Video Abstract

Video Abstract

CONTEXT:

Whether to resuscitate extremely premature infants (EPIs) is a clinically and ethically difficult decision to make. Indications and practices vary greatly across different countries and institutions, which suggests that resuscitation decisions may be influenced more by the attitudes of the individual treating physicians. Hence, gaining in-depth insight into physicians’ attitudes improves our understanding of decision-making regarding resuscitation of EPIs.

OBJECTIVE:

To better understand physicians’ attitudes toward resuscitation of EPIs and factors that influence their attitudes through a systematic review of the empirical literature.

DATA SOURCES:

Medline, Embase, Web of Science, and Scopus.

STUDY SELECTION:

We selected English-language articles in which researchers report on empirical studies of physicians’ attitudes toward resuscitation of EPIs.

DATA EXTRACTION:

The articles were repeatedly read, themes were identified, and data were tabulated, compared, and analyzed descriptively.

RESULTS:

Thirty-four articles were included. In general, physicians were more willing to resuscitate, to accept parents’ resuscitation requests, and to refuse parents’ nonresuscitation requests as gestational age (GA) increased. However, attitudes vary greatly for infants at GA 23 to 24 weeks, known as the gray zone. Although GA is the primary factor that influences physicians’ attitudes, a complex interplay of patient- and non–patient-related factors also influences their attitudes.

LIMITATIONS:

Analysis of English-only articles may limit generalizability of the results. In addition, authors of only 1 study used a qualitative approach, which may have led to a biased reductionist approach to understanding physicians’ attitudes.

CONCLUSIONS:

Although correlations between GA and attitudes emerged, the results suggested a more complex interplay of factors influencing such attitudes.

Extremely premature infants (EPIs) are infants born before the 28th complete week of gestation (the full gestational period being 40 weeks).1 The mortality rates of EPIs vary depending on gestational age (GA) at birth, technological equipment and pharmaceuticals available at the hospital, and ethical decision-making about how to proceed with the infants’ care.2 In highly developed countries, survival rates for EPIs are <10% at GA 22 weeks, 1% to 64% at GA 23 weeks, 31% to 78% at GA 24 weeks, and 59% to 86% at GA 25 weeks.3,5 EPIs are at an increased risk of having a moderate or severe disability, including a wide range of physical and intellectual impairments such as neurosensory, motor, cognitive, and behavioral impairments.3,6,7 Mortality and morbidity of EPIs are also influenced by sex and birth weight, whether they are twins, whether they are exposed to prenatal steroids and magnesium sulfate, their condition at birth (eg, presence of congenital abnormalities), and postnatal events (eg, sepsis or cerebral complications).6,8 

When an extremely preterm delivery occurs, the first decision to be made is whether to resuscitate the infant.9 According to physicians, this decision is ethically complex.10,13 There is uncertainty about individual prognosis (ie, probability of survival, seriousness of short- and long-term impairments, and future quality of life).10,13,14 Such uncertainty makes it difficult to decide whether active care is appropriate and whether physicians are “going too far.”15 Moreover, deciding whether to resuscitate EPIs raises questions regarding to what extent parents’ requests should be respected.16 

Clinical and moral uncertainties exist at different levels of the decision-making process regarding whether to resuscitate EPIs. First, although national and institutional guidelines indicate when resuscitation should be provided or withheld, agreement on best practices has yet to be reached.12,17,18 Second, the advice and practice of professionals and institutions vary greatly regarding different aspects of the decision-making, such as advised practice for infants of different GAs.2,10,12,19 

Given the diversity of practices and the lack of professional consensus, the decision about whether to resuscitate EPIs is at least partially influenced by the attitudes of the individual physicians who are bearing the clinical and ethical responsibility for the decision made.2 Hence, insight into physicians’ attitudes toward resuscitation of EPIs can contribute to a better understanding of this ethically sensitive decision-making. Therefore, we aim to understand physicians’ attitudes toward resuscitation of EPIs and the factors influencing their attitudes as reported in the empirical literature.

We performed a systematic review of empirical studies on physicians’ attitudes toward resuscitation of EPIs. We followed Peer Review of Electronic Search Strategies20 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)21 guidelines.

A systematic search of Medline, Embase, Web of Science, and Scopus electronic databases was conducted on March 30, 2018. Search strings consisted of 4 categories of search terms: (1) professionals’ subjective dimension (eg, perceptions and attitudes), (2) target population (ie, medical doctors), (3) resuscitation, and (4) EPI. The search strings were developed in collaboration with a librarian (Katholieke Universiteit Leuven) (Table 1). The results from the databases were merged, and duplicate hits were deleted before conducting the title, abstract, and full-text screening. The search was implemented with snowballing and citation tracking to avoid overlooking relevant publications.22 The search process is presented in the PRISMA flow diagram21 (Fig 1).

TABLE 1

Overview of Bibliographic Databases Searched, Search Strings Used, and Search Results of Articles Identified

