Why? - page 2
I couldn't decide weither to put this under OB or NICU... Most everybody likely knows what I do, but just in case...I am Clinical Coordinator for an agency that does PDN on high tech kids...I have... Read More
Jun 1, '02I work in NICU and it boggles the mind. We will get a 25/26 weeker that may get through and a 25 weeker that does not. We can't pick and choose who will make it or not. It is a sad situation. I know when there are a lot of issues with any neonate and the parents want agressive treatment I don't know if they realize that in the long run the baby will have more problems down the line. OBnurse Heather hit it right on money our technology is biting us in our a** big time. We may be able to keep 24/25 weekers alive but will they have the quality of life like you and I?
Jun 1, '02Ummm, Hello everyone...... I am a NICU nurse....... Sorry to disagree, but "saving" 25 weekers is routine in most medium to large hospitals now. 23 and 24 weekers are considered viable if large enough also. 1020 grams is good-sized for 25 weeks, gestational age is not positive unless invitro conception, and at the beginning of a code, there is no way to even guess if life-support should be withdrawn until the dust clears. Baby codes are completely different from adult and most pedi codes.
Neonatal care has changed significantly in the last 10 years and disabilities are becomming less and less common. I have had MANY parents of micropreemies that are so grateful to have their children - even the few with disabilities.
As for there being no family at the delivery: we should not be making judgements on the value of a person based on who was/wasn't able to be at the bedside.
At our facility, the neotatologist talks with all potetial parents of high-risk infants and informs them of risks/benefits of any resucitation that might be needed and he/she assesses the parent(s) desires as to what is acceptable to them. There may not have been time in this case to find out what the mom's wishes were before the birth, but it sounds to me from the condition of the child that there have probably been several opportunities to allow her to go to heaven. Some parents want/love their children no matter what.
kids-r-fun, your heart is hurting for this child. You will do the best you can for her. I hope I have answered some of the "why?"s. Sometimes bad things happen despite the best of intentions.
Jun 1, '02Having worked OB I can undertsand the "why of the initial resuscitation. There is no way of knowing at the birth which babies are "good" and just need to get over the shock of the birth process and which babies are "bad" having severe problems that cause their instability at birth. SO immediately post birth everyone gets treated aggressively because there is no chance to evaluate for any but the most obvious deformities. The thought is that malformed babies can have treatment withdrawn later when we have got all the test results and can allow parents the chance for a somewhat informed consent.
But after birth with a live baby it is almost impossible for parents to say "let my baby die" so the medical staff never stop treating a baby that will have obvious delays.
Jun 1, '02I have seen the same scenario over and over. I shake my head in disbelief when they code a kid that long and sometimes I shake my head when that kid goes home!
I am reading The Lazarus Case.v A book very similar to the above mentioned case
Jun 1, '02Oy. I just had to reply to this one.
I left a NICU because I hated the medical director who would tell (read: LIE) to parents that their 23 weekers had 'a good chance' of living a 'totally normal life' if we resus. them. Of course, they would agree...yes, yes, do everything. And we would. And 2 days later, bruised, gelatinous, and tortured, the poor baby would finally die. And the nurses of course were left to clean up the emotional mess.
But what a difference one week can make. I have seen hamster-sized 24 weekers bounce out of the NICU with no deficits what so ever. I have seen 33 weekers with grade 4 bleeds. It's a roll of the dice, unfortunately. The other posters said it well.... when it comes to a preemie, you just don't know which kid is gonna fly and which kid is gonna crump until they're actually BORN. It sucks, and it's horrible, and it is an emotional/ethical minefield, but we do it because #1 we can and #2 it is what the parents ask us to do.
Now, not all neonatologists are forthcoming about the actual realities of what a child's life can be like if it starts life at the tender age of 24 weeks....and that has a lot to do with the decisions some parents make.
I don't know what to tell you. But I do know how you feel, I sympathize with you, and I ache for your poor patient and her family. God bless 'em.
Jun 1, '02OK, sorry to further clarify on my WHY...
Medium sized hospital, only one for 40 miles.
From the H&P looks like there could have been as much as 30 minutes from gush of blood to delivery.
This baby was born dead, no pulse, no attempt at breathing.
Apgars of 0 and 0.
No one present to 'put on a show' for (Mom under general).
Why was she resusitated at all?
Sorry to keep rehashing this.
