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 age.
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 remains.
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 outcome studies.