Opinions of Argentinean neonatologists on the initiation of life‐sustaining treatment in preterm infants

Abstract

BackgroundIn June 2014, the Argentinean Ministry of Health published guidelines for the management of neonates born at the limit of viability (≤25 weeks of gestation). We explored the opinion of neonatologists in Buenos Aires, Argentina, regarding the initiation of life‐sustaining treatment (LST) in critically ill neonates, focusing on the effect of sociocultural factors on their opinion.MethodsAn anonymous survey was designed to explore the opinions of Argentinean neonatologists on whether or not to initiate LST in newborns born prematurely. Five hundred eighty neonatologists from 36 neonatal units were invited to participate, and 315 specialists from 34 neonatal units completed the survey (response rate 54%). The survey was conducted between June 2014 and February 2015.Results9.5% (30/315) of the neonatologists answered they would begin LST on neonates born at 22 weeks, 42.5% (134/315) at 23 weeks, 37% (117/315) at 24 weeks, 7% (22/315) at 25 weeks, and 4% (12/315) at ≥26 weeks. Cumulatively then, 96% of participants stated they would start LST at 25 weeks of gestation or less. On multivariate analysis, a “transcendent” value of life and lack of consideration of the local legal framework for making medical decisions in the delivery room were statistically associated with an opinion in favor of initiation of LST in neonates born at the limit of viability. More than 50% of the Argentinean neonatologists surveyed answered they would initiate treatment at a gestational age of less than 23 weeks, despite the fact that the recommendations of the Argentinean Ministry of Health are to only give comfort care for these neonates. The opinion of most Argentinean neonatologists surveyed thus differs from that recommended by the guidelines of Argentina.ConclusionThe most frequent opinion of Argentinean neonatologists was to initiate LST in neonates at the limit of viability. Certain factors, in particular the sense of a transcendent meaning to life and lack of consideration of the local legal framework for making medical decisions in the delivery room, seem to influence the decision to start LST.

Morbimortalidad de recién nacidos prematuros extremos en un centro de referencia de Medellín, Colombia durante el período 2014-2019

“…Una definición biológica de "límite de viabilidad" no se ha establecido (31). La decisión de iniciar soporte vital al margen de prematuridad extrema es un debate internacional; se considera posibilidad de sobrevida y expectativa de calidad de vida (30). El proceso de decisión inicia al establecer lineamientos nacionales, teniendo en cuenta otros factores relevantes.…”

“…El proceso de decisión inicia al establecer lineamientos nacionales, teniendo en cuenta otros factores relevantes. En Argentina se basaron en prácticas de las décadas del 2000 y 2010 publicadas de otros países para dictar políticas nacionales en 2014 que sugieren inicio de soporte vital en ≥ 24 semanas; mientras que los ≤ 23 semanas son candidatos a medidas de confort (30). En una encuesta realizada a neonatólogos se determina que factores como «trascendencia de la vida», influencia religiosa, aspectos financieros y marco legal están asociados con la decisión de iniciar soporte vital en edades gestacionales bajas (30).…”

“…En la literatura el límite de viabilidad se ha estimado alrededor de 22-24 semanas (28); con amplia variabilidad, siendo más alto en países de bajos ingresos, en los cuales es rara la sobrevida en menores de 32 semanas (29). En Argentina, se establece como límite de viabilidad ≥ 25 semanas (30). La alta mortalidad hallada en este estudio puede responder a situaciones relacionadas con el sistema de salud, condiciones maternas y la posibilidad de recibir cuidados pregestacionales, prenatales y periparto adecuados.…”

The Ethics and Practice of Periviability Care

“…Not infrequently, practitioners differ from the guidelines in their practice, with personal preferences continuing to play a role. For example, more than half of Argentinean neonatologists surveyed in 2014-2015 practice in contrast to the guidelines issued by the Ministry of Health [46]. It may be that difficulties in reaching a consensus cause many countries to have no periviability guidelines.…”

Limits of Viability: Should We Play God?

“…Twenty five years ago in the developed countries there was a tendency for both obstetricians and pediatricians to underestimate the potential for survival and to overestimate the risks for disability for infants at the limits of viability (Eidelman 2005, Yu 2005). In accordance with the principles from the Convention, the practice of conservative approach of withholding neonatal resuscitation or delaying intensive care should be changed to a proactive approach that results in early intensive care becoming more available to a larger proportion of these preterm infants, because, according to the recent data, more proactive treatment is not increasing the proportion of functional impairment among survivors (Silberberg et al 2018, Domellöf & Jonsson 2018. To realize this principal, more infants at the limits of viability should be born at institutions with the possibility of the delivery of appropriate neonatal intensive care.…”