according to American National Standards Institute recommendations.

The treatment of non-HIV-related conditions in newborns at risk for HIV: a survey of neonatologists.

OBJECTIVES: The purpose of this study was to examine attitudes of neonatologists about treatment of conditions unrelated to the human immunodeficiency virus (HIV) for critically ill newborns at risk for HIV. METHODS: Questionnaires were mailed to the 1508 members of the Section on Perinatal Medicine of the American Academy of Pediatrics; 63% completed the survey (n = 951). The survey included structured questions about treatment for hypothetical cases and open-ended questions eliciting reasons for decisions. RESULTS: Differences in recommendations for treatment by both maternal and infant HIV status were substantial and statistically reliable. For example, 98% of respondents recommended life-saving cardiac surgery for a neonate with no risk for HIV, but only 93% recommended such surgery for a child of an HIV-positive mother; only 50% recommended the same surgery for a newborn known to be infected. The corresponding figures for chronic dialysis were 91%, 61%, and 26%. Most expected diminished quality of life for both infected and uninfected children of HIV-positive mothers. CONCLUSIONS: Recommendations about life-sustaining treatment for non-HIV-related conditions varied by HIV status. These data on physician attitudes raise the possibility that infants labeled as HIV positive, whether infected or not, may suffer discrimination.

Caring for gravely ill children.

BACKGROUND: Much has been written about the care of the hopelessly ill adult, but there is little guidance for pediatric health care professionals in the management of children who are critically or terminally ill. METHODS: Through a 3-day meeting in Tarrytown, NY, attended by a group of pediatricians and others directly involved in these issues, a principled approach was developed for the treatment of, and health care decision-making for, children who are gravely ill. RESULTS: The group agreed that the needs and interests of the child must be the central focus of any treatment plan and that the child should be involved to as great extent possible, consistent with developmental maturity, in the decision-making process. Quality of future life should be viewed as being relevant in all decisions. Parents are believed to be the natural guardians of children and ought to have great latitude in making decisions for them. However, parental discretion is not absolute and professionals must maintain an independent obligation to protect the child's interests. CONCLUSIONS: Decision-making should be collaborative among patient, parents, and professionals. When conflict arises, consultation and ethics committees may assist in resolution. When cure or restoration of function is no longer possible, or reasonable, promotion of comfort becomes the primary goal of management. Optimal use of pain medication and compassionate concern for the physical, psychological, and spiritual well-being of the child and family should be the primary focus of the professionals caring for the dying child.

Branched-chain amino acids and respiratory pattern and function in the neonate.

Branched-chain amino acids (BCAA) increase respiratory drive in adults and improve diaphragmatic function in vitro. This study was designed to examine the effects of increased amounts of BCAA in intravenous nutrition on respiratory function and episodes of apnea in premature infants. An open cross-over design was used, with each patient serving as his own control. Ten premature infants, 34 weeks' gestation or less, were observed. Mean gestational age was 30.6 weeks (range 27 to 33 weeks), mean birth weight was 1487 gm +/- 300 gm, and the age at study was 5 to 33 days. For three consecutive 24-hour periods, the infants received routine total parenteral nutrition (TPN) (30% BCAA), enriched TPN (53% BCAA), and routine TPN (30% BCAA). Pulmonary function, apnea frequency, blood chemistry, and amino acid pattern were measured. Enriched TPN resulted in significant increases in all infants in dynamic compliance, from 2.41 +/- 1.07 to 4.55 +/- 2.78 ml/cm H2O (p < 0.025), and in specific dynamic compliance from 1.67 +/- 0.64 to 3.1 +/- 1.51 ml/cm H2O/kg (p < 0.005). Total pulmonary resistance decreased from 40.3 +/- 23.3 to 24.0 +/- 20.9 cm H2O/L/sec (p < 0.05), and peak-to-peak pressure decreased from 5.96 +/- 0.93 to 4.09 +/- 2.34 cm H2O (p < 0.05). All values returned to baseline with resumption of the routine TPN. In four infants with significant apnea, the average number of episodes of apnea decreased from 58 during standard TPN to 11 with the enriched solution infusion during matched 12-hour periods (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)