DatabaseGroup 1: Subjective DimensionGroup 2: Target PopulationGroup 3: ResuscitationGroup 4: EPIsResults,an
Medline (((((“Attitude”[Mesh:NoExp] OR attitude[tiab] OR attitudes[tiab] OR opinion*[tiab])) OR (“Attitude of Health Personnel”[Mesh:NoExp] OR health personnel attitudes[tiab] OR staff attitudes[tiab]) OR (“attitude to death”[Mesh] OR attitudes to death[tiab])) OR (“Health Knowledge, Attitudes, Practice”[Mesh] OR experience*[tiab] OR perspective*[tiab] OR preference*[tiab] OR argument*[tiab] OR insight*[tiab] OR view*[tiab] OR feeling*[tiab])) OR “Intuition”[Mesh] OR intuition*[tiab] OR intention*[tiab]) Physician[MeSH] OR Physician*[tiab] OR doctor*[ tiab] OR clinician*[ tiab] OR neonatologist[MeSH] OR neonatologist*[ tiab] OR pediatrician*[ tiab] OR obstetrician*[ tiab] OR healthcare provider*[ tiab] ((((((“Resuscitation”[Mesh] OR resuscitation[tiab] OR cardio pulmonary resuscitation[tiab] OR CPR[tiab] OR basic cardiac life support[tiab] OR reanimation[tiab] OR neonatal resuscitation[tiab])) OR (“Decision Making”[Mesh:NoExp] OR decision making[tiab] OR treatment decisions[tiab] OR end-of-life decisions[tiab])) OR (“Intensive Care, Neonatal”[Mesh] OR neonatal intensive care[tiab])) OR (“Intensive Care Units, Neonatal”[Mesh] OR neonatal ICU[tiab] OR NICU[tiab] OR neonatal intensive care units[tiab]))) (((“Infant, Newborn”[Mesh] OR infant[tiab] OR infants[tiab] OR newborn[tiab] OR newborns[tiab] OR neonate[tiab] OR neonates[tiab] OR low-birth-weight infant*[tiab] OR premature infant*[tiab] OR preterm infant*[tiab] OR extremely premature infant[tiab] OR neonatal prematurity[tiab] OR viability[tiab] OR extreme prematurity[tiab])) OR (“Premature Birth”[Mesh] OR premature birth[tiab] OR preterm birth[tiab])) 1506 
Embase 'attitude'/de OR 'health personnel attitude'/de OR 'attitude to death'/exp OR 'intuition'/exp OR ((attitude:ab,ti OR attitudes:ab,ti OR health) AND personnel AND attitude:ab,ti OR attitude) AND to AND death:ab,ti OR intuition*:ab,ti OR experience*:ab,ti OR perspective*:ab,ti OR preference*:ab,ti OR opinion*:ab,ti OR argument*:ab,ti OR insight*:ab,ti OR feeling*:ab,ti OR intention*:ab,ti OR view*:ab,ti 'physician'/de OR 'neonatologist'/de OR 'pediatrician'/de OR 'health care personnel'/de OR ((physician:ab,ti OR physicians:ab,ti OR neonatologist:ab,ti OR neonatologists:ab,ti OR pediatrician:ab,ti OR pediatricians:ab,ti OR pediatrician:ab,ti OR pediatricians:ab,ti OR doctor:ab,ti OR doctors:ab,ti OR clinicican:ab,ti OR clinicians:ab,ti OR obstetrician:ab,ti OR obstetricians:ab,ti OR healthcare) AND provider:ab,ti) ('resuscitation'/exp OR 'newborn intensive care'/exp OR 'NICU'/exp OR 'ethical decision making'/de OR 'decision making'/de OR 'clinical decision making'/de OR resuscitation:ab,ti OR 'NICU':ab,ti OR 'newborn intensive care':ab,ti OR 'decision making':ab,ti OR ((treatment NEXT/1 decision*):ab,ti) OR end:ab,ti) AND of:ab,ti AND life:ab,ti AND decision*:ab,ti 'infant'/exp OR infant:ab,ti OR infants:ab,ti OR newborn:ab,ti OR newborns:ab,ti OR neonate:ab,ti OR neonates:ab,ti OR 'extremely low birth weight'/de OR 'extremely low birth weight':ab,ti OR 'extremely premature infant*':ab,ti OR 'prematurity'/exp OR 'premature labor'/exp OR 'premature labor'/de OR ((extreme NEXT/1 prematurity):ab,ti) OR 'preterm birth':ab,ti OR 'premature birth':ab,ti OR 'viability':ab,ti 127 
Web of Science TS= (attitude OR attitudes OR opinion* OR health personnel attitude OR health personnel attitudes OR staff attitude OR staff attitude OR attitude to death OR experience* OR perspective* OR preference* OR argument* OR insight* OR view* OR feeling* OR intuition* OR intention*) TS=(Physicians* OR doctor* OR clinician* OR obstetrician* OR healthcare provider* OR pediatrician* OR pediatrician* OR neonatologist*) TS= (Resuscitation OR cardio pulmonary resuscitation OR CPR OR basic cardiac life support OR reanimation OR neonatal resuscitation OR decision making OR treatment decisions OR end-of-life decisions OR neonatal intensive care OR neonatal ICU OR NICU OR neonatal intensive care units) TS=(infant OR infants OR newborn OR newborns OR neonate OR neonates OR low-birth weight infant* OR premature infant* OR preterm infant* OR extremely premature infant OR neonatal prematurity OR viability OR extreme prematurity OR premature birth OR preterm birth) 1115 
Scopus TITLE-ABS-KEY attitude OR attitudes OR opinion* OR “health personnel attitud*” OR “staff attitude*” OR experience* OR perspective* OR preference* OR argument* OR insight*or AND view* OR feeling* OR intuition* or intention*) TITLE-ABS-KEY (physicians* OR doctor* OR clinician* OR obstetrician* OR “healthcare provider*” OR pediatrician* OR pediatrician* OR neonatologist*) TITLE-ABS-KEY (resuscitation OR “cardiopulmonary resuscitation” OR CPR OR “neonatal resuscitation” OR “decision making” OR “treatment decision*” OR “end-of-life decision*” OR “neonatal intensive care” OR “neonatal ICU” OR “neonatal intensive care unit*”) TITLE-ABS-KEY (infant OR infants OR newborn OR newborns OR neonate OR neonates OR “low-birth-weight infant*” OR “premature infant*” OR “preterm infant*” OR “extremely premature infant” OR “neonatal prematurity” OR viability OR “extreme prematurity” OR “premature birth*” OR “preterm birth*”) 342 
DatabaseGroup 1: Subjective DimensionGroup 2: Target PopulationGroup 3: ResuscitationGroup 4: EPIsResults,an
Medline (((((“Attitude”[Mesh:NoExp] OR attitude[tiab] OR attitudes[tiab] OR opinion*[tiab])) OR (“Attitude of Health Personnel”[Mesh:NoExp] OR health personnel attitudes[tiab] OR staff attitudes[tiab]) OR (“attitude to death”[Mesh] OR attitudes to death[tiab])) OR (“Health Knowledge, Attitudes, Practice”[Mesh] OR experience*[tiab] OR perspective*[tiab] OR preference*[tiab] OR argument*[tiab] OR insight*[tiab] OR view*[tiab] OR feeling*[tiab])) OR “Intuition”[Mesh] OR intuition*[tiab] OR intention*[tiab]) Physician[MeSH] OR Physician*[tiab] OR doctor*[ tiab] OR clinician*[ tiab] OR neonatologist[MeSH] OR neonatologist*[ tiab] OR pediatrician*[ tiab] OR obstetrician*[ tiab] OR healthcare provider*[ tiab] ((((((“Resuscitation”[Mesh] OR resuscitation[tiab] OR cardio pulmonary resuscitation[tiab] OR CPR[tiab] OR basic cardiac life support[tiab] OR reanimation[tiab] OR neonatal resuscitation[tiab])) OR (“Decision Making”[Mesh:NoExp] OR decision making[tiab] OR treatment decisions[tiab] OR end-of-life decisions[tiab])) OR (“Intensive Care, Neonatal”[Mesh] OR neonatal intensive care[tiab])) OR (“Intensive Care Units, Neonatal”[Mesh] OR neonatal ICU[tiab] OR NICU[tiab] OR neonatal intensive care units[tiab]))) (((“Infant, Newborn”[Mesh] OR infant[tiab] OR infants[tiab] OR newborn[tiab] OR newborns[tiab] OR neonate[tiab] OR neonates[tiab] OR low-birth-weight infant*[tiab] OR premature infant*[tiab] OR preterm infant*[tiab] OR extremely premature infant[tiab] OR neonatal prematurity[tiab] OR viability[tiab] OR extreme prematurity[tiab])) OR (“Premature Birth”[Mesh] OR premature birth[tiab] OR preterm birth[tiab])) 1506 
Embase 'attitude'/de OR 'health personnel attitude'/de OR 'attitude to death'/exp OR 'intuition'/exp OR ((attitude:ab,ti OR attitudes:ab,ti OR health) AND personnel AND attitude:ab,ti OR attitude) AND to AND death:ab,ti OR intuition*:ab,ti OR experience*:ab,ti OR perspective*:ab,ti OR preference*:ab,ti OR opinion*:ab,ti OR argument*:ab,ti OR insight*:ab,ti OR feeling*:ab,ti OR intention*:ab,ti OR view*:ab,ti 'physician'/de OR 'neonatologist'/de OR 'pediatrician'/de OR 'health care personnel'/de OR ((physician:ab,ti OR physicians:ab,ti OR neonatologist:ab,ti OR neonatologists:ab,ti OR pediatrician:ab,ti OR pediatricians:ab,ti OR pediatrician:ab,ti OR pediatricians:ab,ti OR doctor:ab,ti OR doctors:ab,ti OR clinicican:ab,ti OR clinicians:ab,ti OR obstetrician:ab,ti OR obstetricians:ab,ti OR healthcare) AND provider:ab,ti) ('resuscitation'/exp OR 'newborn intensive care'/exp OR 'NICU'/exp OR 'ethical decision making'/de OR 'decision making'/de OR 'clinical decision making'/de OR resuscitation:ab,ti OR 'NICU':ab,ti OR 'newborn intensive care':ab,ti OR 'decision making':ab,ti OR ((treatment NEXT/1 decision*):ab,ti) OR end:ab,ti) AND of:ab,ti AND life:ab,ti AND decision*:ab,ti 'infant'/exp OR infant:ab,ti OR infants:ab,ti OR newborn:ab,ti OR newborns:ab,ti OR neonate:ab,ti OR neonates:ab,ti OR 'extremely low birth weight'/de OR 'extremely low birth weight':ab,ti OR 'extremely premature infant*':ab,ti OR 'prematurity'/exp OR 'premature labor'/exp OR 'premature labor'/de OR ((extreme NEXT/1 prematurity):ab,ti) OR 'preterm birth':ab,ti OR 'premature birth':ab,ti OR 'viability':ab,ti 127 
Web of Science TS= (attitude OR attitudes OR opinion* OR health personnel attitude OR health personnel attitudes OR staff attitude OR staff attitude OR attitude to death OR experience* OR perspective* OR preference* OR argument* OR insight* OR view* OR feeling* OR intuition* OR intention*) TS=(Physicians* OR doctor* OR clinician* OR obstetrician* OR healthcare provider* OR pediatrician* OR pediatrician* OR neonatologist*) TS= (Resuscitation OR cardio pulmonary resuscitation OR CPR OR basic cardiac life support OR reanimation OR neonatal resuscitation OR decision making OR treatment decisions OR end-of-life decisions OR neonatal intensive care OR neonatal ICU OR NICU OR neonatal intensive care units) TS=(infant OR infants OR newborn OR newborns OR neonate OR neonates OR low-birth weight infant* OR premature infant* OR preterm infant* OR extremely premature infant OR neonatal prematurity OR viability OR extreme prematurity OR premature birth OR preterm birth) 1115 
Scopus TITLE-ABS-KEY attitude OR attitudes OR opinion* OR “health personnel attitud*” OR “staff attitude*” OR experience* OR perspective* OR preference* OR argument* OR insight*or AND view* OR feeling* OR intuition* or intention*) TITLE-ABS-KEY (physicians* OR doctor* OR clinician* OR obstetrician* OR “healthcare provider*” OR pediatrician* OR pediatrician* OR neonatologist*) TITLE-ABS-KEY (resuscitation OR “cardiopulmonary resuscitation” OR CPR OR “neonatal resuscitation” OR “decision making” OR “treatment decision*” OR “end-of-life decision*” OR “neonatal intensive care” OR “neonatal ICU” OR “neonatal intensive care unit*”) TITLE-ABS-KEY (infant OR infants OR newborn OR newborns OR neonate OR neonates OR “low-birth-weight infant*” OR “premature infant*” OR “preterm infant*” OR “extremely premature infant” OR “neonatal prematurity” OR viability OR “extreme prematurity” OR “premature birth*” OR “preterm birth*”) 342 

