In neonatology, there are four major clinical approaches when a child is born at the limit of viability. A more comprehensive approach is in addition to these four approaches, which incorporates the opinion of the community may limit the therapeutic possibilities as community resources available to children and parents.
Shared responsibilities in clinical approaches in neonatology
The first approach described is that of waiting for certainty. In some situations difficult to judge or extremely urgent, some doctors can not decide on the prognosis of the child and can not advise parents in their decision. They then propose to undertake treatment to collect data that will clarify the prognosis and decision making. The physician then assumes responsibility immediate decisions pending that evolution is accurate. The problem arises when it avoids discussing prognosis and continues processing without seeking the advice of parents, because it is, for example, unable to cope with a potential demand of parents to stop maneuvers. Some authors associate this approach with a paternalistic attitude of the physician, may be related to a discomfort with the possibility of death.
The statistical approach favors treatment according to current statistical data. It does not individualized approach and may offer hope or despair unreal. The problem is to define the acceptable level of mortality and morbidity. It can relieve the doctor and the parents of the decision, indicating a threshold for survival and favorable prognosis which it is permitted to intervene. By cons, it removes any clinical judgment in particular situations. The company then assumes a more prominent role.
More rarely, some doctors explain the consequences of prematurity in length and breadth, without recommending a specific approach to the child, and leave the choice to parents. This detailed approach disempowers the doctor. The principle of fidelity is then discarded. Parents can not make that choice because they do not possess adequate knowledge. They need to be supported in an individualized orientation based on the situation they live.
The individual approach requires time and emotional engagement of empathic physician, divides the decision process between parents and physician, individualized approach according to the clinical status of the child and takes into account the reality of parents. It allows flexibility in the decision, which could reduce conflict. This approach requires the concepts of communications and psychology and, most importantly, time. Even in extremely difficult situations, the fact to explain the reasons for a decision to allow all parties to understand the situation.
The integrated approach is characterized by an individualized approach, whose tags are defined by the community who expressed an opinion about acceptable levels of treatment based on available resources and in individual risk of mortality and morbidity. It thus ensures a balance between the various parties in reaching a consensus on the choice to take on behalf of the child born prematurely.