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Futility considerations in the neonatal intensive care unit
1Children's National Medical Center, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC 20010, USA.
Insights
Medical decision-making in neonatal intensive care has evolved over 35 years, grappling with the concept of treatment futility. Current legal and societal pressures create unresolved challenges for neonatologists and families.
Area of Science:
- Neonatal Intensive Care
- Medical Ethics
- Health Law
Background:
- Medical decision-making in neonatal intensive care units (NICUs) has a complex history.
- The concept of treatment futility has been a persistent ethical challenge for neonatologists over the past 35 years.
- Shifting roles of healthcare providers, families, and societal proxies have influenced these decisions.
Purpose of the Study:
- To summarize and comment on the historical evolution of medical decision-making in the NICU.
- To emphasize the role of futility considerations in neonatal care.
- To analyze the impact of legal and societal mandates on these decisions.
Main Methods:
- Historical review of medical decision-making epochs in neonatal intensive care.
- Analysis of the evolving roles of stakeholders including physicians, families, and legal/societal entities.
- Examination of the influence of regulations, court decisions, and economic factors.
Main Results:
- Futility has been a central consideration for neonatologists, particularly with severe malformations, birth asphyxia, and extreme prematurity.
- Parental autonomy has gained increasing affirmation in decision-making processes.
- Legal and economic pressures from the 1980s and 1990s have imposed boundaries, sometimes conflicting with ethical considerations.
Conclusions:
- The issue of medical futility in neonatal care in the United States remains unresolved.
- Conflicting legal and societal mandates complicate decision-making processes.
- Ongoing dialogue is needed to address the complexities of futility in neonatal intensive care.
Abstract:
The purpose of this article is to summarize and comment on the history of medical decision making in the neonatal intensive care nursery, emphasizing considerations of futility. Several epochs will be described, with shifting roles of health care providers, the infant's family, and proxies for society at large. Futility has been an issue in the intensive care of newborn infants throughout the last 35 years. Long before the Baby Doe regulations and the formation of ethics committees, neonatologists tried to determine which care measures were indicated. Given the frequency of severe malformations, birth asphyxia, and extreme prematurity, it has been a common event for the responsible physician to ask himself: will this treatment be beneficial or merely futile? As the therapeutic armamentarium became more powerful and complex, the choices from among a possible array of interventions became increasingly difficult. The autonomy of parents as decision makers was increasingly affirmed. In the 1980s, the federal government, the courts, and frequent malpractice suits set boundaries on medical decision making. In the 1990s, third party payors became increasingly assertive in limiting resource expenditure. These legal and societal mandates are frequently at variance with one another. Thus the issue of medical futility, as it applies to neonates in the United States, must be considered unresolved.