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The limits of viability: A national consensus document

The limits of viability: A national consensus document. Malcolm Battin*. Survival Inborn Babies by Birth Weight. Cambridge – vent cohort (green>1kg). Cambridge < 1kg & vent cohorts. UCH London UK. Perinatal care at the borderlines of viability: consensus workshop.

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The limits of viability: A national consensus document

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  1. The limits of viability: A national consensus document Malcolm Battin*

  2. Survival Inborn Babies by Birth Weight Cambridge – vent cohort (green>1kg) Cambridge < 1kg & vent cohorts UCH London UK

  3. Perinatal care at the borderlines of viability: consensus workshop Grey Zone between 230 and 256 weeks Parental wishes Condition at birth & anomalies Withdraw of intensive care in grey zone is influenced by neurological complications Med J Aust. 2006 6;185(9):495-500

  4. Perinatal care at the borderlines of viability: consensus workshop Grey Zone between 230 and 256 weeks Parental wishes Condition at birth & anomalies Withdraw of intensive care in grey zone is influenced by neurological complications Med J Aust. 2006 6;185(9):495-500

  5. Survival of admitted infants

  6. ACR 2015 – A Gill commentry

  7. Thoughts from the famous … • “To understand God's thoughts we must study [the] statistics, for these are the measure of his purpose.” Florence Nightingale

  8. Survival of 24 Week Infants Boland ANZJOG 2016

  9. Counselling • Survival • Relevant local data • Births Vs NICU admissions • Appropriate for clinical situation • Population data Vs individual

  10. ANZNN survival to discharge (2016)

  11. Prediction of individual outcome • Congenital anomalies • Antenatal steroids • Sex • Optimal growth • Multiple gestation • Infection or asphyxia • Condition at birth ? • Apgar scores?

  12. Counselling • Survival • Relevant local data • Births Vs NICU admissions • Appropriate for clinical situation • Population data Vs individual • Quality of survival • Short term morbidity • Long term morbidity

  13. ANZNN data: IVH

  14. ANZNN 2010-2013 Neurodevelopmental outcomes

  15. National Guideline • Informed by good quality data • Starting point of quality care • Ensure babies transferred appropriately & timely • Equity of access • Facilitate good counselling by experts • Clear plan across multidisciplinary groups • Include parental wishes

  16. National Guideline

  17. National Guideline

  18. Who was involved ? • Paediatric Society & Perinatal Society of New Zealand • RACP (Paediatrics) & RANZCOG • NZCOM & College of Nurses Aotearoa • New Zealand Maternal Fetal Medicine Network • University of Otago Bioethics Centre • Consumer groups - Sands & Neonatal Trust • Feedback from: • New Zealand College of General Practitioners • National Maternity Monitoring Group & PMMRC • TeOra Māori Medical Practitioner Association • Maternity Quality and Safety Consumer Committee • Health and Disability Commissioner

  19. Communication Support people Trained interpreter Ensure privacy Acknowledge cultural & religious beliefs Experienced O&G, Paediatrics, M/W Check list and clearly document decisions

  20. Shared decision making Review all information Consider individual circumstances GA, estimated weight, multiple gestation, anomalies, infection, maternal factors < 23/40 active support not recommended ≥ 23+0/40 intervention dependent on individual circumstances

  21. Decision Support

  22. Comfort / Palliative care • Consistent with family/whanau wishes • Take time and review plan as needed • Pain and symptom management • Avoid unnecessary interventions • Counsel regarding signs of life • Facilitate memory creation • Provide cultural / spiritual support

  23. Practice point • Considering active transfer from 22+5wks allows time for: • antenatal corticosteroids • magnesium sulphate infusion • arrival at tertiary centre prior 23+0 wks • Decision to provide active NICU care can be reviewed if situation or family wishes change

  24. Standardized approach • An opportunity to develop formal 23/24 week bundle of care: • Surfactant & ventilation strategies • Skin care • PDA management, fluid balance and TPN • Strategies on prevention of infection and NEC e.g. fungal prophylaxis, probiotics, lactoferrin • Breast milk bank

  25. Final points • A comprehensive strategy for care < 24 wks will potentially have benefit > 24 weeks • Opportunity to develop bundle of care • Implementation strategy for document • Need for ongoing education • Approach based on current evidence • Interdisciplinary communication important

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