ABS, abstract; TS, topic.

a

Number of articles returned for the indicated search.

FIGURE 1

Electronic literature search for the identification and selection of articles dealing with physicians’ attitudes toward the care of EPIs. The flowchart is organized according to the PRISMA guidelines outlined by Liberati et al.21 

FIGURE 1

Electronic literature search for the identification and selection of articles dealing with physicians’ attitudes toward the care of EPIs. The flowchart is organized according to the PRISMA guidelines outlined by Liberati et al.21 

Guided by predefined criteria, 2 authors (A.C. and C.G.) independently conducted the abstract and full-text screening. Disagreements about article inclusion were resolved by discussion until consensus was reached. Inclusion and exclusion criteria were defined on the basis of type of study, participants, and outcome measures (Table 2). Regardless of these strict inclusion and exclusion criteria, some biases may be introduced in the review. For instance, studies reporting on self-reported attitudes may be affected by social desirability bias. In addition, resuscitation and additional treatment of EPIs requires technological and pharmaceutical equipment, which means that in low-income countries where there is lack or scarcity of such equipment, EPIs may not be resuscitated. This may lead to the exclusion of low-income countries from the review and the introduction of cultural bias.

TABLE 2

Inclusion and Exclusion Criteria for Selection of Articles on Physicians’ Attitudes Toward Resuscitation of EPIs

IncludedaExcluded
Types of study reported on
  • Published empirical studies with quantitative, qualitative, or mixed-methods designs • Dissertations, books, book chapters, theoretical articles, guidelines, and reviews 
• Publication language is English  
• Inclusion was not restricted to a particular time period  
Types of participants in the study
  • Practicing physicians in studies sampling their attitudes alone, or • Studies in which only the attitudes of nonphysician clinicians (eg, nurses, midwives, trainees, or students) were sampled 
• Practicing physicians in combined studies of nonphysician clinicians or parents, only if physicians’ data could be separately extracted • Studies in which only the attitudes of EPI parents, relatives, and other nonphysician stakeholders were sampled 
Outcome measures in study reported on
  • Physicians’ attitudes, perceptions, feelings, opinions toward and arguments for or against resuscitation versus nonresuscitation • Measures of the actual involvement of physicians in the decision-making process and the current decision-making practice 
• Measures of resuscitation as a holistic process and measures focusing on the different steps of resuscitation separately • Measures of withholding or withdrawal of active treatments or intensive care in general 
 • Measures of infants with extremely low birth wt in generalb 
IncludedaExcluded
Types of study reported on
  • Published empirical studies with quantitative, qualitative, or mixed-methods designs • Dissertations, books, book chapters, theoretical articles, guidelines, and reviews 
• Publication language is English  
• Inclusion was not restricted to a particular time period  
Types of participants in the study
  • Practicing physicians in studies sampling their attitudes alone, or • Studies in which only the attitudes of nonphysician clinicians (eg, nurses, midwives, trainees, or students) were sampled 
• Practicing physicians in combined studies of nonphysician clinicians or parents, only if physicians’ data could be separately extracted • Studies in which only the attitudes of EPI parents, relatives, and other nonphysician stakeholders were sampled 
Outcome measures in study reported on
  • Physicians’ attitudes, perceptions, feelings, opinions toward and arguments for or against resuscitation versus nonresuscitation • Measures of the actual involvement of physicians in the decision-making process and the current decision-making practice 
• Measures of resuscitation as a holistic process and measures focusing on the different steps of resuscitation separately • Measures of withholding or withdrawal of active treatments or intensive care in general 
 • Measures of infants with extremely low birth wt in generalb 

Infants born before 28 weeks’ gestation.1 

a

Screening of articles was not limited by publication date; the entire date range was included in searches of the Medline, Embase, Web of Science, and Scopus databases.

b

When identifying premature infants, we recognize that EPIs and infants with extremely low birth weight partially overlap. To ensure homogeneity and comparability of the cross-study data, we excluded articles in which the study considered only birth weight as the identifying factor and analysis of variables related to infants with low birth weight in general.

