Trial of Therapy on Trial: Inconsistent Thresholds for Discussing Withdrawal of Life-Sustaining Therapies in the Neonatal Intensive Care Unit

Abstract

Objective This study aimed to establish the degree of variability in thresholds for discussing withdrawal of life-sustaining therapies (WLST) in periviable infants among neonatal intensive care unit (NICU) personnel.

Study Design A vignette-style survey was administered to NICU personnel at two urban NICUs assessing likelihood of discussing WLST or support for discussing WLST (on a scale from 1, not at all likely/supportive to 10, extremely likely/supportive) in 10 clinical scenarios.

Results Response rates ranged by clinical role from 26 to 89%. Participant responses ranged from 1 to 10 in 5 out of 10 vignettes for NICU attendings, and 9 out of 10 vignettes for bedside nurses. Lower gestational age (22–23 vs. 24–25 weeks) was associated with increased likelihood to discuss WLST in some but not all scenarios.

Conclusion NICU personnel have widely variable criteria for discussing WLST which threatens the informed consent process surrounding resuscitation decisions in a “trial of therapy” framework.

Key Points

• NICU personnel have variable criteria for WLST.

• Parents have little say in whether WLST is offered.

• Disclosure of variable criteria is not routine.

Keywords

neonatology - pediatrics - withdrawal of life-sustaining therapies - bioethics - trial of therapy - periviability

Authors' Contributions

J.M. was responsible for designing the study protocol, conducting the survey, interpreting results, making tables and figures, and primary writing of the manuscript. J.A. and K.R. were responsible for analyzing data, assisted with interpreting results, and provided feedback on the manuscript. N.H. was responsible for designing the study with J.M. and contributed to writing the manuscript.

Publication History

Received: 02 August 2022

Accepted: 06 September 2022

Accepted Manuscript online:
12 September 2022

Article published online:
07 December 2022

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