Abstract

Fifty-four physicians were interviewed to examine their perceptions of providing resuscitative efforts to extremely low birth weight neonates at the margins of viability. For this group of newborns, the use of resuscitative technology has drastically reduced mortality, but has contributed to a cohort of children with significant long-term physical and developmental morbidity. Using naturalistic inquiry, indepth interviews of physicians in five perinatal subspecialties were conducted throughout the U.S. Tape-recorded interviews were transcribed verbatim and analyzed using NUD*IST software and line by line constant comparison. Seventy-five codes were conceptualized into six themes: role expectation, uncertainty, awareness, internal/external forces, burden, and continuing quandaries. Participants revealed that despite awareness of morbidity and mortality statistics, 96% offered resuscitation to all ELBW neonates in the delivery room. Main factors influencing decision making were inability to determine accurate gestational age; parental requests to "do everything"; the desire to move from a "chaotic" delivery room into a controlled NICU for further evaluation; and the role perception of having been "trained to save lives." Physicians were burdened by the dying/devastated babies and by their inability to predict which neonates had a chance for intact survival. Many experienced conflicts with colleagues or partners over what were supportable neonates, with a better match between obstetric expectations and neonatal goals desired. Legal constraints and NICU care costs were not currently prevailing issues; many believed that insurance companies and managed care would eventually be the deciding factors in what babies at what ages and weights received resuscitation. These physicians looked to society to make the moral decisions. One important finding was that physicians described no other model than technological intervention for the ELBW premature neonate, making no mention of alternative provisions of comfort or hospice care. Additional education in ethical decision making, the use of comfort or hospice care in the delivery room, and inclusion of an ethical component to the Neonatal Resuscitation Protocol are recommended. Prenatal education clearly delineating the margins of viability is suggested. Continued societal input to guide physicians and support for physicians making difficult delivery room decisions should be offered