Answer the questions regarding the following scenario.
SITUATION:
Anultrasound performed on a woman who was 23 weeks pregnant revealedmultiple findings suspicious for trisomy 21 syndrome, (Downsyndrome). The woman and her husband were devastated, saying theycould not possibly raise a child with mental retardation andphysical anomalies, and they requested a termination. Theobstetrician recommended amniocentesis for chromosomal analysisthat would give definitive diagnosis of trisomy 21, and the testwas performed. The parents said they planned to terminate thepregnancy if the results of the chromosome analysis confirmed Downsyndrome.
Beforethe results were returned, the woman arrived at the labor anddelivery unit with a tender abdomen, purulent discharge from thecervix, and high fever. She appeared to have an acute intrauterineinfection from the amniocentesis procedure. Antibiotics werestarted, but it soon became clear that the woman was becomingseptic; the obstetrician on call recommended rapid delivery of thefetus. The woman and her husband again clearly stated that theywanted no resuscitation performed on the infant after delivery. Thecouple and the physicians agreed that, given the probability of aseverely anomalous infant, the plan would be to provide onlycomfort care measures.
The woman’s labor was induced and she delivered a livebornfemale infant, surprisingly robust. The infant had a strong cry,kicked vigorously, and was much larger than anticipated. Theneonatologists examining the infant found themselves reconsideringtheir decision to withhold resuscitation. Suddenly the seeminglycertain prenatal diagnosis of Down syndrome appeared implausible,given the appearance of a strong infant without apparent anomalies.The NICU team realized that, under any other circumstance,resuscitation measures would be well under way; they became uneasyas they watched the premature infant’s forceful kicking andenergetic cries. Within minutes to hours the female infant’s lungswould tire and she would die without respiratory support.
The physicians announced to the parents their decision toreverse their previous plan to withhold care based on the healthyappearance of the neonate. The neonatologist described theresuscitation measures they planned to begin. The parents wereinfuriated. “We had an agreement,” the father retorted. “My wifeand I made it very clear to you that we cannot manage an impairedchild. This is our decision to make—we’re the parents, and it isyour duty to respect our wishes.”
1. Explain the ethical dilemmas presentedin the above scenario. What action do you feel isappropriate and why?
2. What are the facts about outcomes ofextreme prematurity?
3. Based on these facts, is resuscitationappropriate?
4. Who is liable if this infant is notresuscitated? Under what circumstancesshould resuscitation be discontinued if it is started inthis instance?
5. What are the potential morbiditiespost-resuscitation of an extremely preterminfant?
6. Discuss the following topics from thisarticle:
A Review of Ethical Issues Involved in PrematureBirth
http://www.ncbi.nlm.nih.gov/books/NBK11389/
a. The “Best Interests” Standard and DecisionMaking
Whatis parental autonomy?
Shouldparental autonomy guide the decisions of the healthcareteam?
b. Parental Informed Consent: LegalPrecedents
Discussthe legal issue in this situation.
Doyou think the action by Dr. Messenger isappropriate? Why or why not?
State v. Messenger (1994) in Michigan affirmed theright of an infant’s father to refuse treatment for his child whowas born at 25 weeks of gestation. The Messenger infant wasresuscitated against the expressed wishes of his parents. Once inthe NICU, the infant’s father, a physician, asked to be alone withhis son and disconnected the ventilator so that the infant wouldexpire. Dr. Messenger was charged with manslaughter and tried in acriminal court, where he was acquitted by ajury.
c. Legal Cases Concerning Delivery RoomResuscitation
Discussthe legal cases presented in the article.
Millerv. HCA (Texas, 2003)
Montalvov. Borkovec (Wisconsin, 2002)
d. Recent Legislation DefiningPersonhood
Whatestablishes “personhood?”
e. Professional Guidelines for Decision Making atthe Limits of Viability
Explaincurrent guidelines as outlined by the American Academy ofPediatrics
f. Professional Guidelines for Limitation of LSMT inthe United States
Explaincurrent guidelines as outlined by the American Academy ofPediatrics
g. Pain Management and Palliative Care at the End ofLife
Discusspain management and palliative care as it relates tonewborns
h. The Concept of Futility in the Care of ExtremelyIll Infants
Describethe concept of futility in the care of extremely illinfants
Whenare life-sustaining measures considered futile?
i. How do financial, social and educational costsplay a role in the resuscitation of ELBWinfants?