The included quantitative studies were appraised by using the tool developed by Hawker et al,23 whereas the included qualitative studies were appraised by using the Critical Appraisal Skills Programme (CASP).24 Quality appraisal was conducted by 2 authors (A.C. and C.G.) independently. The 2 sets of assessments were compared, and in cases of disagreements, assessments were discussed until a consensus was achieved. Quality assessment was indicative rather than evaluative, meaning that articles were not excluded on the basis of their methodologic quality.

Data extraction and synthesis consisted of several steps. The results of each step were discussed within the research group comprising experts in neonatology, nursing science, philosophy, and bioethics. First, the included articles were repeatedly read to familiarize ourselves with the material. Next, the results section of each article was read, and relevant data were extracted to identify the articles’ main themes. This step produced 4 themes, providing the structure to describe the results: (1) physicians’ attitudes toward resuscitation versus nonresuscitation, (2) physicians’ attitudes toward parents’ requests to resuscitate versus to not resuscitate, (3) influence of physicians’ demographic characteristics, and (4) influence of case-related factors on attitudes. Finally, data within each theme were tabulated to identify comparable sets of data. On the basis of the tables, data were analyzed and compared to identify relevant attitudinal patterns and influencing factors. The general trends were then described, and exceptions were further analyzed to understand their basis. Given the lack of sufficient data for EPIs younger than GA 22 weeks, only data related to the period between the 22nd and 27th weeks were extracted.

The systematic search yielded 34 relevant publications (Table 3). The publication dates range from 1998 to 2017. The studies originated from 27 countries, representing 5 continents: North America (n = 14), Oceania (n = 6), Asia (n = 3), Europe (n = 10), and Africa (n = 1).

