As requested, here is my argumentative paper. I was taking the con side of aggressive resuscitation of 24 weekers when there are scarce resources available. (PS - I received 100% on this!)
Copyright - AtYourCervix, 2009
Resuscitation of Extremely Premature Infants at 24 Weeks Gestation When Medical Resources are Scarce
In the United States, great advances have been made over the years in medical technology and the advancement of many areas of health care. However, one area that continues to have a poor outcome is the infant mortality rate: there are 40 countries that have better infant mortality rates than the United States (Central Intelligence Agency, 2008). The aggressive nature of resuscitating extremely premature infants at or before 24 weeks gestation could very well be one reason for the poor ranking among the other countries in the world (CDC, 2008). Medical resources to resuscitate such extremely premature infants are not found at every hospital, healthcare facility, birth center or clinic. Long term prognosis at 24 weeks gestation is poor. Depending on the availability of medical and financial resources, the prognoses for positive outcomes for such infants are dismal and likely non-existent. It is more compassionate and humane to provide comfort care only for extremely preterm infants. Thus, infants born at extreme prematurity, before or at 24 weeks gestation, should not be vigorously resuscitated when medical resources are scarce, saving such aggressive measures for infants born at higher gestations.
By definition, neonatal resuscitation is assessment and interventions utilitized after birth to assist a baby with breathing and helping maintain a heartbeat (Wikibooks). Simple methods consist of repositioning the infant, drying of birth fluids, clearing the airway, and keeping the baby warm (American Academy of Pediatrics, 2006). Initial and ongoing assessments include monitoring of the heart rate, respiratory effort, color, muscle tone and grimace reflex (AAP, 2006). More advanced and aggressive measures of resuscitation require medical equipment and include the use of oxygen, bag and mask, endotracheal intubation, gastric and endotracheal suctioning, chest compressions and medications (AAP, 2006). A program used specifically for the training of health care providers world-wide in neonatal resuscitation is the American Heart Association/American Academy of Pediatrics Neonatal Resuscitation Program, also referred to as NRP.
In a facility with a high level neonatal intensive care unit, supplies and resuscitation measures are both available and utilized at births starting from approximately 23-24 weeks gestation. However, not all facilities have the access or ability to be able to resuscitate newborns born extremely preterm or at an extremely low birth weight. Of the 5,708 hospitals registered with the American Hospitals Association in the United States (American Hospitals Association, 2008), there are approximately only 1500 Neonatal Intensive Care units (McGrath, 2007). NICU units are further divided into different levels of care provided: from Level 2, which provides care for mildly ill infants, but does not provide mechanical ventilation, up to Level 3D, which provides a wide range of care up to and including mechanical ventilation and cardiac surgery requiring cardiac bypass or extracorporeal membrane oxygenation (Phibbs et al., 2007).
Infants born at Level 3 NICUs at a gestational age of 24 weeks and an approximate birth weight of 500 grams, have a survival rate at just 28% (NICHD, 2008). This states simply the percentage of infants that survive, and does not take into account those infants that have long term moderate to severe or profound neurodevelopmental impairment. Of the 28% of infants that do survive, those that do not experience moderate to severe neurodevelopmental impairment are estimated to be only 12% (NICHD, 2008). Approximately 88% of surviving infants have some degree of neurodevelopmental impairment. So, for every 100 babies born at 24 weeks gestation, approximately 28 will survive, and only 3 of the original 100 will go on to have no lasting sequelae. These are staggering statistics. Outcomes for infants born at 24 weeks at hospitals and other health care facilities without high level NICU care are even worse. There are no studies or statistics of survival of infants born at non-NICU containing facilities. The assumption that can be inferred is that none of the infants born at about 24 weeks gestation survive.
According to the 2008 World Fact Book, published by the Central Intelligence Agency, the United States currently ranks at number 41 out of 219 countries for infant mortality rates (CIA, 2008). For such a progressive nation with increased technology in the health care field, that speaks volumes for how behind the United States is in caring for its youngest citizens, compared to other developed nations of the world. Infant mortality in the United States worsened slightly from 2000 to 2005, primarily due to the increase in preterm births and its associated mortalities (CDC, 2008). Also, according to the CDC (2008), in 2000, 65.6% of all infant deaths occurred in premature infants. In 2005, that amount increased to 68.6%. With a slowly rising percentage of premature births occurring annually, the mortality rates will continue to increase. If the United States continues to have an increase in both premature births and infant mortality, the current infant mortality ranking among other nations will continue to worsen.
