When Is Intensive Care Warranted for the Most Immature Infants?

Withholding or starting, withdrawing or continuing, high-technology interventions available to extremely premature newborns is a fundamental challenge in obstetrics and neonatology. Attempting to save an infant's life is a judgment fraught with uncertainty and risk because suffering can be prolonged, long-term outcomes are frequently unfavorable, and socio-economic inequities are burdensome to families. Survival rates of 22-23-24-week infants are increasing in hospitals that promote "active care," yet morbidity rates and long-term neurodevelopmental impairments remain substantial and not improving. Outcomes acceptable to some pregnant women and families are not to others. Delivery of premature infants, particularly by cesarean section, is associated with maternal health risks. Intensive care of extremely premature infants is expensive, and lost opportunity costs are under-appreciated. Autonomy of pregnant women contrasted with the rights of the fetus and infant are culture and religion-affected, technology-influenced, and powerfully persuaded by physicians and institutions who possess a conflict of interest related to career goals, research, and income, all factors not necessarily shared by pregnant women.Physicians should resist dogmatic positions tethered to unproven technologies and nonrigorous evidence. Some hospitals promote near-universal intensive care of 22-23-24-week infants while others recommend palliative care, differences curiously seen between and within countries, even cities. The legitimate zone of parental discretion is characterized by the value pluralistic shared decision-making of informed consent and is endorsed by the American Academy of Pediatrics, the Canadian Paediatric Society, and the American College of Obstetricians and Gynecologists. Physicians should objectively provide clinical outcomes, compassionately listen to pregnant women's concerns and preferences, and resist presenting care options as a restrictive protocol, or a wide-open menu. Because there is no unifying cultural or bioethical ethos, we should embrace shared decision-making recognizing inherent contingencies and tensions, with humble circumspection of possible nihilism (which might influence palliative care), and therapeutic fury (which might promote unreasonable zeal for interventional care). · Extreme prematurity requires knowing outcomes.. · Parental discretion may broaden with uncertainty.. · Shared decision-making assumes informed consent.. · Parental values differ from the values of physicians.. · Asymmetry of responsibility supports parental values..