Critically Ill Newborns
The newborn intensive care unit (NICU) is a common setting for difficult ethical challenges, often involving life-and-death decisions. These may include withholding treatment such as resuscitation, mechanical ventilation, or surgery, or withdrawing life-sustaining medical treatment such as mechanical ventilation and artificial nutrition and hydration. Such decisions are frequently faced because of the high morbidity and mortality of some conditions commonly encountered in this setting, such as extreme prematurity, perinatal asphyxia, and major congenital anomalies. Who should decide when a treatment should be withheld or withdrawn? Ideally, decisions are made by the parents, providers, and nurses working together, but what is to be done when they disagree? On what basis should decisions be made? Ideally, a careful ethical analysis is carried out, based on solid clinical and prognostic data and the values of those involved in making the decision. In reality, data are often very vague and values are often not shared in common, but a decision must nevertheless be reached.
Such critical ethical decisions may be more common in the NICU than in other pediatric settings, but they are certainly not unique to the NICU. Nonetheless, is there something unique about ethical problems encountered with this patient population? For example, is borderline viability based on extreme prematurity a unique situation in pediatrics, or is it analogous to other problems sometimes encountered in the care of older children? Are clinicians more willing to withdraw or withhold life-sustaining treatment for this patient population than for others in pediatrics or adult medicine? If so, is this justified?A 36-year-old woman who has been pregnant 3 times but has no living children presents to the hospital in active labor and ruptured membranes at 22 weeks and 5 days’ gestation. The fetus is a female singleton, the product of in nitro fertilization. Pregnancy was otherwise unremarkable, including several normal ultrasounds. Estimated fetal weight is 530 grams. On physical examination the cervix is dilated and the obstetrician believes that delivery will occur within the next several hours. The pediatric team meets with the woman and her husband to share information, answer questions, and discuss the plan.
1. What options should be offered to the parents for resuscitation and treatment?
2. If informed parents request resuscitation and intensive care but the clinical team feels they are inappropriate, is the team nevertheless obligated to provide it?
3. If informed parents decline resuscitation and intensive care measures but the clinical team feels it is inappropriate to withhold those measures, is the team nevertheless obligated to withhold those treatments?
4. What ethical principles or approaches can be applied to guide clinicians and parents through the care provided to this child?