TABLE 3

Overview of Studies in the Included Articles

StudyCountryAimSample Size and RRData CollectionEthical Considerations
Quantitative studies      
 Armstrong et al25  Ireland To determine how physicians apply the best-interest standard 200 health care professionals and medical students. RR: 74% (n = 148); health care professionals’ RR: 63% (n = 93); students’ RR: 37% (n = 55) Questionnaire included 8 resuscitation scenarios of incompetent, critically ill patients and questions about resuscitation preferences Anonymity of participants was ensured 
 Arzuaga and Meadow26  United States To identify differences in resuscitation practices for EPIs (GA 22–25 wk) and influencing factors 2123 members of the perinatal section of the American Academy of Pediatrics. RR: 30% (n = 637) Questionnaire included collection of demographic data, presentation of scenarios, and attitudinal questions Approval of the institutional review board was obtained 
 Arzuaga et al27  United States To investigate the associations between physicians’ personal characteristics and attitudes toward resuscitation of EPIs (GA 22–23 wk). 626 physician members of the Islamic Medical Association of North America. RR: 41% (n = 255) Questionnaire included presentation of scenarios and attitudinal questions Anonymity of participants was ensured 
 Ballard et al28  United States To investigate the associations between fear of litigation and attitudes toward resuscitation 949 neonatologists from the American Medical Association Masterfile. RR: 63.0% (n = 598) Survey included a vignette and attitudinal questions (2 different versions used)  Approval of the Institutional Review Boards of the Children’s Hospital of Philadelphia and University of Pennsylvania was obtained 
 Bell et al29  Romania To investigate physicians’ attitudes toward withholding or withdrawing intensive care for impaired infants 95 neonatologists participating at the National Congress of Neonatology in Iasi, Romania. RR: none Survey included 36 multiple-choice or close-ended questions Anonymity of participants and voluntary participation was ensured 
 Charafeddine et al30  Lebanon To determine physicians’ attitudes toward resuscitation of EPIs (GA 23–26 wk) and influencing factors for attitudes 328 practicing neonatologists and pediatricians registered in the Lebanese Order of Physicians. RR: 36% (n = 120) Questionnaire included demographic data, closed-ended questions on management of preterm deliveries and EPIs, and counseling Approval from the institutional review board and verbal consent to participate were obtained 
 Cummings et al31  United States To determine physicians’ opinions regarding threshold for resuscitating EPIs (GA 21–27 wk) 65 neontologists in the perinatal section of the American Academy of Pediatrics. RR: 69% (n = 45) Questionnaire included demographic data, different scenarios, and attitudinal questions Anonymity of participants was ensured 
 De Leeuw et al32  Italy, Spain, France, Germany, Netherlands, Luxembourg, United Kingdom, Sweden, Hungary, Estonia, and Lithuania To determine physicians’ attitudes toward resuscitation for infants at the borderline of viability 1574 physicians. RR: 89% (n = 1401) Questionnaire included different ethical scenarios Anonymity of participants was ensured 
 Duffy and Reynolds33  United Kingdom To determine pediatricians’ attitudes toward parental treatment preferences 123 consultants and trainees. Consultants’ RR: 49% (n = 54); trainees’ RR: 51% (n = 57) Questionnaire included demographic data, closed-ended questions on management of EPIs and counseling, and freedom for text comments Approval of the Surrey Research Ethics Committee was obtained 
 Geurtzen et al34  Netherlands To explore physicians’ preferences toward treatment of EPIs (GA 22–26 wk) despite the guidelines 205 obstetricians and neonatologists. RR: 60% (n = 122) Survey questionnaire included demographic data, 1 scenario, and 3 attitudinal questions Approval of local institutional review board was obtained, and anonymity of participants was ensured 
 Gooi et al35  Australia To explore nontertiary obstetricians’ opinions toward treatment of EPIs (GA 22–28 wk) 232 obstetricians. RR: 75% (n = 174) Questionnaire included demographic data, clinical case, and questions about treatment preferences and outcomes Voluntary participation was ensured 
 Hansen et al36  Norway To determine physicians’ attitudes toward resuscitation of critically ill patients (aged 24 wk–80 y) 1650 practicing physicians. RR: 65% (n = 1069) Questionnaire included 8 resuscitation scenarios involving incompetent, critically ill patients; questions about resuscitation preferences — 
 Kariholu et al37  United Kingdom To determine staff’s opinions toward resuscitation for EPIs (<GA 27 wk) 37 participants: consultant pediatricians and neonatologists (n = 20), specialists’ registrars (n = 13), and nursing staff (n = 4) Questionnaire included questions on opinions about the GA at which to start resuscitation Anonymity of participants was ensured 
 Khan et al38  Ireland To determine health care providers’ attitudes toward resuscitation for EPIs (GA 22–27 wk) and the influence of the expected outcomes 300 health care providers. RR: 55% (n = 175); neonatologists’ RR: 70%; obstetricians’ RR: 74%; pediatricians’ RR: not reported; senior midwives’ and nurses’ RR: 70% Questionnaire included questions on the antenatal, intrapartum, and postnatal management of mother and infant Anonymity of participants was ensured 
 Kunkel et al39  United States and Canada To determine the influence of maternal characteristics on neonatologists’ recommendations for periviable pregnancies 3000 neonatologists in the United States and Canada. RR: 16% (n = 471); included in the study: n = 328 Web-based survey contained 8 clinical case vignettes portraying mother with different characteristics Approval of Institutional Review Board of Indiana University was obtained 
 Laventhal et al40  United States To determine physicians and obstetricians’ attitudes toward resuscitation of critically ill patients 4450 pediatricians and obstetricians; 743 participants: physicians (n = 204), nurses (n = 539). RR: 15% (n = 695) Questionnaire included demographic data, 8 resuscitation scenarios of incompetent critically ill patients, and questions about resuscitation preferences Anonymity of participants and voluntary participation was ensured 
 Lavin et al41  United States To explore health care providers’ opinions about resuscitation of EPIs (GA 22–26 wk) RR: not reported  Questionnaire included questions on opinions about resuscitation and counseling — 
 Lavoie et al42  Canada To describe neonatologists’ attitudes toward delivery room resuscitation of EPIs (GA 23–26 wk) 169 neonatologists. RR: 74% (n = 121) Phone survey questionnaire included demographic data, whether parents requested withholding resuscitation, and open-ended attitudinal questions Approval of the University of British Columbia’s Behavioral Research Ethics Board and the Children’s and Women’s Health Centre Research Ethics Board was obtained 
 Martinez et al43  Japan, Australia, Hong Kong, Singapore, Taiwan, and Malaysia To determine what factors influence resuscitation practices and neonatologists’ attitudes toward EPIs (GA 22–25 wk) 618 neonatologists in the participating countries. RR: 51% (n = 318) Questionnaire included demographic data and questions on preferred treatment and counseling Approval of the Research Ethics Committee of the University of California and at each site was obtained before the study. 
 McAdams et al44  Mongolia To identify factors that influence health care professionals’ practices and attitudes toward parental involvement in neonatal resuscitation decisions 210 health care providers randomly selected. RR: 100% (n = 210) Questionnaire included demographic data, vignettes, and close-ended and multiple-choice questions Approval of the Institutional Review Board of the University of Washington was obtained, and anonymity of participants and voluntary participation was ensured 
 Mills et al16  Australia To explore physicians’ attitudes toward resuscitation of critically ill incompetent patients and toward the best-interest standard (age of patients: GA 24 wk–80 y) 140 neonatologists. RR: 78% (n = 109) Questionnaire included demographic data, 8 resuscitation scenarios of incompetent critically ill patients, and questions about resuscitation preferences — 
 Mulvey et al45  Australia To determine obstetricians’ attitudes toward resuscitation of EPIs and infants with extremely low birth wt 187 obstetricians. RR: 48% (n = 89) Questionnaire included demographic data and questions on antenatal counseling and resuscitation — 
 Munro et al46  Australia To investigate neonatologists’ attitudes toward antenatal counseling and resuscitation for EPIs (<GA 26 wk) 100 neonatologists. RR: 70% (n = 70) Questionnaire included demographic data and attitudinal questions on resuscitation and counseling — 
 Norup47  Denmark To describe pediatricians’ attitudes toward treatment of EPIs (>GA 24 wk) 954 physicians. RR: 69% (n = 664) Questionnaire included demographic data, fictional cases, and attitudinal questions; 2 different versions were used The regional Research Ethics Committee stated participant approval was unnecessary, and anonymity of participants was ensured 
 Oei et al48  Australia To explore physicians’ and nurses’ attitudes toward resuscitation of EPIs (<GA 28 wk) 76 neonatologists and 57 nurses. Neonatologists’ RR: 93% (n = 71); nurses’ RR: 72% (n = 41) Questionnaire included graded questions, open-ended questions, and numeric responses Anonymity of participants was ensured 
 Partridge et al49  United States To determine factors that influence delivery room resuscitation decisions for EPIs (<GA 26 wk) 445 neonatologists practicing in California. RR: 61% (n = 270) Survey included demographic data, multiple-choice and open-ended questions on resuscitation of EPIs, counseling, and threshold of viability Approval of the Committee on Human Research of the University of California was obtained, and anonymity of participants was ensured 
 Partridge et al50  South Africa To explore physicians’ attitudes toward life support and counseling for EPIs (GA 23–30 wk) 394 practicing pediatricians and neonatologists. RR: 24% (n = 93) Questionnaire included demographic data and attitudinal questions on counseling, management of delivery, and resuscitation Approval of the Research Ethics Committee and the University of Witwatersrand Institutional Review Board was obtained, and anonymity of participants was ensured 
 Partridge et al51  United States To describe neonatologists’ perceptions of the Born-Alive Infants Protection Act for EPIs (GA 20–24 wk) 376 neonatologists in California. RR: 44% (n = 156) Questionnaire included a copy of the Born-Alive Infants Protection Act, demographic data, and questions on current and future practices regarding counseling and resuscitation Approval of the Research Ethics Review Board of the University of California was obtained, and anonymity of participants and voluntary participation was ensured 
 Peerzada et al52  United States To explore neonatologists’ attitudes toward parental wishes regarding resuscitation of EPIs (GA 22–26 wk) 175 practicing level II and III neonatologists. RR: 85% (n = 149) Cross-sectional survey contained close-ended questions on threshold for intervention, vignettes, and attitudinal questions Approval of the Committee on Clinical Investigation at Children’s Hospital Boston was obtained, and anonymity of participants was ensured 
 Peerzada et al53  Sweden To explore neonatologists’ attitudes toward parental wishes regarding resuscitation of EPIs (GA 22–26 wk) 124 neonatologists. RR: 71% (n = 88) Cross-sectional survey contained close-ended questions on threshold for intervention, vignettes, and attitudinal questions Approval from the Research Ethics Committee of Umeå University was obtained, and anonymity of participants was ensured 
 Ramsay and Santella54  United States To understand physicians’ definition of live birth/fetal death and their attitudes toward resuscitation of EPIs (<GA 24 wk) 73 neonatologists and obstetricians. RR: 79% (n = 58) Phone survey; 2 different versions were used Approval of Columbia University Medical Center’s Institutional Review Board was obtained, and anonymity of participants was ensured 
 Singh et al55  United States To determine physicians’ treatment preferences for EPIs born in the gray zone (GA 23–26 wk) 500 neonatologists in 2003; RR: 63% (n = 304); 550 neonatologists in 1996; RR: 66% (n = 362) Questionnaire included 4 different scenarios and attitudinal questions Approval of the Institutional Review Board of the University of Chicago was obtained 
 Weiss et al56  United States To explore factors that influence resuscitation decisions for EPIs (<GA 28 wk) 129 neonatologists practicing in Illinois. RR: 66% (n = 85) 27-item survey included demographic data and attitudinal questions Approval of the Children’s Memorial Hospital Institutional Review Board was obtained 
Qualitative study      
 Collyns et al57  New Zealand To investigate physicians’ ethical reasoning in decisions concerning treatments for EPIs and abortion 16 neonatal pediatric and obstetric and/or gynecologist registrars and consultants Semistructured interviews (20–60 min) — 
