Counseling parents on the cusp of delivering an extremely preterm infant is performed thousands of times every year in North America, Europe, Japan and in centers situated in other countries around...

ObjectiveTo present (1) the ethical concepts related to the debate on resuscitation of extremely premature infants (EPIs) as they are described in the ethical literature; and (2) the ethical arguments based on these concepts.DesignWe conducted a systematic review of the ethical literature. We selected articles based on the following predefined inclusion/exclusion criteria: (1) English language articles (2) presenting fully elaborated ethical arguments (3) on resuscitation (4) of EPIs, that is, infants born before 28 weeks of gestation.AnalysisAfter repeated reading of articles, (...) we developed individual summaries, conceptual schemes and an overall conceptual scheme. Ethical arguments and concepts were identified and analysed.ResultsForty articles were included out of 4709 screened. Personhood, best interest, autonomy and justice were concepts grounding the various arguments. Regarding these concepts, included authors agreed that the best interest principle should guide resuscitation decisions, whereas justice seemed the least important concept. The arguments addressed two questions: Should we resuscitate EPIs? Who should decide? Included authors agreed that not all EPIs should be resuscitated but disagreed on what criteria should ground this decision. Overall, included authors agreed that both parents and physicians should contribute to the decision.ConclusionsThe included publications suggest that while the best interest is the main concept guiding resuscitation decisions, justice is the least important. The included authors also agree that both parents and physicians should be actively involved in resuscitation decisions for EPIs. However, our results suggest that parents’ decision should be over-ridden when in contrast with the EPI’s best interest. (shrink)

ArgumentsPhysicians who counsel expectant parents about the needs for resuscitation and intensive care for an extremely preterm infant must be able to address many clinical facts and be prepared to face several ethical considerations. Such counseling is generally more than an acquisition of informed consent. It must be guided by ethical principles, values held dear by parents, relational priorities and directed toward an informed and shared decision-making process. Parents may come with a need for clinical facts, a desire that they (...) be heard as they express their values, and to help physicians realize that many are determined to follow a certain path well before such counseling occurs. They may well not be moved by counseling of the physician but still desire to be heard, respected, and allowed to contribute to their newborn’s care plans.ConclusionsRealizing this, the physician can be accepting and develop a trusting relationship with the parents that will be of value throughout the hospitalization regardless of outcome. (shrink)