Limits of Viability: Perspectives of Portuguese Neonatologists and Obstetricians

Authors

  • Inês Pais-Cunha Serviço de Neonatologia. Unidade Autónoma de Gestão da Mulher e Criança. Unidade Local de Saúde São João. Porto.; Faculdade de Medicina. Universidade do Porto. Porto. Portugal.
  • Sara Peixoto Serviço de Neonatologia. Unidade Autónoma de Gestão da Mulher e Criança. Unidade Local de Saúde São João. Porto.; Serviço de Neonatologia. Hospital Pedro Hispano. Unidade Local de Saúde de Matosinhos. Matosinhos. Portugal.
  • Henrique Soares Serviço de Neonatologia. Unidade Autónoma de Gestão da Mulher e Criança. Unidade Local de Saúde São João. Porto.; Faculdade de Medicina. Universidade do Porto. Porto. Portugal.
  • Sandra Costa Serviço de Neonatologia. Unidade Autónoma de Gestão da Mulher e Criança. Unidade Local de Saúde São João. Porto.; Faculdade de Medicina. Universidade do Porto. Porto. Portugal.

DOI:

https://doi.org/10.20344/amp.21473

Keywords:

Decision Making, Gestational Age, Infant, Premature, Neonatology, Obstetrics, Physicians, Portugal, Surveys and Questionnaires

Abstract

Introduction: Advances in neonatal care have improved the prognosis in extremely preterm infants. The gestational age considered for active treatment has decreased globally. Despite implemented guidelines, several studies show variability in practice. The aim of this study was to understand theperspectives of Portuguese neonatologists and obstetricians regarding the management of extremely preterm infants.
Methods: An online survey was sent through the Portuguese Neonatology Society and the Portuguese Society of Obstetrics and Maternal-Fetal Medicine from August to September 2023.
Results: We obtained 117 responses: 53% neonatologists, 18% pediatricians, and 29% obstetricians, with 62% having more than 10 years of experience. The majority (80%) were familiar with the Portuguese Neonatology Society consensus on the limits of viability and 46% used it in practice; 62% were unaware of Portuguese morbidity-mortality statistics associated with extremely preterm infants. Most (91%) informed parents about morbiditymortality concerning the gestational age more frequently upon admission (64%) and considered their opinion in the limit of viability situations (95%). At 22 weeks gestational age, 71% proposed only comfort care, while at 25 and 26 weeks, the majority suggested active care (80% and 96%, respectively). Less consensus was observed at 23 and 24 weeks. At 24 weeks, most obstetricians offered active care with the option of comfort care by parental choice (59%), while the neonatology group provided active care (65%), p < 0.001. Regarding the lower limit of gestational age for in utero transfer, corticosteroid administration, cesarean section for fetal indication, neonatologist presence during delivery, and endotracheal intubation; neonatologists considered a lower gestational age than obstetricians (23 vs 24 weeks; p = 0.036; p < 0.001; p < 0.001; p = 0.021; p < 0.001, respectively).
Conclusion: Differences in perspectives between obstetricians and neonatologists in limits of viability situations were identified. Neonatologists considered a lower gestational age in various scenarios and proposed active care earlier. Standardized counseling for extremely preterm infants is crucial to avoid ambiguity, parental confusion, and conflicts in perinatal care.

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References

World Health Organization. Preterm birth. 2023. [cited 2024 May 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/preterm-birth.

Glass HC, Costarino AT, Stayer SA, Brett CM, Cladis F, Davis PJ. Outcomes for extremely premature infants. Anesth Analg. 2015;120:1337-51. DOI: https://doi.org/10.1213/ANE.0000000000000705

Steurer MA, Anderson J, Baer RJ, Oltman S, Franck LS, Kuppermann M, et al. Dynamic outcome prediction in a socio-demographically diverse population-based cohort of extremely preterm neonates. J Perinatol. 2017;37:709-15. DOI: https://doi.org/10.1038/jp.2017.9

Jarjour IT. Neurodevelopmental outcome after extreme prematurity: a review of the literature. Pediatr Neurol. 2015;52:143-52. DOI: https://doi.org/10.1016/j.pediatrneurol.2014.10.027

Seri I, Evans J. Limits of viability: definition of the gray zone. J Perinatol. 2008;28:S4-8. DOI: https://doi.org/10.1038/jp.2008.42

Condie J, Caldarelli L, Tarr L, Gray C, Rodriquez T, Lantos J, et al. Have the boundaries of the ‘grey zone’ of perinatal resuscitation changed for extremely preterm infants over 20 years? Acta Paediatr. 2013;102:258-62. DOI: https://doi.org/10.1111/apa.12119

Sociedade Portuguesa de Neonatologia. Preterm birth. 2014. [cited 2024 May 17]. Available from: https://www.spneonatologia.pt/wp-content/uploads/2016/11/2014-Viabilidade.pdf.

