Delivery Room Resuscitation Decisions for Extremely Premature Infants

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Abstract
Background. Neonatologists are criticized for overtreating extremely premature infants who die despite invasive and costly care. Withholding resuscitation at delivery has been recommended as a way to minimize overtreatment. It is not known how decisions to forgo initiating aggressive care are made, or whether this strategy effectively decreases overtreatment. Objective. To identify whether physicians9 or parents9 preferences primarily determine the amount of treatment provided at delivery, to examine factors associated with the provision of resuscitation, and to assess whether resuscitation at delivery significantly postpones death in nonsurvivors. Methods. We evaluated delivery room resuscitation decisions and mortality for all infants born at 23 to 26 weeks gestation at the University of North Carolina Hospitals from November 1994 to October 1995. On the day of delivery, the attending neonatologist completed a questionnaire regarding discussion with the parents before delivery, the prognosis for survival estimated before delivery, the degree of certainty about the prognosis, parents9 preference for the amount of treatment at delivery, and the degree of influence exerted by parents and physicians on the amount of delivery room treatment provided. Medical records were reviewed for demographics and hospital course. Results. Thirty-one of 41 infants were resuscitated (intubation and/or cardiopulmonary resuscitation) at delivery. Resuscitation correlated with increasing gestational age, higher birth weight, estimated prognosis for survival ≥10%, and uncertainty about prognostic accuracy. Physicians saw themselves as primarily responsible for delivery room resuscitation decisions when the parents9 wishes about initiating care were unknown, and as equal partners with parents when they agreed on the level of care. When disagreement existed, doctors always thought parents preferred more aggressive resuscitation, and identified parents as responsible for the increased amount of treatment at delivery. Twenty-four infants died before hospital discharge. The median age at death was 2 days when physicians primarily determined the amount of treatment at delivery, 1 day when parents primarily determined the amount of treatment, and <1 day when responsibility was shared equally. The median age at death was <1 day when physicians and parents agreed about the preferred amount of treatment at delivery and 1.5 days when they disagreed. The median age at death was <1 day when parents9 preferences were known before delivery and 4 days when parents9 preferences were unknown. Conclusions. Physicians resuscitated extremely premature infants at delivery when they were very uncertain about an infant9s prognosis or when the parents9 desires about treatment were unknown. When parents9 preferences were known, parents usually determined the amount of treatment provided at delivery. Resuscitation at delivery usually postponed death by only a few days, decreasing prognostic uncertainty and honoring what physicians perceived were parents9 wishes for care, without substantially contributing to overtreatment.