Why?

Q. · Jun 2, 2002

I'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. :)

nell · Jun 2, 2002

kids-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/vol106/issue3/images/large/pe0904560001.jpeg

And the website where you can learn all about it:

http://www.pediatrics.org/cgi/content/full/106/3/e29

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
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.

Hoping to ease your mind,

Nell

Teshiee · Jun 3, 2002

I don't know what drug that medical director was on but he was wrong. I believe in being up close honest with the whole situation. Still give their options which every parent has no matter what we think it is up to the parents. We can't decide who lives or dies we just take it one viable day at a time.

Jenny P · Jun 3, 2002

Kids, I sent you a PM about this. Our choice is not so much to question WHY such a thing happens, it is to look for our own answer to that question: WHY?

We are imperfect humans in an imperfect world. I don't think we intend to play God; but sometimes it certainly may look that way.

prn nurse · Jun 3, 2002

It is not us nurses who are doing the "saving" ...It is not ""Why are WE doing it??"" Not WE as in nurses.....

In my neck of the woods anyway, There's a half dozen hospitals within a few miles of each other.....the neonatologists compete with each other..........they've been competing it for twenty years ! If they hear one of the hospitals, (and they all communicate with each other), has revived and maintained a 1000 gram fetus, then.....if at our hospital, a 980 gram is delivered, they will work like hell to sustain it and have EVERYBODY in the hospital working 24/7 to sustain it. It doesn't have a thing to do with any of the things you all have mentioned here....patient, Gods' plan for the patient, God, parents, ad infinitum.............

It is a serious competition....it is EGO. The doctor's ego,...he is the one who is controlling the situation. Besides , that little dab of flesh is a veritable gold mine for the hospital....The state...your state taxes will pay up to four million dollars keeping it alive....

Big bucks..... the b.s. about keeping it alive because of the patient's destiny , Gods' ordaining of its' soul, the parents' , etc. is just b.s. dished to nurses to make the process palatable to us, so we will participate in the game. After all, we are benefactors too....$$$. A hospital with 2 or 3 800 grammers has a steady paycheck from your state revenue offices..... and the 4 mill can be increased if necessary. Doctors have a powerful state and national lobby.

Call it what it is...ego and greed...

Why???

Call it ego gratification and greed $$$$

As in all things, follow the money....

Q. · Jun 3, 2002

Prn-

You raise some interesting points, but I look at it a different way. While the neos are "competing" you say, to maintain a younger infant than the next hospital, aren't they in fact, acting also on the demands of society?

Society demands and expects that these docs can save these tiny babies. At least around here, the small community hospitals that don't have the latest, techo hoopla are looked down upon within society - because society places value on big time, techno hoopla.

Hospitals aren't built, and services aren't offered that aren't exactly what the public wants.

Also, if the public didn't want these docs to save these babies, they wouldn't opt to go to a hospital with a NICU, they wouldn't opt to deliver at that gestation, so it doesn't matter WHAT services that hospital offered, if the public didn't patron that place, the docs wouldn't get rich, as you say.

The docs get rich because MORE and MORE patients go to them - as a result of what they CAN do, because the public DEMANDS it. They don't get rich simply from keeping a 2000 grammer on a vent. That actually costs the hospital money, and, in alot of cases, the sickest babies are usually on T-19 or no insurance or some other slow to reimburse program.

The doc gets rich because their patient base increases, as a result of what they can offer.

nell · Jun 3, 2002

prn nurse

I have NEVER run into this, and I have worked in several areas where hospitals competed for business.

This competition should be reported to your hospital's ethics committee.