Skupski DW, Chervenak FA, McCullough LB, Bancalari E, Haumont D, Simeoni U, et al. Ethical dimensions of periviability. J Perinat Med. 2010;38:579-83. DOI: https://doi.org/10.1515/jpm.2010.098

Doyle LW. Neonatal intensive care at borderline viability--is it worth it? Early Hum Dev. 2004;80:103-13. DOI: https://doi.org/10.1016/j.earlhumdev.2004.05.009

Sullivan A, Cummings CL. Decision making at extreme prematurity: Innovation in clinician education. Semin Perinatol. 2022;46:151529. DOI: https://doi.org/10.1016/j.semperi.2021.151529

Gallagher K, Shaw C, Parisaei M, Marlow N, Aladangady N. Attitudes about extremely preterm birth among obstetric and neonatal health care professionals in england: a qualitative study. JAMA Netw Open. 2022;5:e2241802. DOI: https://doi.org/10.1001/jamanetworkopen.2022.41802

Geurtzen R, Draaisma J, Hermens R, Scheepers H, Woiski M, van Heijst A, et al. Perinatal practice in extreme premature delivery: variation in Dutch physicians’ preferences despite guideline. Eur J Pediatr. 2016;175:1039-46. DOI: https://doi.org/10.1007/s00431-016-2741-7

Chan KL, Kean LH, Marlow N. Staff views on the management of the extremely preterm infant. Eur J Obstet Gynecol Reprod Biol. 2006;128:142-7. DOI: https://doi.org/10.1016/j.ejogrb.2006.01.012

Boland RA, Davis PG, Dawson JA, Doyle LW. What are we telling the parents of extremely preterm babies? Aust N Z J Obstet Gynaecol. 2016;56:274-81. DOI: https://doi.org/10.1111/ajo.12448

Gooi A, Oei J, Lui K. Attitudes of Level II obstetricians towards the care of the extremely premature infant: a national survey. J Paediatr Child Health. 2003;39:451-5. DOI: https://doi.org/10.1046/j.1440-1754.2003.00187.x

Ferrand A, Poleksic J, Racine E. Factors influencing physician prognosis: a scoping review. MDM Policy Pract. 2022;7:23814683221145158. DOI: https://doi.org/10.1177/23814683221145158

de Vos MA, van der Heide A, Maurice-Stam H, Brouwer OF, Plötz FB, Schouten-van Meeteren AY, et al. The process of end-of-life decision-making in pediatrics: a national survey in the Netherlands. Pediatrics. 2011;127:e1004-12. DOI: https://doi.org/10.1542/peds.2010-2591

Bucher HU, Klein SD, Hendriks MJ, Baumann-Hölzle R, Berger TM, Streuli JC, et al. Decision-making at the limit of viability: differing perceptions and opinions between neonatal physicians and nurses. BMC Pediatr. 2018;18:81. DOI: https://doi.org/10.1186/s12887-018-1040-z

Bry K, Bry M, Hentz E, Karlsson HL, Kyllönen H, Lundkvist M, et al. Communication skills training enhances nurses’ ability to respond with empathy to parents’ emotions in a neonatal intensive care unit. Acta Paediatr. 2016;105:397-406. DOI: https://doi.org/10.1111/apa.13295

Nguyen T, Ho L. Review on neonatal end-of-life decision-making: medical authority or parental autonomy? Proc Singap Healthc. 2013;22:140-5. DOI: https://doi.org/10.1177/201010581302200210

British Association of Perinatal Medicine. Enhancing shared decision making in neonatal care - a BAPM framework for practice. 2019. [cited 2024 May 17]. Available from: www.bapm.org/resources/158-enhancing-shareddecision-making-in-neonatal-care.

Légaré F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff. 2013;32:276-84. DOI: https://doi.org/10.1377/hlthaff.2012.1078

Daboval T, Shidler S, Thomas D. Shared decision making at the limit of viability: a blueprint for physician action. PLoS One. 2016;11:e0166151. DOI: https://doi.org/10.1371/journal.pone.0166151

Boss RD, Hutton N, Sulpar LJ, West AM, Donohue PK. Values parents apply to decision-making regarding delivery room resuscitation for high-risk newborns. Pediatrics. 2008;122:583-9. DOI: https://doi.org/10.1542/peds.2007-1972

Safer Care Victoria. Extreme prematurity guideline. Clinical guidance. 2020. [cited 2024 Mar 10]. Available from: https://www.safercare.vic.gov.au/sites/default/files/2020-12/20201222%20Extreme%20Prematurity%20Guideline_FINAL.pdf.

Jefferies AL, Kirpalani HM. Counselling and management for anticipated extremely preterm birth. Paediatr Child Health. 2012;17:443-6. DOI: https://doi.org/10.1093/pch/17.8.443

Taittonen L, Korhonen P, Palomäki O, Luukkaala T, Tammela O. Opinions on the counselling, care and outcome of extremely premature birth among healthcare professionals in Finland. Acta Paediatr. 2014;103:262-7. DOI: https://doi.org/10.1111/apa.12498

Guinsburg R, Branco de Almeida MF, Dos Santos Rodrigues Sadeck L, Marba ST, Suppo de Souza Rugolo LM, Luz JH, et al. Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists. J Perinatol. 2012;32:913-9. DOI: https://doi.org/10.1038/jp.2012.28

Char D. The advance of rescue technologies and the border of viability. Am J Bioeth. 2017;17:40-1. DOI: https://doi.org/10.1080/15265161.2017.1340995

Yanagisawa T, Nakamura T, Kokubo M. Prognosis of 22- and 23-gestational-week-old infants at our facility: a retrospective cohort study. Am J Perinatol. 2024;41:660-8. DOI: https://doi.org/10.1055/a-1779-4032

Published

2024-07-26

How to Cite

1.
Pais-Cunha I, Peixoto S, Soares H, Costa S. Limits of Viability: Perspectives of Portuguese Neonatologists and Obstetricians. Acta Med Port [Internet]. 2024 Jul. 26 [cited 2024 Oct. 5];37(9):617-25. Available from: https://www.actamedicaportuguesa.com/revista/index.php/amp/article/view/21473

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