Resuscitation in the “Gray Zone” of Viability: Determining Physician Preferences and Predicting Infant Outcomes

Singh, Jaideep; Fanaroff, Jon Mark; Andrews, Bree; Caldarelli, Leslie; Lagatta, Joanne; Plesha-Troyke, Susan; Lantos, John D.; Meadow, William

doi:10.1542/peds.2006-2966

Cited by 176 publications

(143 citation statements)

References 18 publications

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“…6,8,[14][15][16][17] Importantly, these data have not changed substantially over the past 10 to 15 years. [8][9][10][11][12] In an earlier study, although approximately 10% of neonates born at 22 weeks' gestation survived to admission to the NICU, none of them were alive by 6 months of age. 18 In more recent studies, none of the infants born at <23 weeks were reported to survive to discharge from the NICU.…”

Section: Resultsmentioning

confidence: 96%

“…12 Below the lower limit of the 'gray zone,' the infant is too immature to have any reasonable chance for survival without severe deficits. For these infants, provision of care other than comfort care is unreasonable.…”

Section: Resultsmentioning

confidence: 99%

“…[19][20] It appears that these findings, and perhaps the practicing neonatologists' own experiences, have influenced the approach to the management provided in the delivery room to the smallest and most immature neonates, as a recent survey of academic and private neonatologists in the United States has found that only 4% of the participants would resuscitate a neonate at 23 weeks' gestation with a birth weight of <500 g. 12 It further states that 57% of the responders would provide comfort care only, and 36% would defer the decision to parental wishes for these extremely immature infants. 12 Data from the Vermont-Oxford Network's database covering a 5-year period at the end of the past decade reveal that survival to discharge among 4172 infants with a birth weight between 401 and 500 g and a gestational age of 23.3 ± 2.1 weeks was only 17%. 21 Of note is that this paper did not report survival to discharge according to gestational age; it used birth weight instead as it is a more accurately definable variable for a retrospective study querying a large database.…”

Section: Resultsmentioning

confidence: 99%

“…Importantly, autonomy and futility in the area of infant viability do not meet at a well-defined line of maturity. 12 Rather, their interaction is characterized by the presence of a 'gray zone,' a wider range of gestational age. 5,8,12 The goal of this paper is to define the current limits of infant viability with a special focus on the gestational age range of the 'gray zone,' where physician-patient (or surrogate) discussions, negotiations and compromise may be the most appropriate model for consensus development or conflict resolution.…”

Section: Introductionmentioning

confidence: 99%

“…12 Rather, their interaction is characterized by the presence of a 'gray zone,' a wider range of gestational age. 5,8,12 The goal of this paper is to define the current limits of infant viability with a special focus on the gestational age range of the 'gray zone,' where physician-patient (or surrogate) discussions, negotiations and compromise may be the most appropriate model for consensus development or conflict resolution. 13 In addition, the authors offer a nonevidence-based algorithm the practicing neonatologist may consider when facing the prospect of caring for infants in the 'gray zone' of infant viability.…”

Section: Introductionmentioning

confidence: 99%

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Limits of viability: definition of the gray zone

2008

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Introduction: As survival and long-term morbidity of very preterm infants have improved over the past decade, the limits of infant viability, the level of maturity below which survival and/or acceptable neurodevelopmental outcome are extremely unlikely, have also decreased. Study Design:In an effort to define the current limits of infant viability, the data in the literature on survival and long-term neurodevelopmental outcome in very preterm neonates have been reviewed. Result:The gestational age and birth weight below which infants are too immature to survive, and thus provision of intensive care is unreasonable, appears to be at <23 weeks and <500 g, respectively. Infants born at X25 weeks' gestation and with a birth weight of X600 g are mature enough to warrant initiation of intensive care, as the majority of these patients survive, and at least 50% do so without severe long-term disabilities. Finally, for infants born between 23 0/7 and 24 6/7 weeks' gestation and with a birth weight of 500 to 599 g, survival and outcome are extremely uncertain. For these infants born in the so-called 'gray zone' of infant viability, the line between patient autonomy and medical futility is blurred, and medical decision-making becomes even more complex and needs to embrace careful consideration of several factors. These factors include appraisal of prenatal data and the information obtained during consultations with the parents before delivery; evaluation of the patient's gestational age, birth weight and clinical condition upon delivery; ongoing reassessment of the patient's response to resuscitation and intensive care and continued involvement of the parents in the decision-making process after delivery.Conclusion: Based on these findings an algorithm is offered for consideration for neonatologists managing infants born in the 'gray zone' of infant viability. However, caution must be exercised when one considers incorporating this guideline into clinical practice because the algorithm is based on the analysis of the findings in the literature and the authors' experience rather than direct evidence.

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Section: Resultsmentioning

confidence: 96%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Limits of viability: definition of the gray zone

2008

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End-of-Life Decisions in Dutch Neonatal Intensive Care Units

Verhagen¹,

Dorscheidt²,

Engels³

et al. 2009

Arch Pediatr Adolesc Med

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Gestational Ageism

Wilkinson¹

2012

Arch Pediatr Adolesc Med

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ublished guidelines for resuscitation of extremely premature infants emphasize the importance of the gestational age of the infant. However, some ethicists and pediatricians have questioned these guidelines, suggesting that this may represent a form of discrimination. A policy of nonresuscitation of elderly patients older than a certain age would constitute a form of ageism and would likely be unacceptable to the broader community. Are resuscitation decisions for premature newborn infants analogous to resuscitation of elderly patients? Are current neonatal resuscitation guidelines discriminatory? This article looks at the relationship between discrimination based on gestational age and chronological age. There are 2 levels of gestational ageism and 2 separate strands of argument against gestational age guidelines. I conclude that resuscitation decisions for premature infants share many features with those for elderly patients, although there are also some relevant differences. I propose the use of gestational age equivalence as an alternative framework for practice.

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Resuscitation in the “Gray Zone” of Viability: Determining Physician Preferences and Predicting Infant Outcomes

Abstract: The "gray zone" for delivery room resuscitation seems to be between 500 and 600 g and 23 and 24 weeks. For infants born in that zone, neonatologists' reliance on accurate prediction of death or morbidity in the delivery room may be misplaced.

Cited by 176 publications

References 18 publications

Limits of viability: definition of the gray zone

Limits of viability: definition of the gray zone

End-of-Life Decisions in Dutch Neonatal Intensive Care Units

Gestational Ageism

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