DELIVERY ROOM RESUSCITATION DECISIONS FOR EXTREMELY PREMATURE-INFANTS

Background. Neonatologists are criticized for overtreating extremely p remature infants who die despite invasive and costly care. Withholding resuscitation at delivery has been recommended as a way to minimize o vertreatment. It is not known how decisions to forgo initiating aggres sive care are made, or whether this strategy effectively decreases ove rtreatment. Objective. To identify whether physicians' or parents' pre ferences primarily determine the amount of treatment provided at deliv ery, to examine factors associated with the provision of resuscitation , and to assess whether resuscitation at delivery significantly postpo nes death in nonsurvivors. Methods. We evaluated delivery room resusci tation decisions and mortality for all infants born at 23 to 26 weeks gestation at the University of North Carolina Hospitals from November 1994 to October 1995. On the day of delivery, the attending neonatolog ist completed a questionnaire regarding discussion with the parents be fore delivery, the prognosis for survival estimated before delivery, t he degree of certainty about the prognosis, parents' preference for th e amount of treatment at delivery, and the degree of influence exerted by parents and physicians on the amount of delivery room treatment pr ovided. Medical records were reviewed for demographics and hospital co urse. Results. Thirty-one of 41 infants were resuscitated (intubation and/or cardiopulmonary resuscitation) at delivery. Resuscitation corre lated with increasing gestational age, higher birth weight, estimated prognosis for survival greater than or equal to 10%, and uncertainty a bout prognostic accuracy. Physicians saw themselves as primarily respo nsible for delivery room resuscitation decisions when the parents' wis hes about initiating care were unknown, and as equal partners with par ents when they agreed on the level of care. When disagreement existed, doctors always thought parents preferred more aggressive resuscitatio n, and identified parents as responsible for the increased amount of t reatment at delivery. Twenty-four infants died before hospital dischar ge. The median age at death was 2 days when physicians primarily deter mined the amount of treatment at delivery, 1 day when parents primaril y determined the amount of treatment, and <1 day when responsibility w as shared equally. The median age at death was <1 day when physicians and parents agreed about the preferred amount of treatment at delivery and 1.5 days when they disagreed. The median age at death was <1 day when parents' preferences were known before delivery and 4 days when p arents' preferences were unknown. Conclusions. Physicians resuscitated extremely premature infants at delivery when they were very uncertain about an infant's prognosis or when the parents' desires about treatm ent were unknown. When parents' preferences were known, parents usuall y determined the amount of treatment provided at delivery. Resuscitati on at delivery usually postponed death by only a few days, decreasing prognostic uncertainty and honoring what physicians perceived were par ents' wishes for care, without substantially contributing to overtreat ment.