Neonatal Perinatal Medicine Fellow Yale School of Medicine CLINTON, Connecticut, United States
Background: The impermissible-permissible-obligatory (IPO) framework can provide guidance during shared decision making to define the limits of parental authority when clinicians disagree with parents’ decisions. The zone of parental discretion includes interventions that are considered ethically permissible but not obligatory, such as resuscitation of some extremely premature infants. However, there is little guidance on how to approach critical clinical decisions when parents disagree with each other over interventions in the zone of parental discretion. Objective: We aimed to provide guidance for clinicians faced with critical decisions when there is disagreement between parents within the zone of parental discretion. Design/Methods: We described a clinical case involving parental disagreement over resuscitation of a periviable premature infant, which is considered within the zone of parental discretion. We discussed potential approaches based on established ethical principles of shared decision-making. Results: We described a prenatal consult for a woman in preterm labor at 23 weeks in which the mother desired comfort measures only, but the father requested full resuscitation. Ideally, with further counseling the neonatologist could help the parents reach a joint decision. If delivery became imminent before this occurred, however, the clinician would need to be prepared with a plan for delivery room management. We identified 4 potential options: (1) defer to the pregnant parent; (2) attempt resuscitation if either parent requests it; (3) withhold resuscitation unless both parents agree to it; or (4) decide about resuscitation using a proposed framework of advisability. We explored the merits and ethical pitfalls of each approach and proposed an expansion of the IPO framework as a potential solution. This approach uses consideration of clinical details, prognosis, and parents’ values to determine the advisability of ethically permissible interventions.
Conclusion(s): In the zone of parental discretion, interventions perceived by the physician as advisable (i.e. recommended) but not ethically obligatory should be performed if either parent requests them, while inadvisable treatments should only be administered if both parents agree to them. This expanded IPO framework can be applied broadly to aid in shared decision-making when parents disagree with each other in the zone of parental discretion.
