Challenges in Ethical care in the NICU .pptx

Challenges in Ethical care in the NICU

1. Ethical Dilemmas in the Neonatal Intensive Care Unit

2. Medical and Ethical Issues Neonatologists and parents must consider several major ethical issues when they make decisions concerning medical care for the preterm infant. Frequently, these issues are complex and necessitate the dovetailing of numerous ethical decisions with strictly medical decisions to achieve the final resolution. The following discussion is not inclusive but merely highlights some of the issues that complicate decision making in neonatal medicine.

3. Dependent Patient One issue that creates ethical complexity in the neonatal intensive care unit (NICU) is the inability of the patient to exercise autonomy—that is, the preterm infant is incapable of making decisions for himself. Because babies cannot participate directly in decision making, influence may be exerted by multiple interested parties: 1. ethically and socially, babies have recognized rights to health care; 2. parents have ethically, legally, and socially recognized rights and responsibilities for decision making; 3 physicians have ethical responsibilities and legal constraints for making decisions about care of their patients 4. the state has expressed an interest in protecting the rights and well-being of its newborn citizens through the court system.

4. Uncertain Outcome.— A second issue of concern for physicians and parents responsible for ethical decision making is the uncertainty of outcome for the preterm infant. The survival and morbidity have been reported for selected groups of preterm infants. For example, 30 to 60% of infants born at less than 28 weeks of gestation will die. In addition, 40 to 60% of those infants who survive will have intracerebral bleeding12 and 30 to 40% of these surviving babies will have neurologic morbidity. No predictive tool is available, however, for distinguishing at birth those babies who will survive from those who will die; nor can any test administered in infancy reliably discern the child with a major neurologic deficit from the normal child.

5. Absence of Established Guidelines.— Another issue that complicates decision making for the preterm infant is the lack of nationally recognized standards in NICU medicine for establishing clear guidelines for care that is "appropriate." Ten years ago, the survival rate for the newborn weighing less than 1,000 g was 20 to 40%; now it is 75 to 80%. In this rapidly changing NICU environment, several authors have proposed different guidelines, based on different criteria, about the use of resuscitative efforts for infants. For example, Britton and associates concluded that NICU support is unwarranted for babies weighing less than 700 g because of the high rates of mortality and morbidity among these infants