Is Treatment Futile for an Extremely Premature Infant With Giant Omphalocele?

Abstract

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.

Medical and ethical challenges in the case of a prenatally undiagnosed massive congenital brain tumor

“…As outlined by Wilkinson et al, 12 'lethality' is difficult to define and the question of 'futility' of care may be more relevant. [13][14][15] Guidance on withdrawal of care in situations requiring stabilization and transport is limited and only Dulkerian et al 16 discussed these issues in the context of neonatal transport. In this setting, time to assess futility and 'best interest' 13 is limited.…”

Giant omphalocele: current perspectives

“…16 In a setting of severe pulmonary compromise and extreme prematurity, further treatment might even be considered futile. Feltman et al 17 addressed these issues in a recent publication. It is important to discuss prognosis with parents.…”

Limitação terapêutica para crianças portadoras de malformações cerebrais graves

“…Feltman et al 23 also describe a peculiar case involving severe comorbidities -extreme prematurity and omphalocele. The parents insistently requested that the infant be subjected to a surgical procedure and, afterwards, to cardiorespiratory resuscitation techniques; however, the medical staff foresaw that such procedures would not prove effective.…”

“…Although Feltman et al 23 argue that any treatment may be evaluated with respect to its suspension or renouncement, more drastic decisions regarding ethics fall upon the procedure of artificial breathing/ mechanical ventilation support and enteral nourishment, each of them presenting peculiar ethical aspects. Advanced support for mechanical ventilation through the insertion of orotracheal intubation represents a treatment method that is too invasive and painful, and frequently requires strong sedatives and analgesic medicine in order to be introduced or maintained.…”