Jun 1, '02kids...what is the normal procedure for a baby like that?
what are we trained to do?
unless of course the family objects. in this case there was no family. its protocol to try.
thats your WHY
its not up to us to decide which ones we attempt to bring back. we dont decide which ones live. we do the same for them all and then god decides.
we are just intermediaries.
from what you have told us it seems a sin for her to have lived but who are we to say?
you will surely drive yourself insane with that question. ..there is no answer in our grasp. its not on us.
Jun 1, '02I spent 8 years as an L&D nurse in a teaching hospital before I came to surgery in a small rural hospital. A few months ago, I was called in at 4 am for a stat section. There is no such thing as a crash section here, many of our staff , including me, live 30 minutes away. When I entered the OR, I was appalled to hear the heart tones auscultated at 76. We waited 25 more minutes for the surgeon to arrive. When he lifted a blue lifeless baby from the womb, I knew it was fruitless. An inexperienced crew worked that baby over for 22 minutes until they got a heartrate of 66. That kid is still alive, and prognosis is she will stay alive a long time. She has a flat EEG, only brain stem activity. She was a perfect full term 8 pound infant, now she is a vegetable. The emotional upheaval and monetary expense her life causes is beyond comprehension. I agree. Why? For what? Why do we play God with people?
Jun 2, '02I wish I had the right things to say, but I don't. I agree with alot of what the other posters are saying. I just wanted you to know that my heart goes out to you.
Jun 2, '02every one for you words of encouragement.
I agree there is no good answer.
Probably the best is "because we can".
I worked with adults before I fell in love with peds. I have had to code many... some viable, some not, some successfully, again some not...and I did ask myself why many times. The difference was they had started out alive.
I just feel sick when I think about what this baby has endured and will for what ever time she has. I can't delude myself into thinking she will ever be anymore than she is now.
Until this week I was contemplating career paths with NICU as my goal. This baby girl changed everything, including me.
I just don't know if I can do this anymore.
Jun 2, '02I had a similiar experience several years ago, but with a much different outcome.
I was working a level 2 nursery when a mom came in to be induced at 26 weeks. The mom and dad had known for quite a while that the baby was a trisomy 13 baby. She continued the pregnancy after finding out due to her objection to abortion.
When the time came for mom to deliver, we had a doc, the L&D nurse, me from nursery, a bereavement counselor and a room full of family. Once the baby was delivered, I took it to the warmer, got an APGAR of 2, cleaned him up a little bit, did the footprints and fingerprints, wrapped him in a blanket and handed him to the mother and father. By that time his APGAR was 1 and he had stopped attempts at respirations. As the mother and father said their goodbyes the baby was pronounced. He lived about 4-5 minutes.
A lot of planning went into making this birth a positive experience for everyone. The bereavement counselor had spent time with the family and had learned of their wishes to enjoy the life of their baby, no matter how short it was going to be. After the baby was pronounced, I brought a basin to bed side and helped the mom bath her son and then dress him in clothes bought especially for his birth, the dad also stepped in to help at this time. After that was done and mom had her baby again I left the room. During the next 6 hours that mom spent in the LDR the family all said their goodbyes, the baby's feet were cast in plaster for mom, and the family just spent time holding their newest member. It was the most emotional birth and death I have ever been part of.
Could we have resuciatated this baby? I believe so. With aggressive measures this baby may not have died right then. But had we accomplished this, what type of future would this child have. Trisomy 13 is associated with many physical defects and severe mental retardation. This baby had a bilateral cleft palate, a 2 vessel cord, and who knows what unseen defects. I feel the family did the right thing in this case by not insisting on aggressive measures, but each case must be individual.
It is not up to us, the healthcare profession, to decide on which baby gets resuciatated and which doesn't. It is the family's decision, and most have not thought that far ahead. The birthing process is supposed to be a time of great joy. But when something goes terribly wrong, the parents are not prepared to make snap decisions involving the life of their newborn, so it is left to us. And we are very good at what we do, and with the help of machines and drugs and perhaps intervention from something higher, we are able to prevent the immediate death of the baby. Afterwards, when the adreneline has worn off, and everybody is thinking a little calmer we begin qustion whether or not the right thing was done. Well, it is to late at that time, now our efforts must be directed at maintaining the life of the baby and ensuring the best possible outcome for the baby. Sometimes the outcome is pretty dismal. All we can do is to say we did the right thing, and if it happens again we would probably do the same thing.
