Professional Guidelines for the Care of Extremely Premature Neonates: Clinical Reasoning vs. Ethical Theory.

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ESPR421
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Abstract: :

Background: Professional statements guide decision-making around neonatal resuscitation at the border of viability. A systematic review of international guidelines by Guillen et al in 2015 found considerable variability between statements in both the type of data they included, and their clinical recommendations for infants at 23-24 weeks of gestation age (GA). Thus, this GA range marks an ethical gray zone. A systematic analysis of how professional statements utilize ethical frameworks within their recommendations is lacking.

Objective: To identify ethical frameworks used within neonatal professional statements on decision-making for resuscitation of extremely premature infants.

Methods: We reviewed published management guidelines for neonatal resuscitation at 22+0-25+0 weeks GA as previously identified by Guillen et al in 2015. PubMed and Google scholar were searched for updates to selected guidelines. A modified ground theory was used for analysis. Open coding was done by each author to identify items that were used to direct ethical decision-making. Items were reviewed using an iterative process to group them under exclusive categories. Categories were grouped under overarching themes or frameworks. These frameworks were then compared to ethical frameworks previously defined by the Neufield Council on Bioethics.

Results: Of 31 previously selected guidelines, 24 were accessible and available in English for review. These yielded 100 items grouped into 8 categories: counseling practices, clinical care management, data, uncertainty, outcomes, quality of life, ethical principles, and rights. From these categories, four ethical themes emerged, fitting the defined ethical frameworks of consequentialism, principlism, and rights-based ethics. A fourth theme, clinical reasoning, was identified as another framework for guiding decision-making that did not fit a defined ethical framework. While all guidelines organized ethical considerations within a clinical reasoning framework, few explicitly defined how an ethical framework could be applied in clinical decision-making.

Conclusion: Professional statements on neonatal resuscitation at the border of viability use a clinical reasoning framework to present data and ethical considerations that guide decision-making in this ethical gray zone. Little content is dedicated to how ethical frameworks may be applied to this decision-making. Elaborating on the ethical frameworks from which these practical recommendations are based would enhance these guidelines.

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Yale University
Yale University

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