PC1071: Exploring the Experiences of Neonatologists in Caring for Periviable Neonates: A Pilot Study

Background: Due to advancements in technology, infants born at earlier gestational ages are receiving resuscitative care. These extremely premature infants are often described as “perviable,” an ambiguous term usually referring to uncertainty about the efficacy of resuscitative treatment. Clinicians often use specific clinical characteristics to identify and guide the treatment of periviable infants, though the lack of national and international consensus has resulted in wide variation in practical decision-making. Consequently, resuscitation of periviable infants can be fraught with clinical and ethical uncertainty. Although the ethical ramifications of caring for periviable infants have been studied with respect to nursing students, medical students, and resident physicians, there are very few studies that have explored the implications on practicing neonatologists.

Methods: In this qualitative study, authors used phenomenology to understand the experience of neonatologists in the resuscitation of periviable neonates and the influence of non-clinical perspectives on their ethical decision-making (IRB #5190494). Interviews were conducted outside the clinical setting by a non-physician naïve to neonatology and consisted of 7 open-ended questions. Interviews were audio-recorded and transcribed. The interviewer de-identified the data and provided it to two physicians. The physicians analyzed the data via phenomenology, a qualitative methodology that aims to provide rich, descriptive accounts of lived experiences. Each transcript was broken down into meaning units, themes, and general constituents through an iterative analysis process to arrive at a final structure of the experience. Physicians underwent bracketing interviews to eliminate bias, and trustworthiness was further enhanced by having the two investigators compare notes after analysis.

Results: 12 interviews were conducted with attending neonatologists with an equal distribution between sexes. The participants’ experience ranged from 1 to greater than 21 years. Participants described periviability as a process of navigating through incongruity, doubt, guilt, and grave uncertainty. During difficult situations, physicians referred to past experiences, personal beliefs, and values while attempting to remain connected with the medical team and the patient’s family. This dynamic process helped to give meaning to clinical decision-making, providing a method of coping during and after the experience. Participants reported tension in trying to reconcile this subjective embodiment of the experience with traditional objective clinical decision-making considerations.

Conclusion: It is reductionist to define periviability solely by an infant’s clinical characteristics to the exclusion of the ambiguity that surrounds the experience. Our study presents periviability as an experiential process that extends beyond granular medical decision-making for extremely preterm infants. In broadening the definition of “periviability” into an experiential concept, this term can then be used to encompass caring for patients of all ages at the margins of life and death whose treatment efficacy is in question. Clinicians who face similar experiences can be comforted in knowing that they are not alone in these challenging situations.