Variation in the Treatment of Infants Born at the Borderline of Viability

Abstract

Kaempf et al,1 in this month's Pediatrics , describe their experience with a formalized instrument for counseling pregnant women who are threatening to deliver between 22 and 26 weeks' gestation. They devised and pilot-tested their counseling instrument several years ago.2 Their report documents the satisfaction of women whose perinatal counseling at Providence St Vincent Medical Center (PSC) over 4 years was guided by the use of this counseling protocol. There were 320 births of infants between 22 and 26 weeks' gestation. Sixty of these deliveries were emergent and occurred without counseling. All of these infants were resuscitated at birth. Two hundred sixty births occurred after an opportunity for counseling using the guideline. Fifty (19%) women were interviewed extensively about their experience, and 25 (10%) were reinterviewed months later. The women were happy with the counseling experience. This seemed true whether the outcome was intact survival, survival with impairment, or death. The authors recommend that other centers should (or at least could) adopt a similar approach to counseling women in comparable circumstances. A few comments seem appropriate: one is methodologic and the rest are moral. Methodologically, the problem is in determining whether the good psychosocial outcomes were the result of the PSC protocol itself or were, perhaps, the result of the sort of NICU environment in which physicians would collaborate to develop such a protocol. It is impossible to tell from the data. There was no control group, not even a historical one. We do not know whether women who delivered at PSC before the protocol were generally dissatisfied, whether internal discord among the staff decreased, or even whether the types of decisions that followed protocol-driven counseling differed from those that occurred without the protocol. Perhaps the women were happy because the PSC doctors are really good doctors and … Address correspondence to John D. Lantos, MD, Center for Practical Bioethics, 1111 Main St, Suite 500, Kansas City, MO 64105. E-mail: jlantos{at}practicalbioethics.org