Viability and thresholds for treatment of extremely preterm infants: survey of UK neonatal professionals

Abstract

Background: Decisions about treatments for extremely preterm infants (EPIs) born in the 'grey zone' of viability can be ethically complex. This 2020 survey aimed to determine views of UK neonatal staff about thresholds for treatment of EPIs given a recently revised national Framework for Practice from the British Association of Perinatal Medicine.

Methods: The online survey requested participants indicate the lowest gestation at which they would be willing to offer active treatment and the highest gestation at which they would withhold active treatment of an EPI at parental request (their lower and upper thresholds). Relative risks were used to compare respondents' views based on profession and neonatal unit designation. Further questions explored respondents' conceptual understanding of viability.

Results: 336 respondents included 167 consultants, 127 registrars/fellows and 42 advanced neonatal nurse practitioners (ANNPs). Respondents reported a median grey zone for neonatal resuscitation between 22⁺¹ and 24⁺⁰ weeks' gestation. Registrars/fellows were more likely to select a lower threshold at 22⁺⁰ weeks compared with consultants (Relative Risk (RR)=1.37 (95% CI 1.07 to 1.74)) and ANNPs (RR=2.68 (95% CI 1.42 to 5.06)). Those working in neonatal intensive care units compared with other units were also more likely to offer active treatment at 22⁺⁰ weeks (RR=1.86 (95% CI 1.18 to 2.94)). Most participants understood a fetus/newborn to be 'viable' if it was possible to survive, regardless of disability, with medical interventions accessible to the treating team.

Conclusion: Compared with previous studies, we found a shift in the reported lower threshold for resuscitation in the UK, with greater acceptance of active treatment for infants <23 weeks' gestation.

Keywords: ethics; neonatology; palliative care; resuscitation.

Figure 1

Lowest gestation participants would be willing to offer active/survival-focused care and stabilisation (Active Treatment) at parental request (n=303). One consultant was not willing to select a gestational age with the information provided thus was excluded. One ANNP indicated that they would always offer Active Treatment at parental request. The line graph shows the cumulative percentage, indicating the proportion of respondents prepared to provideActive Treatment at a given gestation if parents request it. The stacked bar graph indicates the number of respondents who selected a particular lower threshold. For example, 47 consultants selected a lower threshold of 23⁺⁰ weeks, and 91% of consultants were willing to provide Active Treatment for an infant born at 23⁺⁰ weeks. ANNP, advanced neonatal nurse practitioner.

Figure 2

Highest gestation participants would be willing to withhold active/survival-focused care and stabilisation (Active Treatment) at parental request (n=294). Two consultants were not willing to select a gestational age with the information provided thus were excluded. Four respondents indicated never being willing to withhold Active Treatment at parental request, while 10 indicated that they had no upper limit for withholding Active Treatment. The line graph shows the cumulative percentage, indicating the proportion of respondents prepared to withhold Active Treatment at a given gestation if parents refused it. The stacked bar graph indicates the number of respondents who selected a particular upper threshold. For example, 35 consultants selected an upper threshold of 24⁺⁰ weeks, and 53% of consultants were willing to withhold Active Treatment for an infant born at 24⁺⁰ weeks.ANNP, advanced neonatal nurse practitioner.

Figure 3

Level of agreement with statements regarding how viability and medical practices change over time (n=204).