StudyCountryAimSample Size and RRData CollectionEthical Considerations
Quantitative studies      
 Armstrong et al25  Ireland To determine how physicians apply the best-interest standard 200 health care professionals and medical students. RR: 74% (n = 148); health care professionals’ RR: 63% (n = 93); students’ RR: 37% (n = 55) Questionnaire included 8 resuscitation scenarios of incompetent, critically ill patients and questions about resuscitation preferences Anonymity of participants was ensured 
 Arzuaga and Meadow26  United States To identify differences in resuscitation practices for EPIs (GA 22–25 wk) and influencing factors 2123 members of the perinatal section of the American Academy of Pediatrics. RR: 30% (n = 637) Questionnaire included collection of demographic data, presentation of scenarios, and attitudinal questions Approval of the institutional review board was obtained 
 Arzuaga et al27  United States To investigate the associations between physicians’ personal characteristics and attitudes toward resuscitation of EPIs (GA 22–23 wk). 626 physician members of the Islamic Medical Association of North America. RR: 41% (n = 255) Questionnaire included presentation of scenarios and attitudinal questions Anonymity of participants was ensured 
 Ballard et al28  United States To investigate the associations between fear of litigation and attitudes toward resuscitation 949 neonatologists from the American Medical Association Masterfile. RR: 63.0% (n = 598) Survey included a vignette and attitudinal questions (2 different versions used)  Approval of the Institutional Review Boards of the Children’s Hospital of Philadelphia and University of Pennsylvania was obtained 
 Bell et al29  Romania To investigate physicians’ attitudes toward withholding or withdrawing intensive care for impaired infants 95 neonatologists participating at the National Congress of Neonatology in Iasi, Romania. RR: none Survey included 36 multiple-choice or close-ended questions Anonymity of participants and voluntary participation was ensured 
 Charafeddine et al30  Lebanon To determine physicians’ attitudes toward resuscitation of EPIs (GA 23–26 wk) and influencing factors for attitudes 328 practicing neonatologists and pediatricians registered in the Lebanese Order of Physicians. RR: 36% (n = 120) Questionnaire included demographic data, closed-ended questions on management of preterm deliveries and EPIs, and counseling Approval from the institutional review board and verbal consent to participate were obtained 
 Cummings et al31  United States To determine physicians’ opinions regarding threshold for resuscitating EPIs (GA 21–27 wk) 65 neontologists in the perinatal section of the American Academy of Pediatrics. RR: 69% (n = 45) Questionnaire included demographic data, different scenarios, and attitudinal questions Anonymity of participants was ensured 
 De Leeuw et al32  Italy, Spain, France, Germany, Netherlands, Luxembourg, United Kingdom, Sweden, Hungary, Estonia, and Lithuania To determine physicians’ attitudes toward resuscitation for infants at the borderline of viability 1574 physicians. RR: 89% (n = 1401) Questionnaire included different ethical scenarios Anonymity of participants was ensured 
 Duffy and Reynolds33  United Kingdom To determine pediatricians’ attitudes toward parental treatment preferences 123 consultants and trainees. Consultants’ RR: 49% (n = 54); trainees’ RR: 51% (n = 57) Questionnaire included demographic data, closed-ended questions on management of EPIs and counseling, and freedom for text comments Approval of the Surrey Research Ethics Committee was obtained 
 Geurtzen et al34  Netherlands To explore physicians’ preferences toward treatment of EPIs (GA 22–26 wk) despite the guidelines 205 obstetricians and neonatologists. RR: 60% (n = 122) Survey questionnaire included demographic data, 1 scenario, and 3 attitudinal questions Approval of local institutional review board was obtained, and anonymity of participants was ensured 
 Gooi et al35  Australia To explore nontertiary obstetricians’ opinions toward treatment of EPIs (GA 22–28 wk) 232 obstetricians. RR: 75% (n = 174) Questionnaire included demographic data, clinical case, and questions about treatment preferences and outcomes Voluntary participation was ensured 
 Hansen et al36  Norway To determine physicians’ attitudes toward resuscitation of critically ill patients (aged 24 wk–80 y) 1650 practicing physicians. RR: 65% (n = 1069) Questionnaire included 8 resuscitation scenarios involving incompetent, critically ill patients; questions about resuscitation preferences — 
 Kariholu et al37  United Kingdom To determine staff’s opinions toward resuscitation for EPIs (<GA 27 wk) 37 participants: consultant pediatricians and neonatologists (n = 20), specialists’ registrars (n = 13), and nursing staff (n = 4) Questionnaire included questions on opinions about the GA at which to start resuscitation Anonymity of participants was ensured 
 Khan et al38  Ireland To determine health care providers’ attitudes toward resuscitation for EPIs (GA 22–27 wk) and the influence of the expected outcomes 300 health care providers. RR: 55% (n = 175); neonatologists’ RR: 70%; obstetricians’ RR: 74%; pediatricians’ RR: not reported; senior midwives’ and nurses’ RR: 70% Questionnaire included questions on the antenatal, intrapartum, and postnatal management of mother and infant Anonymity of participants was ensured 
 Kunkel et al39  United States and Canada To determine the influence of maternal characteristics on neonatologists’ recommendations for periviable pregnancies 3000 neonatologists in the United States and Canada. RR: 16% (n = 471); included in the study: n = 328 Web-based survey contained 8 clinical case vignettes portraying mother with different characteristics Approval of Institutional Review Board of Indiana University was obtained 
 Laventhal et al40  United States To determine physicians and obstetricians’ attitudes toward resuscitation of critically ill patients 4450 pediatricians and obstetricians; 743 participants: physicians (n = 204), nurses (n = 539). RR: 15% (n = 695) Questionnaire included demographic data, 8 resuscitation scenarios of incompetent critically ill patients, and questions about resuscitation preferences Anonymity of participants and voluntary participation was ensured 
 Lavin et al41  United States To explore health care providers’ opinions about resuscitation of EPIs (GA 22–26 wk) RR: not reported  Questionnaire included questions on opinions about resuscitation and counseling — 
 Lavoie et al42  Canada To describe neonatologists’ attitudes toward delivery room resuscitation of EPIs (GA 23–26 wk) 169 neonatologists. RR: 74% (n = 121) Phone survey questionnaire included demographic data, whether parents requested withholding resuscitation, and open-ended attitudinal questions Approval of the University of British Columbia’s Behavioral Research Ethics Board and the Children’s and Women’s Health Centre Research Ethics Board was obtained 
 Martinez et al43  Japan, Australia, Hong Kong, Singapore, Taiwan, and Malaysia To determine what factors influence resuscitation practices and neonatologists’ attitudes toward EPIs (GA 22–25 wk) 618 neonatologists in the participating countries. RR: 51% (n = 318) Questionnaire included demographic data and questions on preferred treatment and counseling Approval of the Research Ethics Committee of the University of California and at each site was obtained before the study. 
 McAdams et al44  Mongolia To identify factors that influence health care professionals’ practices and attitudes toward parental involvement in neonatal resuscitation decisions 210 health care providers randomly selected. RR: 100% (n = 210) Questionnaire included demographic data, vignettes, and close-ended and multiple-choice questions Approval of the Institutional Review Board of the University of Washington was obtained, and anonymity of participants and voluntary participation was ensured 
 Mills et al16  Australia To explore physicians’ attitudes toward resuscitation of critically ill incompetent patients and toward the best-interest standard (age of patients: GA 24 wk–80 y) 140 neonatologists. RR: 78% (n = 109) Questionnaire included demographic data, 8 resuscitation scenarios of incompetent critically ill patients, and questions about resuscitation preferences — 
 Mulvey et al45  Australia To determine obstetricians’ attitudes toward resuscitation of EPIs and infants with extremely low birth wt 187 obstetricians. RR: 48% (n = 89) Questionnaire included demographic data and questions on antenatal counseling and resuscitation — 
 Munro et al46  Australia To investigate neonatologists’ attitudes toward antenatal counseling and resuscitation for EPIs (<GA 26 wk) 100 neonatologists. RR: 70% (n = 70) Questionnaire included demographic data and attitudinal questions on resuscitation and counseling — 
 Norup47  Denmark To describe pediatricians’ attitudes toward treatment of EPIs (>GA 24 wk) 954 physicians. RR: 69% (n = 664) Questionnaire included demographic data, fictional cases, and attitudinal questions; 2 different versions were used The regional Research Ethics Committee stated participant approval was unnecessary, and anonymity of participants was ensured 
 Oei et al48  Australia To explore physicians’ and nurses’ attitudes toward resuscitation of EPIs (<GA 28 wk) 76 neonatologists and 57 nurses. Neonatologists’ RR: 93% (n = 71); nurses’ RR: 72% (n = 41) Questionnaire included graded questions, open-ended questions, and numeric responses Anonymity of participants was ensured 
 Partridge et al49  United States To determine factors that influence delivery room resuscitation decisions for EPIs (<GA 26 wk) 445 neonatologists practicing in California. RR: 61% (n = 270) Survey included demographic data, multiple-choice and open-ended questions on resuscitation of EPIs, counseling, and threshold of viability Approval of the Committee on Human Research of the University of California was obtained, and anonymity of participants was ensured 
 Partridge et al50  South Africa To explore physicians’ attitudes toward life support and counseling for EPIs (GA 23–30 wk) 394 practicing pediatricians and neonatologists. RR: 24% (n = 93) Questionnaire included demographic data and attitudinal questions on counseling, management of delivery, and resuscitation Approval of the Research Ethics Committee and the University of Witwatersrand Institutional Review Board was obtained, and anonymity of participants was ensured 
 Partridge et al51  United States To describe neonatologists’ perceptions of the Born-Alive Infants Protection Act for EPIs (GA 20–24 wk) 376 neonatologists in California. RR: 44% (n = 156) Questionnaire included a copy of the Born-Alive Infants Protection Act, demographic data, and questions on current and future practices regarding counseling and resuscitation Approval of the Research Ethics Review Board of the University of California was obtained, and anonymity of participants and voluntary participation was ensured 
 Peerzada et al52  United States To explore neonatologists’ attitudes toward parental wishes regarding resuscitation of EPIs (GA 22–26 wk) 175 practicing level II and III neonatologists. RR: 85% (n = 149) Cross-sectional survey contained close-ended questions on threshold for intervention, vignettes, and attitudinal questions Approval of the Committee on Clinical Investigation at Children’s Hospital Boston was obtained, and anonymity of participants was ensured 
 Peerzada et al53  Sweden To explore neonatologists’ attitudes toward parental wishes regarding resuscitation of EPIs (GA 22–26 wk) 124 neonatologists. RR: 71% (n = 88) Cross-sectional survey contained close-ended questions on threshold for intervention, vignettes, and attitudinal questions Approval from the Research Ethics Committee of Umeå University was obtained, and anonymity of participants was ensured 
 Ramsay and Santella54  United States To understand physicians’ definition of live birth/fetal death and their attitudes toward resuscitation of EPIs (<GA 24 wk) 73 neonatologists and obstetricians. RR: 79% (n = 58) Phone survey; 2 different versions were used Approval of Columbia University Medical Center’s Institutional Review Board was obtained, and anonymity of participants was ensured 
 Singh et al55  United States To determine physicians’ treatment preferences for EPIs born in the gray zone (GA 23–26 wk) 500 neonatologists in 2003; RR: 63% (n = 304); 550 neonatologists in 1996; RR: 66% (n = 362) Questionnaire included 4 different scenarios and attitudinal questions Approval of the Institutional Review Board of the University of Chicago was obtained 
 Weiss et al56  United States To explore factors that influence resuscitation decisions for EPIs (<GA 28 wk) 129 neonatologists practicing in Illinois. RR: 66% (n = 85) 27-item survey included demographic data and attitudinal questions Approval of the Children’s Memorial Hospital Institutional Review Board was obtained 
Qualitative study      
 Collyns et al57  New Zealand To investigate physicians’ ethical reasoning in decisions concerning treatments for EPIs and abortion 16 neonatal pediatric and obstetric and/or gynecologist registrars and consultants Semistructured interviews (20–60 min) — 

