摘要专业声明在生存能力边界指导新生儿复苏阈值。Guillen等人2015年对国际准则的系统回顾。发现23-24周胎龄(GA)婴儿的临床建议之间存在相当大的差异。作者得出结论,所包含数据类型的差异是该道德灰色区域内不同复苏阈值的潜在来源。“声明如何提出支持他们建议的道德考虑,以及这可能是如何解释可变性的,没有得到严格的探索。我们在220-250周GA对25个现行国际新生儿复苏指南进行了混合方法探索性分析。使用修正的扎根理论进行定性分析,得出34种不同的代码,八类,和四个总体主题。三个主题,结果主义,原则性,以权利为基础,由这些伦理框架的核心概念组成。第四个主题,临床推理,描述了咨询实践,医疗管理,结果数据,和预后的不确定性,没有任何道德背景。临床推理的主题出现在25个指南中的22个指南中。十条准则没有任何道德主题。与没有确定的道德主题的指南相比,具有确定的道德主题的指南更有可能推荐舒适护理。并建议在较高的平均GA(22.7周与22.0周,p=0.03)。因此,伦理概念如何纳入指南可能会影响复苏阈值。我们认为,在“灰色地带”中纳入有关复苏的伦理考虑因素的明确讨论将澄清为建议提供信息的价值观,并促进关于随着结局的不断发展,新生儿学应如何接近生存的讨论。
AbstractProfessional statements guide neonatal resuscitation thresholds at the border of viability. A 2015 systematic review of international
guidelines by Guillen et al. found considerable variability between statements\' clinical recommendations for infants at 23-24 weeks gestational age (GA). The authors concluded that differences in the type of data included were one potential source for differing resuscitation thresholds within this \"ethical gray zone.\" How statements present ethical considerations that support their recommendations, and how this may account for variability, has not been as rigorously explored. We performed a mixed-methods exploratory analysis of 25 current international
guidelines for neonatal resuscitation at 22+0-25+0 weeks GA. Qualitative analysis using a modified grounded theory yielded 34 distinct codes, eight categories, and four overarching themes. Three themes, consequentialism, principlism, and rights-based, consisted of concepts central to these ethical frameworks. The fourth theme, clinical reasoning, described counseling practices, medical management, outcomes data, and prognostic uncertainty, without any ethical context. The theme of clinical reasoning appeared in 22 of 25
guidelines. Ten
guidelines lacked any ethical theme.
Guidelines with an identified ethical theme were more likely to recommend comfort care than
guidelines without an identified ethical theme, and recommended it at a higher average GA (22.7 weeks vs. 22.0 weeks, p = 0.03). Thus, how ethical concepts are incorporated into guidelines potentially impacts resuscitation thresholds. We argue that inclusion of explicit discussion of ethical considerations surrounding resuscitation in the \"gray zone\" would clarify values that inform recommendations and facilitate discussions about how neonatology ought to approach periviability as outcomes continue to evolve.