[Ethical considerations in the management of infants born at the limit of viability].
Despite ongoing progress in perinatal care over the past decade, mortality rates of infants born before 24 completed weeks of gestation have remained high, and the majority of survivors have at least some degree of neurosensory impairment. With increasing knowledge of long-term follow-up data, quality of life aspects have become more important in treatment decisions for infants born at the limit of viability. Many countries have adopted an individualized approach to the care of these infants. Provisional intensive care is initiated in the delivery room and continued in the neonatal intensive care unit as long as there is a reasonable chance of survival and the expected quality of life appears to justify the patient's pain and suffering. On the other hand, redirection of care becomes an ethically justifiable option once the burdens have begun to outweigh the benefits. The published recommendations from different countries show considerable variability. For example, the gestational age below which preference should be given to palliative care ranges between 22 (Germany, Japan) and 25 completed weeks of gestation (Netherlands). Similarly, parental participation in surrogate decision making varies from country to country. Recommendations which emphasize quality of life aspects tend to encourage parental participation more than recommendations which are primarily based on a sanctity of life ideology. The quest to improve care for infants born at the limit of viability will continue. Trying to push the limit of viability towards even lower gestational ages is not a priority. Research efforts should focus on improving long-term outcome for survivors and on developing high quality palliative care for non-survivors.
Berger
T M
TM
Neonatologische und Pädiatrische Intensivstation, Kinderspital Luzern. thomas.berger@ksl.ch
Holzgreve
W
W
D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D007235:Infant, Premature, Diseases / Q000401:mortality* / Q000628:therapy*; D038622:Internationality; D018743:Perinatal Care / Q000941:ethics*; D017410:Practice Guidelines as Topic