[Newborn at the limit of viability. Part 1: Ethical dilemmas, international recommendations]

Immense scientific and technological progress in perinatal medicine during the 1990s enabled to save extremely immature newborns. The fact faced doctors with new challenges and ethical problems regarding especially infants born at the limit of viability (22-26 weeks of gestation). The aim of this study is an attempt to answer the question concerning the mode of operation in the delivery room and/or NICU towards this group of infants. Decisions may concern undertaking resuscitation, limiting medical procedures and the use of palliative care. Materials for preparation of this paper included international recommendations developed by teams of specialists (part 1), as well as Polish recommendations (part 2). The first part presents world epidemiological data regarding survival rate and long-term developmental assessment of extremely low gestational age infants, indicating difficulties in interpretation of some of the research. We also emphasized the discrepancies in precise evaluation of gestational age, which is of great significance for qualifying the newborn into the group unable to survive or at the limit of viability. For better assessment of the research, recommendations developed by FIGO Committee in 1994 are presented: "Ethical aspects in management of newborn infants at the threshold of viability." In the discussion part we presented differences between world recommendations regarding newborns at the limit of viability, emphasizing the need to define the "grey zone" (gestational age at which there is doubt about the newborns' viability and development and, as a result, the possibility of making "good" therapeutic decisions is limited). In summary it has been emphasized that at the current state of knowledge decisions cannot be based solely on gestational age and estimated body weight, but other factors improving or worsening the prognosis should be taken into consideration as well. Finally the situation in Poland is discussed, indicating problems regarding this group of newborns. It is also emphasized that a Team for Ethical Recommendations in Perinatology, appointed in 2009, developed recommendations which are discussed in the second part of the paper.