No abstract

We will examine several ethical considerations in the resuscitation of infants born at the margin of gestational viability in analyzing a case of preterm labor. More specifically, we will discuss the obligations of physicians in characterizing expected outcomes, both mortality and longterm morbidity, for extremely premature infants and how potential adverse outcomes should be framed-as complications of prematurity itself or as iatrogenic complications of care. We will also explore how the concept of a "trial of therapy" can support parents and neonatologists in decision making concerning withholding or withdrawing care for periviable infants. CaseDr. Mattingly met Miriam and Thomas when Miriam arrived a week ago in preterm labor, which was successfully stopped with tocolytics. Suspecting that Miriam would again have preterm labor, that the baby would be born extremely prematurely, needing NICU care to survive, and that the baby's prognosis might be poor, he has met with the couple over the last few days to determine which NICU interventions they might want.Miriam and Thomas wanted to know what sort of life their baby would have if they committed to doing everything NICU staff could to help him live. Dr. Mattingly explained that there had been significant advancements in the care of premature infants, but that the future of their child was still uncertain. He discussed various risks premature infants might face including breathing difficulty related to immature lungs, which might necessitate a breathing tube and could result in long-term problems, and injury to the developing brain and eyes that could result in lifelong sensory, cognitive, and motor impairments. He discussed surgery their child might need for his heart, and the risk of intestinal injury and infections while in the NICU. He told the couple that their child might die early or late in his NICU course. "Of course," Dr. Mattingly had said, "decisions about when and how much to intervene are up to you." He also explained the option of comfort care, which would focus on keeping the infant comfortable after birth, without attempts at resuscitation; in this case, the focus would not be on survival, but on making sure the time he had would be as peaceful as possible.