RR, response rate; —, not applicable.

Thirty-three studies were quantitative, and 1 was qualitative (Table 3). In all of the quantitative studies, authors used a descriptive design (ie, questionnaire survey) with closed-ended or graded questions. Fictional cases or different scenarios linked to attitudinal questions were used in 18 studies, and in-depth interviews were used in the qualitative study.

An in-house custom questionnaire was developed and used in most of the studies. The custom questionnaire developed by Janvier et al58 was used in 4 studies.16,25,36,40 Similarly, other questionnaires were used twice in different studies.

The study setting was indicated in only 13 studies, the majority of which were conducted either in NICUs (n = 4) or in perinatal and neonatal centers (n = 5).

Overall, 8682 physicians participated in the included studies, with reported sample sizes ranging from 16 to 1401. In a majority of the studies, authors reported on the attitudes of neonatologists (n = 13), physicians (n = 7), obstetricians (n = 2), or consultants (n = 1) alone or in combination (n = 7). The remaining studies were used to compare attitudes of physicians and nurses (n = 4).

The quality assessment results for the included quantitative and qualitative studies are summarized in Tables 4 and 5. Only 4 low-quality studies emerged from our evaluation. All quantitative studies had good or fair results on quality, meaning that their findings were appropriately described and easily understandable.23 Moreover, with only a few exceptions, most of the reports had abstracts, introductions, and aims that we rated as having fair or good quality. However, in 12 studies, researchers failed to adequately describe their data analysis, and in 17 reports, researchers failed to include an adequate ethics section. Finally, although the qualitative study was of high quality, the researchers failed to consider limitations resulting from the relationship between researchers and participants.

