Ethical Dilemmas in Neonatal Care at the Limit of Viability

Abstract

Advances in neonatal care have pushed the limit of viability to incrementally lower gestations over the last decades. However, surviving extremely premature neonates are prone to long-term neurodevelopmental handicaps. This makes ethics a crucial dimension of periviable birth management. At 22 weeks, survival ranges from 1 to 15%, and profound disabilities in survivors are common. Consequently, there is no beneficence-based obligation to offer any aggressive perinatal management. At 23 weeks, survival ranges from 8 to 54%, and survival without severe handicap ranges from 7 to 23%. If fetal indication for cesarean delivery appears, the procedure may be offered when neonatal resuscitation is planned. At a gestational age ≥24 weeks, up to 51% neonates are expected to survive the neonatal period. Survival without profound neurologic disability ranges from 12 to 38%. Beneficence-based obligation to intervene is reasonable at these gestations. Nevertheless, autonomy of parents should also be respected, and parental consent should be sought prior to any intervention. Optimal counselling of parents involves harmonized cooperation of obstetric and neonatal care providers. Every fetus/neonate and every pregnant woman are different and have the right to be considered individually when treatment decisions are being made.

Nitrate in drinking water and pregnancy outcomes: A narrative review of epidemiological evidence and proposed biological mechanisms

“…The WHO tightly prescribes the defintions of PTB with the following categories: extremely preterm (less than 28 weeks); very preterm (28 to less than 32 weeks); and moderate to late preterm (32 to less than 37 weeks) [54]. While the lower gestational age threshold at which therapeutic (rather than palliative) neonatal care is offered varies across jurisdictions, most births <23 weeks are regarded as non-viable due to ethical, technical and physiological constraints at these extremes of birthweight (typically <500 g) and organ immaturity [59]. Future studies should adhere to commonly defined categories and naming conventions for PTB to enhance comparability.…”

Special Issue: Intensive Care for Critically Ill Neonates: Clinical Diagnosis and Treatment

“…There are certainly many of them, but to mention only three: How should we approach extremely premature infants at the limit of viability? In addition, when and how to decide when faced with the end of life of critically ill infants and, lastly, the issue of interventional clinical trials with critically ill infants [23][24][25]. Space limitations do not allow these issues to be treated in detail, but they certainly should be discussed within teams.…”