Resuscitation at the limit of viability: trapped between a rock and a hard place

Current professional guidelines, such as the Neonatal Resuscitation Program, specify significant roles for parents in decision-making at periviability. However, current federal regulations and some legal precedents indicate that resuscitation decisions should be made by the physician at the time of delivery, based on physical assessment of the infant. The enforcement of such approach would potentially increase the resuscitation of infants with poor prognoses.

To characterize the resuscitation practices of neonatologists attending deliveries of premature infants at the borderline of viability, in the context of current federal legislation.

A questionnaire was administered to directors of all level III neonatal intensive care units in the state of New Jersey, eliciting resuscitation decisions for hypothetical birth scenarios as well as knowledge of legal statutes.

Resuscitation decisions for infants born at 24 weeks of gestational age were not associated with parental wishes. In contrast, parental requests were significantly associated with decisions whether to treat infants born at 22 and 23 weeks gestation. Most neonatologists believed they were knowledgeable about federal legislation, but that knowledge did not change the way they practiced.

Our findings suggest that resuscitation of premature infants at 24 weeks gestation is the standard of care in New Jersey, a socioeconomically and ethnically diverse state that may represent broader national trends. The high compliance with parental wishes at 22 or 23 weeks is probably related to physicians' expectation of poor outcomes at these gestational ages. This approach is consistent with current recommendations of the Neonatal Resuscitation Program but may not be compatible with existing federal statutes and legal precedent.