不能设置生存能力的任意胎龄限制,在临床实践中,重点应该放在生存间隔上-所谓的预后不确定性的“灰色地带”。对于此间隔内的情况,最适当的决策过程仍有争议,而生存能力已成为生物伦理学的最大挑战之一。由于社会经济原因,普遍公认的道德原则可能会有不同的解释,文化,和宗教方面。在长期生存能力的情况下,对于干预措施是否能使临床利益与伤害达到更大的平衡,存在相当大的不确定性.此外,胎儿或新生儿无法行使自主性,医生和父母将充当患者代理人。当父母和医生不同意婴儿的最佳利益时,没有家长式态度的对话至关重要,医生应该只提供,但不推荐,围产期干预措施。父母的选择,基于全面的信息,应在医学上可行和适当的范围内得到尊重。当父母和医生之间发生分歧时,如何达成共识?专业指南可以作为讨论的框架和起点。在现实中,然而,准则很少划出明确的界限,在许多情况下仍然含糊不清,措辞含糊不清。地方伦理委员会可以提供咨询,并在讨论期间担任主持人,但是伦理委员会没有决策优先权。咨询在生存讨论中扮演着最重要的角色,考虑到胎儿和母体的特殊特征,以及父母的价值观。应注意与咨询相关的几个警告:应尽量减少信息碎片或不一致,预后最好以积极的框架表示,应避免过度依赖统计。建议在出生前做出有关新生儿复苏的决定,而不是以新生儿出生时的外观为条件。不管做什么决定,重要的是要确保产前和产后的一致性。本文描述了个别医生,中心,各国在决定启动或放弃重症监护的方法上有所不同。不可能提供全球共识的观点,也不可能有统一的道德,道德,或实用的策略。然而,道德上合理的,优质护理包括产科和新生儿团队的早期参与,以实现连贯的,可理解的,非家长式,平衡的护理计划。最终,医生需要根据当地标准调整预期,当地结果数据,和当地新生儿支持的可用性。
An arbitrary gestational age limit of viability cannot be set, and in clinical practice the focus should be on a
periviability interval-the so-called \"gray zone\" of prognostic uncertainty. For cases within this interval, the most appropriate decision-making process remains debatable and
periviability has emerged as one of the greatest challenges in bioethics. Universally recognized ethical principles may be interpreted differently due to socioeconomic, cultural, and religious aspects. In the case of
periviability, there is considerable uncertainty over whether interventions result in a greater balance of clinical good over harm. Furthermore, the fetus or neonate is unable to exercise autonomy and the physicians and parents will act as patient surrogates. When parents and physicians disagree about the infant\'s best interest, a dialogue without paternalistic attitudes is essential, whereby physicians should only offer, but not recommend, perinatal interventions. Parental choice, based on thorough information, should be respected within the limits of what is medically feasible and appropriate. When disagreements between parents and physicians occur, how is consensus to be achieved? Professional guidelines can be helpful as a framework and starting point for discussion. In reality, however, guidelines only rarely draw categorical lines and in many cases remain vague and ambiguously worded. Local ethics committees can provide counseling and function as moderators during discussions, but ethics committees do not have decision precedence. Counseling assumes the most significant role in
periviability discussions, taking into consideration the particular fetal and maternal characteristics, as well as parental values. Several caveats should be observed relative to counseling: message fragmentation or inconsistence should be minimized, prognosis should preferably be presented in a positive framing, and overreliance on statistics should be avoided. It is recommended that decisions regarding neonatal resuscitation in the
periviability interval be made before birth and not conditional on the newborn\'s appearance at birth. Regardless of decision, it is important to assure pre- and postnatal coherence. The present article describes how individual physicians, centers, and countries differ in the approach to the decision to initiate or forgo intensive care in the periviability interval. It is impossible to provide a global consensus view and there can be no unifying ethical, moral, or practical strategy. Nevertheless, ethically justified, quality care comprises early involvement of the obstetric and neonatal team to enable a coherent, comprehensible, nonpaternalistic, and balanced plan of care. Ultimately, physicians will need to adjust the expectations to the local standards, local outcome data, and local neonatal support availability.