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Extremely premature birth and the choice of neonatal intensive care versus palliative comfort care: an 18-year single-center experience

Journal of Perinatology volume 36, pages 190–195 (2016)Cite this article

Subjects

Abstract

Objective:

Review all live births 22 0/7 through 26 6/7 weeks gestation born 1996 through 2013 at our institution to describe the decision process and immediate outcomes of palliative comfort care (PCC) versus neonatal intensive care (NICU) and whether any significant family complaints or quality assurance concerns arose.

Study Design:

Retrospective chart review, physician and ethicist interview process and database review focused upon our established periviability counseling guidelines that are directive of PCC at 22 weeks gestation and NICU at 26 weeks but supportive of informed family choice of either option at 23, 24 and 25 weeks.

Result:

At 22 weeks—all 54 infants had PCC; at 23 weeks—29/78 (37%) chose NICU care, 6/29 (21%) infants survived; at 24 weeks—79/108 (73%) chose NICU care, 47/79 (59%) survived; at 25 weeks—147/153 (96%) chose NICU care, 115/147 (78%) survived; and at 26 weeks—all infants had NICU care, 176/203 (87%) survived. Over 18 years and 606 births, we identified only three significant concerns from families and/or physicians that required formal review.

Conclusion:

Most pregnant women and families choose NICU care for their extremely premature infant, but if given the option via shared decision making, a significant proportion will choose PCC at gestational ages that some NICUs mandate resuscitation. We support a reasoned dialogue and bioethical framework that recognizes human values to be irreducibly diverse, sometimes conflicting, and ultimately incommensurable—value pluralism. Respectful shared decision making requires thoughtful and compassionate flexibility, nuanced and individualized suggestions for PCC or NICU and the reduction of hierarchical directives from physicians to families. We continue to advocate and rely upon informed family preference between 23 and 25 weeks gestation in our updated 2015 periviability guidelines.

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Acknowledgements

This investigation was supported by the Providence Health and Services Foundation (Portland, OR) and Northwest Newborn Specialists, PC (Portland, OR). The sponsors had no role in the design or conduct of the study. We are indebted to every pregnant woman who presented to Providence St Vincent Medical Center 1996 through 2013 with the possibility of extremely premature birth. We acknowledge their travail, thank them for their insight, respect their experience and learn from them and pledge to improve our counseling and care process. We thank Nicole Tipping, RN for her skilled assistance and dedication to accurate chart and data base review and Lian Wang, MS for her expertise in providing statistical analysis.

Author contributions

The principal investigator Joseph W Kaempf, MD had full access to the data in the study and takes responsibility for the integrity and accuracy of the data analysis. JWK was responsible for the original conception and design of the study and drafted the first and final versions of the manuscript. Co-authors MWT and JT assisted in critical review of the manuscript at every step, all data analysis and participated in the manuscript formulation and final revision.

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Authors and Affiliations

  1. Department of Neonatology, Providence St Vincent Medical Center and the Providence Health System, Portland, OR, USA

    J W Kaempf

  2. Department of Maternal Fetal Medicine, Providence St Vincent Medical Center and the Providence Health System, Portland, OR, USA

    M W Tomlinson

  3. Center for Healthcare Ethics, Providence St Vincent Medical Center and the Providence Health System, Portland, OR, USA

    J Tuohey

Authors
  1. J W Kaempf
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  3. J Tuohey
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Corresponding author

Correspondence to J W Kaempf.

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Supplementary Information accompanies the paper on the Journal of Perinatology website

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Kaempf, J., Tomlinson, M. & Tuohey, J. Extremely premature birth and the choice of neonatal intensive care versus palliative comfort care: an 18-year single-center experience. J Perinatol 36, 190–195 (2016). https://doi.org/10.1038/jp.2015.171

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