1. Our intention in this write-up [1] was to
bring this concept into discussion and not discuss practical ethical
dilemmas faced, as these will vary with the settings even in
geographically localized areas. A sound knowledge of ethics in this
area would allow the readers to apply them to their situation. We do
not intend to be prescriptive in any way.
2. The article was reviewed twice and it was
probably felt that Live Birth and Signs of Life were not required to
be defined. We would even now baulk at defining ‘full life support’
and ‘comfort care’ due to reasons mentioned in the article at the
end under "Complexity of the Indian Scenario." Concerning
examination of heart rate (HR), in an unpublished study from our
center, HR was not assessed in 39% of normal delivery care. However,
all resuscitations that required ventilation had HR assessed as per
NRP guidelines [2]. This study is an audit of random videos and
hence participants were not aware that the video would be analyzed.
3. Weight has a similar fallacy as gestational
age. In a neonate requiring resuscitation, weight is often guessed
rather than measured before initiating resuscitative measures.
Hence, it will always be worthwhile to ensure that we follow
guidelines used across the world since gestational age rather than
weight correlates with long-term neurodevelopmental outcomes. Even
after completion of resuscitation, weight measurement may not be
accurate in peripheral centers.
4. We would not agree to many points provided in
the proposed algorithm. We need to decide which methods of
gestational age assessment are to be relied upon. We have already
shown our hesitation to use weight as a deciding criteria. As we
have suggested, instead of few experts putting forth a
recommendation, it is necessary to have a consultation process
probably over a period of 6 months to one year among all
stakeholders (including nurses, hospital administrators, ethicists,
lawyers, parent groups, etc.), and following standard
guideline development processes. A recommendation that comes out of
a broader consultation is likely to be accepted.
5. In cases when there is no therapy that can
benefit an infant (anencephaly/certain severe cardiac deformities/
non-viable GA), a decision by care providers not to try predictably
futile endeavors is ethically and legally justifiable. As such
therapies do not help the child, are sometimes painful for the
infant (and probably distressing to the parents), and offer no
reasonable probability of saving life for a substantial period.
Ethical principle applied here is beneficence and non-maleficence.
The table was proposed by President’s commission
1983 [3]. It mentions that sometimes parents may want to consider
treatment when its believed futile by physicians. As long as this
choice does not cause substantial suffering for the child, providers
should accept it; although, individual health care professionals who
find it personally offensive to engage in futile treatment may
decline the treatment and arrange to withdraw from the case.
