Case Study 26 : EXTREMELY PREMATURE INFANTS
Challenges
A baby boy was born pre-term at 24 weeks age of gestation by last menstrual period, to a 19 year old G2P1, via spontaneous vaginal delivery, with no difficult extraction nor meconium staining. At birth patient spontaneously opened his eyes, had a weak cry, heart rate less than 100, limp, acrocyanotic, with no reflex irritability, and had a birth weight of 488 gms. Ambubagging followed, and later intubation.
The pediatrician informed the parents that their child would probably die in less than 24 hours because of extreme prematurity, and, in any case, would almost surely not survive one week.
Question
Should extraordinary measures be taken to resuscitate and care for the baby boy?
Solutions
There is no moral obligation to make use of ethically extraordinary measures – i.e., those that offer no realistic hope for recovery, or entail too much burden to the patient, family or society. But there are instances in which the family might decide to apply extraordinary procedures when resources are available, at least for some period of time, and for some reason or another (e.g., to settle some family matters, to verify the patient’s response to certain procedures, etc.).
Considerations for hope for recovery include, among others, the patient’s condition, congenital anomalies and current statistics on premature infant mortality. As for burden, one has to take into account the patient’s discomfort, the family’s struggles (physical and emotional), expenses (use of Neonatal Intensive Care Unit, surfactants and other medications, lost opportunities such as salary, having to sell properties), long-term factors (post-hospitalization care, mortality, child’s development and deficits), and allocation of scarce resources (availability of beds, depletion of department’s budget in the case of charity patients, possibility of transfer to another hospital). Emotions, such as pity, both on the part of the family and of the health care team, must be handled properly.
Each hospital should establish guidelines on the care of premature infants based on age, weight, APGAR score, immediate positive response (e.g., within three days), etc. Options must always be clearly discussed with parents (principle of free and informed consent), even before delivery if possible.
