The neonatologist’s perspective on whether to resuscitate

After our experience having Gabriel at 22 weeks and 6 days of gestation with the doctors first saying that resuscitation was impossible (beginning of week 22), then one of them trying to talk us out of it (end of week 22), we developed a rather strong opinion that doctors and parents should intervene for all preemies and try to save them.

But, as this rather long report on pre-term birth explains, it’s not that simple. This link goes to appendix C, on the ethical issues surrounding pre-term birth, and provides some examples of cases:

— Parents did not want to resuscitate their preemie at 23 weeks and 0 days. A hospital administrator had told the medical staff that they had to resuscitate all babies over 500 grams. (This was actually not policy, but it’s what was said.) The baby was resuscitated and survived, but with severe disabilities. The parents sued the hospital and won $60 million, but the case was overturned on appeal. This one was called Miller vs. ACA (2003). The final decision by the Texas Supreme Court affirmed that doctors can overrule the wishes of the parents in emergent circumstances.

–Another case involved a 25-week preemie also resuscitated against the wishes of the parents. The father asked if he could be alone with his son in the NICU, and this was allowed. He then proceeded to disconnect the ventilator, and the baby died. The father was put on trial for manslaughter, and was acquitted by the jury. This one was called State vs. Messenger (1994).

Another thing this essay brings up is that informed consent is also rather difficult to obtain from parents. The author cites a study in which researchers caught up with parents whose children had been enrolled in a trial of a new medicine for neonates. They quizzed the parents on what the trial involved, and most of them flunked, not having much of a good idea of what the risks were. Under the strict standards of informed consent (understanding of the purpose, benefits, and risks of the study; understanding the voluntary nature of the study; and freedom from coercion), the study concludes, only 3 percent of parents passed.

This becomes more problematic when dealing with a resuscitation order on a baby that is about to be born because the parents are quite often in a state of panic and exhaustion when the time comes to make the decision. Doctors often feel they have an obligation to steer the parents one way or another in their decision-making, or make the decision themselves to provide or withhold care. And yet, another study cited here says that when doctors and nurses were asked to estimate the chances of survival for preemies at various stages of development, they usually underestimated the chances.

Hmm… so what does this mean? Of course we were right to ask for resuscitation for Gabriel, but it also means that the doctor’s ethical world is extremely difficult, and it’s made me a little more sympathetic to the doctor who made that wrong recommendation. Although, I think doctors need to be pushed a little bit more in the direction of giving the baby a chance with the medical technology.


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