Parents of infants born at extremely preterm gestations may want a full resuscitation done for their infant because of feeling a “glimmer of hope”, even though they know that their child could very well die shortly after birth (Boss, Hutton, Sulpar, West, and Donohue, 2008). Some parents maintain a hope and belief that everything will be fine, regardless of what medical experts might believe the outcome to be (Boss et al., 2008). Still other parents have a strong spiritual or religious belief that “a miracle would happen despite the physicians” (Boss et al., 2008), standing firm in their faith that God will take care of everything. After all, in the previously stated information from the NICHD estimates, 12% of these infants that survive will not have any form of neurodevelopmental disability. Parents may hold on to these positive, albeit miniscule statistics in the hope and belief that their child will be one of the lucky ones to survive without disability. Other parents may not care about the potential for disabilities, as long as their child survives (Kavanaugh, Savage, Kilpatrick, Kimura and Hershberger, 2005).
The startling truth is that approximately 72% of 24 week gestation infants will die (NICHD, 2008). That’s almost 3 out of 4 infants born at 24 weeks in a facility with a Level 3 NICU. Of those that survive, a full 88% will have moderate to severe neurological development impairments (NICHD, 2008). Looking ahead to 26 weeks gestation births, approximately 25% will “have a handicap severe enough to prohibit them from functioning independently” (Maraskas and Parsi, 2008). This is a huge difference in long term outcomes and prognoses, in just a two week gestational period. This in no way devalues the quality of life, but instead paints a bleak developmental outcome and eventual future for infants born at 24 weeks gestation.
Some people may argue that all lives are sacred and special, and everyone deserves a chance, even if that chance at a normal life is very small. While not denying this belief, the scarcity of appropriate medical resources and staffing must also be considered. The resuscitation of a 24 week gestation infant cannot simply occur because the parents want the resuscitation to happen. If the hospital or healthcare facility does not have the basic resuscitation equipment available in the gestational-appropriate sizes, and does not have NRP trained staff to run the resuscitation, then the chances of successfully resuscitating such a small neonate is slim to none.
At the very minimum, a small preemie size bag and mask, as well as the availability of endotracheal intubation equipment is needed to stabilize a 24 week gestation neonate (AAP, 2006). Unless the infant is born at a facility with a NICU, facilities without a NICU will doubtfully have this much needed, size-appropriate equipment. Even if, by chance, a hospital without a NICU has this equipment available, good outcomes demand an appropriately trained NRP certified provider be readily available to run the resuscitation and do the necessary intubation (AAP, 2006). This skill is found in providers who have more exposure to endotracheal intubation on premature infants, such as neonatologists and nurse practitioners employed in high level NICUs.
It is more humane to forgo resuscitation efforts in extremely premature infants when the medical resources are lacking or scarce. Without the appropriate equipment and providers to give care, the prognosis and outcomes for such preterm infants are dismal and likely non-existent. The more humane way of caring for these infants is to provide compassionate comfort care, until the infant passes away (Guyer, 2006). Instead of providers spending futile time on resuscitative efforts and causing the neonate unneeded pain and suffering, parents could hold and talk to their newborn, creating a loving bond that will remain forever in their minds and hearts.
Comfort or palliative care consists of providing a quiet environment for the family and the dying infant, offering emotional support as needed, and remaining sensitive to the needs of the family (Stokowski, 2004). Keeping the baby warm, either wrapped in warm blankets or under a radiant warmer, can help prevent the “diving reflex” from occurring. This happens when the infant is cold stressed, such as being in a cold environment, and leads to a reflexive bradycardia and an increase in peripheral vasoconstriction (Mondofacto, 2000). Other comfort care measures include calling the infant by his or her given name, keeping the infant comfortable, and using a gentle touch when handling the infant (Stokowski, 2004). Keepsake memories are important for the family and include pictures, foot and handprints, foot and hand molds, as well as memory boxes containing infant bracelets, locks of hair, and blankets. Offering spiritual or pastoral care is important as well for the family.
Extremely premature infants face insurmountable odds. This is true even when they are born in a hospital with an appropriate high level NICU. Adding the lack of medical resources into the picture creates an even more dismal image for positive outcomes. Instead, providing compassionate comfort care to these infants is more humane, to help alleviate any suffering without prolonging the inevitability of death. Aggressive resuscitative efforts should be withheld for extremely preterm infants, born at or before 24 weeks gestation, when there is a lack of medical resources available.
(I omited including the resource list, due to the difficulty in the HTML coding with the old cut and paste function from MS office to blogger).