Why Don’t We Like Preemies?

Abstract

Background: We have previously shown a relative devaluation of neonates compared to older patients (pts). Objective: To explore the reasons behind this devaluation. Design/Methods: Questionnaire and semi-structured interviews. Questionnaire: Scenarios of pts needing resusc: (bullet) 24wk preterm, term baby with brain AV malformation, 2mth with meningitis, 50y with mutiple trauma: all 4 with 50% survival; if survive: 50% normal, 25% major disability. (bullet) Multiply impaired 7y old with cerebral palsy, deafness, learning disability, hyperactivity with new head trauma: 50% survival, 50% chance recovery back to baseline. Respondents were asked whether they thought resusc was in pt's best interest (best int), if they would accept comfort care at family's request, and how they would rank pts in a triage situation. Interviews: How do you evaluate best interests? How did you rank these patients? Why are your answers for the preterm different? Results: Answers from 35 pediatric residents (80% resp rate). (Table presented) Questionnaire: Despite thinking that resusc was in the best int for the majority of pts, respondents accepted comfort care much more often for neonates. Ranking: 1st: 2mth, 2nd: 7y, 3rd: term, 4th: preterm, 5th: 50y. Interviews: Evaluation of best int (themes mentioned by < 10% of residents not included): 56% of respondents said they evaluated best int according to pt's outcomes, 40% to survival, 43% to family's evaluation of the best int, 25% because prior functioning is known, 14% on the pt's age, 14% nature of treatment. I placed the 2 mth old first because: 51% because of personhood/attachment, 47% less sequelae, 31% normal child before, 16% prior functioning known, 13% uncertainty in outcomes. I placed the 7y before other pts because: 23% good quality of life, 23% not very disabled, 30% personhood/attachment. I ranked the preterm after other pts because: 55% personhood/attachment, 29% outcomes, 16% nature of treatment, 13% family's best int, 13% going against nature. Conclusions: The best interest principle was not followed for neonates. Moreover, the preterm infant was often ranked after older patients with similar outcomes. This devalution of preterm infants seems to be due to his lack of personhood, how residents perceive their outcomes and to family preferences. A seriously disabled child is seen as more worthy of resuscitation by the same residents.