Sorry this got so long, it has been a long time since I talked about this one to anybody.
Jun 2, '02I've often thought the same thing, Kids. I've only been an L&D nurse for 4 years but already have been presented with that same question.
I think it's just easier once we know the prognosis. I mean, think about it, if it were you. You have a normal, healthy pregnancy and all of a sudden - WHAM - your tones are in the 70's. We all know there are times when this happens and everything turns out right and well; other times they don't and we end up with babies with flat ECG's, seizure activity, RDS, nerve damage, etc. How are we supposed to tell if THIS one will be the one that comes through without any residual complications? We all know how resilient babies are....could THIS one pull through? How do we know?
A 25 week abruption may be a LITTLE different; I guess I am speaking from otherwise normal pregnancies that go bad and we code and code and code.
I don't have children, but I'd imagine if I were a full-termer and my tones dropped to the 70's or lower, I don't care for HOW long, I'd want them to code my baby until she came around. Enough said. While I've seen many vegetables as a result of that, I've seen just as many, if not more, successful codes. Once the outcome is known, it is easier then to say "well if only....." or "why did we do that......?"
I don't have an answer for you Kids, except that one time my OB instructor made a profound statement that I will never forget and I think has changed my mindset about birth. We were all standing in front of the NICU looking in, and one of the students remarked how much of a miracle it was that these babies were living and had survived to this point. My instructor looked at her and said "No, the REAL miracle is in the normal newborn nursery. With how much that CAN go wrong with pregnancy, and how complex life is, from going to a cell to a human being, it's a miracle that it all turned out right."
And you know what? She's right. It's easy to keep people alive with machines and technology. It's much harder to let Mother Nature do it.
Keep your head about you, Kids.
Jun 2, '02kids-r-fun,
I am sorry you are having such a difficult time with this situation. Maybe learning more about what we do and why will help. You must understand that neonatal resuscitation is not carried out "because we can" or depending on whether there is anyone there "to put on a show for". Many babies, especially pre-termers are "born dead". Due to the "unique physiology of the newly born" the standard of care is to follow NRP (Neonatal Resuscitation Program of the American Academy of Pediatrics) guidelines. Here's the Algorithm for resuscitation: http://www.pediatrics.org/content/vo...904560001.jpeg
And the website where you can learn all about it:
MOST resuscitations have happy endings. You are in a business where you only see the small percentage that have bad outcomes. You said that you went to a care conference: how does the family feel about this child? As I said in a previous post, there have probably been several other opportunities to let this child go, but she is still here.
Here is an excerpt from the NRP guidelines on ethics. It can be found on the site listed above:
There are circumstances in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate. However, national and local protocols should dictate the procedures to be followed. Changes in resuscitation and intensive care practices and neonatal outcome make it imperative that all such protocols be reviewed regularly and modified as necessary.
Noninitiation of Resuscitation
The delivery of extremely immature infants and infants with severe congenital anomalies raises questions about initiation of resuscitation.91-93 Noninitiation of resuscitation in the delivery room is appropriate for infants with confirmed gestation <23 weeks or birth weight <400 g, anencephaly, or confirmed trisomy 13 or 18. Current data suggests that resuscitation of these newly born infants is very unlikely to result in survival or survival without severe disability (Class IIb, LOE 5).94,95 However, antenatal information may be incomplete or unreliable. In cases of uncertain prognosis, including uncertain gestational age, resuscitation options include a trial of therapy and noninitiation or discontinuation of resuscitation after assessment of the infant. In such cases, initiation of resuscitation at delivery does not mandate continued support.
Noninitiation of support and later withdrawal of support are generally considered to be ethically equivalent; however, the latter approach allows time to gather more complete clinical information and to provide counseling to the family. Ongoing evaluation and discussion with the parents and the healthcare team should guide continuation versus withdrawal of support. In general, there is no advantage to delayed, graded, or partial support; if the infant survives, outcome may be worsened as a result of this approach.
Discontinuation of Resuscitation
Discontinuation of resuscitative efforts may be appropriate if resuscitation of an infant with cardiorespiratory arrest does not result in spontaneous circulation in 15 minutes. Resuscitation of newly born infants after 10 minutes of asystole is very unlikely to result in survival or survival without severe disability (Class IIb, LOE 5).96-99 We recommend local discussions to formulate guidelines consistent with local resources and outcome data.