Physicians' neonatal resuscitation of extremely low-birth-weight preterm infants.

Abstract

To examine the perceptions of physicians who make delivery room decisions to resuscitate extremely low-birth-weight (ELBW) neonates at marginal viability. Nurses, parents, economists, and ethicists have questioned resuscitation of ELBW neonates, many of whom experience high levels of morbidity and mortality. Yet no systematic studies were found that addressed physicians' perceptions and delivery room decisions. Descriptive, using naturalistic inquiry. A national U.S. convenience sample was obtained in 1996-1997 of 54 physicians in five perinatal subspecialties who resuscitated ELBW neonates. Tape-recorded and transcribed interviews were analyzed using NUD*IST software and line-by-line constant comparison. Despite awareness of the high morbidity and mortality, 96% of the physicians offered resuscitation to all ELBW neonates in the delivery room. The main factors affecting their decisions were "the role of physician;" having been "trained to save lives;" the belief that "if called, I resuscitate;" the inability to determine gestational age; requests from parents to "do everything;" and the need to move from a "chaotic" delivery room to a controlled neonatal intensive care unit. Six major themes were: role expectation, uncertainty, awareness, internal and external forces, burden, and continuing quandaries. Physicians were burdened by the devastated and dying babies, by their inability to predict which neonates had a chance for intact survival, and by conflicts with colleagues about viability. Statistical probability of survival, legal constraints, and cost of care did not appear to affect greatly their decisions. Physicians asked that society and national policy makers set parameters for resuscitation. The American Academy of Pediatrics' Neonatal Resuscitation Protocol needs revision to delineate the ethical criteria for resuscitation. Early prenatal education for families which clearly teaches the margins of viability and outcomes of early deliveries is also recommended. Physicians must be supported in changing the recessitation paradigm.