Hospitals, doctors vary on viability level of fetuses

10/2/2005

One doctor thinks a premature infant is worth saving, the next one decides intervening is hopeless and offers no treatment.

That is the reality inside neonatal units at American hospitals.

Viability of fetuses has shifted downward over the last three decades, but there's no real consensus among physicians about where the cutoff should be for when to offer treatment and when it's hopeless.

"The fact of the matter is there's a lot of variance from state to state and hospital to hospital about how to approach resuscitation at the limits of viability. There's not anything like a consensus," said Dr. Sadath Sayeed, a neonatologist at the University of California-San Francisco and a research scholar at the Boalt School of Law at the University of California, Berkeley.

"You pay the price for having this discrepancy because a patient who desires a certain outcome may not get it if she goes to one hospital vs. another," he added.

Even among doctors at the same hospital there can be disagreement about what a viable fetus is, according to Dr. Richard Fulroth, director of neonatology at Mercy Children's Hospital in Toledo.

"An argument we've had is what level of child should we be taking care of," Dr. Fulroth said.

As a result, Dr. Fulroth said his hospital has taken the relatively unusual step of drafting formal guidelines for physicians to consult about when to offer treatment for very premature infants. Ethicists, doctors, and others worked for nine months to draft the guidelines, he said.

Basically, the Mercy guidelines suggest that for infants less than 22 weeks, treatment should be considered "futile." From 22 weeks up to 23 weeks, treatment is "probably futile," though treatment will be offered if the parents want to try it. There have been no babies born under 23 weeks of gestational age that have survived in northwest Ohio, he added.

However, once a baby born at the gestational age of 24 weeks and above is delivered, that's the cutoff. In other words, there's no more ambiguity: That's a viable fetus and medical intervention should be offered, even if the parents are reluctant.

Many neonatologist have resisted formal guidelines like this, arguing these decisions are best left in the hands of individual physicians because each baby is different. Dr. Fulroth said he agrees, and would resist legislators trying to mandate guidelines. He said Mercy's guidelines are just that, guidelines, and a doctor is not bound by them. But he said he expects more U.S. hospitals to draft guidelines like Mercy's.