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Thresholds for Resuscitation of Extremely Preterm Infants in the UK, Sweden, and Netherlands
Dominic Wilkinson1,2, Eduard Verhagen3, Stefan Johansson4,5
1Faculty of Philosophy, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, United Kingdom; dominic.wilkinson@philosophy.ox.ac.uk.
Insights
Neonatologists in the UK, Sweden, and Netherlands differ on resuscitation decisions for extremely preterm infants (EPIs). Sweden was most proactive, while the Netherlands was least proactive in these critical infant resuscitation choices.
Area of Science:
- Neonatal Medicine
- Pediatric Critical Care
- Medical Ethics
Background:
- Parental involvement in extremely preterm infant (EPI) resuscitation decisions is accepted but boundaries of the 'gray zone' vary.
- Discrepancies exist in defining the gestational age and prognostic criteria for initiating or withholding resuscitation for EPIs.
Purpose of the Study:
- To compare resuscitation thresholds for extremely preterm infants (EPIs) among neonatologists in the United Kingdom, Sweden, and the Netherlands.
- To investigate variations in the 'gray zone' for neonatal resuscitation decisions across different countries.
Main Methods:
- An online survey was distributed to consultant neonatologists and trainees.
- Respondents evaluated clinical scenarios involving parental requests for or against resuscitation.
- The survey assessed lowest gestational age/worst prognosis for resuscitation and highest gestational age/best prognosis for withholding resuscitation, considering infant condition and resource availability.
Main Results:
- 162 neonatologists completed the survey, with a 30% response rate.
- Significant international differences were observed: Sweden's gray zone was earliest (22-23 weeks), followed by the UK (23-24 weeks), and the Netherlands (24-26 weeks).
- Infant condition at birth influenced thresholds, but resource scarcity did not alter decisions; prognostic thresholds showed wide variation.
Conclusions:
- Substantial differences exist in the approach to resuscitating extremely preterm infants (EPIs) across the UK, Sweden, and the Netherlands, with Sweden being most proactive and the Netherlands least.
- Decision-making shifts were linked to specific gestational ages, though prognostic thresholds for resuscitation showed less international variation.
- These findings highlight the need for standardized guidelines or further discussion on ethical decision-making in neonatal resuscitation.
Background:
It is widely acceptable to involve parents in decision-making about the resuscitation of extremely preterm infants (EPIs) in the gray zone. However, there are different views about where the boundaries of the gray zone should lie. Our aim in this study was to compare the resuscitation thresholds for EPIs between neonatologists in the United Kingdom, Sweden, and the Netherlands.
Methods:
We distributed an online survey to consultant neonatologists and neonatal registrars and fellows that included clinical scenarios in which parents requested resuscitation or nonresuscitation. Respondents were asked about the lowest gestational age and/or the worst prognosis at which they would provide resuscitation and the highest gestational age and/or the best prognosis at which they would withhold resuscitation. In additional scenarios, influence of the condition at birth or consideration of available health care resources was assessed.
Results:
The survey was completed by 162 neonatologists (30% response rate). There was a significant difference between countries; the gray zone for most UK respondents was 23 + 0/7 to 23 + 6/7 or 24 weeks' gestation, compared with 22 + 0/7 to 22 + 6/7 or 23 weeks' gestation in Sweden and 24 + 0/7 to 25 + 6/7 or 26 weeks' gestation in the Netherlands. Resuscitation thresholds were higher if an infant was born in poor condition. There was wide variation in the prognosis that warranted resuscitation or nonresuscitation. Consideration of resource scarcity did not alter responses.
Conclusions:
In this survey, we found significant differences in approach to the resuscitation of EPIs, with a spectrum from most proactive (Sweden) to least proactive (Netherlands). Most survey respondents indicated shifts in decision-making that were associated with particular weeks' gestation. Despite the different approaches to decision-making in the 3 countries, there was relatively little difference between countries in neonatologists' prognostic thresholds for resuscitation.
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