Case #1: A baby is born at 23 weeks gestation, weighing 615
grams. The parents request that no heroic measures be taken. The
Apgar score is 3 at 1 minute. The doctor decides that the baby
looks vigorous. He intubates the baby and transfers him to the
NICU. The parents are irate.
Case #2: A baby is born at 23 weeks, weighing 700 grams. The
parents request that everything be done to save the baby's life.
The Apgar at 1 minute is zero. The doctor decides that the baby is
not viable and offers only comfort care. The parents are irate.
Decisions about life-sustaining treatment for babies born at the
borderline of viability raise ethical, legal, emotional and
economic issues and are among the most complex decisions in
pediatrics. Today, the borderline of viability (sometimes called
the "gray zone") is between 22 and 25 weeks of post-conceptual
These decisions are complex because the outcomes are so variable
- patient can die q uickly, they can survive for weeks or months in
the NICU and then die, or they can survive with outcomes that range
from perfectly healthy to neurologically devastated.
Over the last decade, clinical researchers have tried to refine
the prognostic algorithms in order to better predict which babies
have which outcomes. One approach to such prognostication is to
look at birth weight, gestational age, gender, and race. Another is
to look for predictors of outcome that are assessed during the
first few days of treatment. Both approaches add some precision to
prognostication but, with both, significant uncertainty
We offer links to some recent papers about prognostication and
decision making in the NICU, links to some legal cases that address
these decisions, and a slide presentation summarizing some of the