Medicine by Alexandros G. Sfakianakis,Αλέξανδρος Γ. Σφακιανάκης

Πέμπτη 8 Αυγούστου 2019

An ambulance is dispatched to a full-term imminent birth. As they arrive, the newborn is delivered and, after a minute shows no signs of cardiorespiratory effort. Newborn resuscitation is delivered and despite best efforts the situation is becoming increasingly futile. Five minutes have passed with no detectable cardiac activity; the midwife and additional paramedics are five minutes away, the nearest hospital fifteen. Should the paramedic crew decide to stay or leave? In 2012, the World Health Organisation (WHO) advised that resuscitation ought to be discontinued after ten minutes, should newborn babies have no detectable heart rate.1 This is reflected globally in North American, UK, and European paediatric guidelines.2-4 Further, pre- and in-hospital newborn resuscitation principles are identical, where additional skills such as establishing an umbilical venous line to administer drug treatments remain a poor outcome determinant. If futility is considered as an unachievable goal with no useful or effective purpose, then we could claim that in this instance, conveyance to hospital is futile. The cost of resources at hospital, including clinicians and treatments, the emotional distress, the risk of pre-hospital blue-light conveyance, and the act of separating the parents from the newborn outweigh the speculative benefit that all options have been exhausted for the child’s survival. Certainly, small studies have indicated that in-hospital therapeutic hypothermia or prolonged resuscitation in the delivery room or Neonatal Intensive Care Unit (NICU) can result in survival.5, 6 Wilkinson and Stenson have argued that if these treatments can be initiated, then it would be reasonable to extend resuscitative efforts to twenty minutes.7 Getting to hospital within this time frame is generally implausible, particularly in rural settings. Moreover, existing pre-hospital strategies emphasise warm ambulances, especially for neonates who are recovering from birth complications. Under pressure, the decision to ‘cool the ambulance’ could unintentionally place a recovering neonate at risk of harm. Are the alternatives morally acceptable? Considering treatment principles are identical, it seems reasonable to remain on scene and continue delivering quality resuscitation with the family in a familiar environment. Additional resources, including the midwife, could then enter a conversation and share decisions with the family about the futility of the situation. Time is bought to establish their wishes and values, and dignify the family in an otherwise tragic situation. I would further argue that caring for the parents should have equal weighting to the newborn, especially as the mother herself is also regarded as a patient. Given that the newborn has no values or capacity to express their preferences, the parents have rightful autonomy over clinician beneficence. Parents may want their newborn child to survive at any cost. However, the likely loss of a child may incur emotional and financial costs such as ended relationships and expensive hospital bills (in non-state funded healthcare systems) that factor into the decisions they must make. Paramedics and other clinicians should not have the right to overlook these issues in favor of prioritising a futile resuscitation. Should resuscitation be discontinued in the pre-hospital setting? Despite parental wishes, pre-hospital treatments are not exhaustive. If there is even a small chance that intravenous umbilical drugs or therapeutic hypothermia can result in survival, then ethically, these should be explored and offered in the act of best interests. Yet, these interventions should be introduced at the scene, and I suggest extended training and guidelines could be explored to implement these measures at a suitable point during a futile resuscitation. If then at twenty minutes all avenues have been attempted and failed, amongst consultation with the family and medical directorate, and in accordance with the WHO statement, it would be ethical to stop. For now, the existing guidelines focus on conveyance regardless of the outcome. This approach does afford the fulfilment that despite futility; all treatment options have been exhausted. The equipoise here is whether this is the illusion that something is being done, or if it is indeed the right action to take. Fortunately, pre-hospital ethical dilemmas such as these are rare occurrences. Paramedics may face futility in a range of situations and environments that simply require a multi-professional team at hospital to decipher what is clinically and morally appropriate. The existence of guidelines and protocols seek to protect clinicians practically, emotionally, and provide normative consistency. We should however, be questioning the clarity of the guidelines and whether they inadvertently impinge upon ethical practice. By Simon Robinson, MSC Simon Robinson, MSc, is a paramedic in London, UK, and PhD student researching decision-making and ethics in caring for acutely unwell children in the ambulance setting.