TABLE 4

Assessment of Quantitative Studies Using Specific Appraisal Criteria

Study (n = 33)Hawker et al23 Criteriaa
123456789Overall Assessment (Out of 36 Possible Points)
Abstract and TitleIntroduction and AimsMethod and DataSamplingData AnalysisEthics and BiasResultsTransferability or GeneralizabilityImplications and Usefulness
Armstrong et al25  Good Fair Good Fair Poor Poor Good Good Fair Moderate 
Arzuaga and Meadow26  Good Good Good Good Fair Fair Good Good Fair High 
Arzuaga et al27  Fair Good Good Good Good Poor Good Good Good High 
Ballard et al28  Good Good Good Fair Good Fair Good Good Good High 
Bell et al29  Fair Fair Poor Fair Very poor Poor Good Fair Good Moderate 
Charafeddine et al30  Good Good Good Good Fair Fair Good Good Fair High 
Cummings et al31  Good Good Good Fair Very poor Poor Fair Fair Fair Moderate 
De Leeuw et al32  Good Good Good Good Good Poor Good Good Poor High 
Duffy and Reynolds33  Fair Fair Good Good Fair Fair Good Fair Fair High 
Geurtzen et al34  Fair Good Good Good Fair Fair Good Fair Fair High 
Gooi et al35  Good Poor Good Good Fair Poor Good Fair Good High 
Hansen et al36  Good Good Good Good Poor Very poor Good Good Good High 
Kariholu et al37  Fair Good Fair Fair Very poor Poor Good Poor Fair Moderate 
Khan et al38  Good Good Fair Fair Fair Poor Good Fair Poor Moderate 
Kunkel et al39  Good Good Good Good Good Fair Good Good Fair High 
Laventhal et al40  Good Fair Good Fair Fair Fair Good Fair Fair High 
Lavin et al41  Good Fair Fair Fair Poor Very poor Good Fair Fair Moderate 
Lavoie et al42  Good Fair Fair Good Good Poor Good Fair Fair High 
Martinez et al43  Good Good Good Fair Fair Fair Fair Fair Poor Moderate 
McAdams et al44  Good Good Good Fair Fair Fair Good Fair Fair High 
Mills et al16  Fair Good Good Poor Very poor Very poor Fair Fair Poor Low 
Mulvey et al45  Fair Fair Poor Fair Very poor Very poor Good Poor Poor Low 
Munro et al46  Poor Good Poor Poor Very poor Very poor Good Poor Fair Low 
Norup, 199847  Fair Fair Fair Good Fair Fair Good Fair Fair Moderate 
Oei et al48  Good Fair Fair Poor Poor Poor Fair Poor Poor Low 
Partridge et al49  Good Fair Fair Good Very poor Good Good Fair Good High 
Partridge et al50  Fair Poor Fair Fair Fair Fair Good Poor Good Moderate 
Partridge et al51  Good Good Fair Fair Good Good Good Fair Fair High 
Peerzada et al52  Good Good Good Good Good Fair Good Good Fair High 
Peerzada et al53  Fair Fair Good Good Good Fair Good Fair Fair High 
Ramsey and Santella54  Fair Poor Fair Good Very poor Good Fair Fair Fair Moderate 
Singh et al55  Good Good Good Good Good Fair Fair Good Fair High 
Weiss et al56  Fair Fair Fair Fair Fair Fair Good Fair Poor Moderate 
Study (n = 33)Hawker et al23 Criteriaa
123456789Overall Assessment (Out of 36 Possible Points)
Abstract and TitleIntroduction and AimsMethod and DataSamplingData AnalysisEthics and BiasResultsTransferability or GeneralizabilityImplications and Usefulness
Armstrong et al25  Good Fair Good Fair Poor Poor Good Good Fair Moderate 
Arzuaga and Meadow26  Good Good Good Good Fair Fair Good Good Fair High 
Arzuaga et al27  Fair Good Good Good Good Poor Good Good Good High 
Ballard et al28  Good Good Good Fair Good Fair Good Good Good High 
Bell et al29  Fair Fair Poor Fair Very poor Poor Good Fair Good Moderate 
Charafeddine et al30  Good Good Good Good Fair Fair Good Good Fair High 
Cummings et al31  Good Good Good Fair Very poor Poor Fair Fair Fair Moderate 
De Leeuw et al32  Good Good Good Good Good Poor Good Good Poor High 
Duffy and Reynolds33  Fair Fair Good Good Fair Fair Good Fair Fair High 
Geurtzen et al34  Fair Good Good Good Fair Fair Good Fair Fair High 
Gooi et al35  Good Poor Good Good Fair Poor Good Fair Good High 
Hansen et al36  Good Good Good Good Poor Very poor Good Good Good High 
Kariholu et al37  Fair Good Fair Fair Very poor Poor Good Poor Fair Moderate 
Khan et al38  Good Good Fair Fair Fair Poor Good Fair Poor Moderate 
Kunkel et al39  Good Good Good Good Good Fair Good Good Fair High 
Laventhal et al40  Good Fair Good Fair Fair Fair Good Fair Fair High 
Lavin et al41  Good Fair Fair Fair Poor Very poor Good Fair Fair Moderate 
Lavoie et al42  Good Fair Fair Good Good Poor Good Fair Fair High 
Martinez et al43  Good Good Good Fair Fair Fair Fair Fair Poor Moderate 
McAdams et al44  Good Good Good Fair Fair Fair Good Fair Fair High 
Mills et al16  Fair Good Good Poor Very poor Very poor Fair Fair Poor Low 
Mulvey et al45  Fair Fair Poor Fair Very poor Very poor Good Poor Poor Low 
Munro et al46  Poor Good Poor Poor Very poor Very poor Good Poor Fair Low 
Norup, 199847  Fair Fair Fair Good Fair Fair Good Fair Fair Moderate 
Oei et al48  Good Fair Fair Poor Poor Poor Fair Poor Poor Low 
Partridge et al49  Good Fair Fair Good Very poor Good Good Fair Good High 
Partridge et al50  Fair Poor Fair Fair Fair Fair Good Poor Good Moderate 
Partridge et al51  Good Good Fair Fair Good Good Good Fair Fair High 
Peerzada et al52  Good Good Good Good Good Fair Good Good Fair High 
Peerzada et al53  Fair Fair Good Good Good Fair Good Fair Fair High 
Ramsey and Santella54  Fair Poor Fair Good Very poor Good Fair Fair Fair Moderate 
Singh et al55  Good Good Good Good Good Fair Fair Good Fair High 
Weiss et al56  Fair Fair Fair Fair Fair Fair Good Fair Poor Moderate 

The specific appraisal criteria are from Hawker et al.23 Scoring: good = 4; fair = 3; poor = 2; very poor = 1.

a

Hawker et al23 appraisal questions: (1) Did they provide a clear description of the study? (2) Was there a clear background and a clear statement of the aims of the research? (3) Is the method appropriate and clearly explained? (4) Was the sampling strategy appropriate to address the aims? (5) Was the description of the data analysis sufficiently rigorous? (6) Have ethical issues been addressed, and what has necessary ethical approval gained? (7) Is there a clear statement of the findings? (8) Are the findings of this study transferable (generalizable) to a wider population? (9) How important are these findings for policies and practice?

TABLE 5

Assessment of Qualitative Study Using the Appraisal Criteria of CASP

StudyCASP CriteriaaOverall Assessment
(Out of 30 Possible)
12345678910
Clear Statement of AimsAppropriate MethodologyAppropriate DesignAppropriate Recruitment StrategyAppropriate Data CollectionAdequate Consideration of the Relationship Between Researcher and ParticipantsEthical Issues ConsideredData Analysis Sufficiently RigorousClear Statement of FindingsWas the Research Valuable
n = 1            
 Collyns et al57  Yes Yes Yes Unclear Yes No No Yes Yes Yes High 
StudyCASP CriteriaaOverall Assessment
(Out of 30 Possible)
12345678910
Clear Statement of AimsAppropriate MethodologyAppropriate DesignAppropriate Recruitment StrategyAppropriate Data CollectionAdequate Consideration of the Relationship Between Researcher and ParticipantsEthical Issues ConsideredData Analysis Sufficiently RigorousClear Statement of FindingsWas the Research Valuable
n = 1            
 Collyns et al57  Yes Yes Yes Unclear Yes No No Yes Yes Yes High 
a

CASP24 appraisal questions: (1) Was there a clear statement of the aims of the research? (2) Was a qualitative methodology appropriate? (3) Was the research design appropriate to address the aims? (4) Was the recruitment strategy appropriate to the aims? (5) Were the data collected in a way that addressed the research issue? (6) Was the relationship between researcher and participants adequately considered? (7) Were ethical issues taken into consideration? (8) Was the data analysis sufficiently rigorous? (9) Was there a clear statement of findings? (10) How valuable was the research? Scoring: yes = 3; unclear = 2; no = 1.

In 19 studies, researchers investigated physicians’ attitudes toward resuscitation or nonresuscitation of EPIs. The researchers of these studies considered the issue from different perspectives. Most researchers examined attitudes according to the GAs of the EPIs. Fewer studies were used to examine this aspect in terms of physicians’ lower threshold for resuscitation, which is defined as the lowest GA below which physicians would not resuscitate (Table 6).

TABLE 6

Summary of Physicians’ Attitudes Toward Resuscitation and Nonresuscitation of EPIs According to GA

GA, wkaResuscitation, %Nonresuscitation, %Threshold for Resuscitation, %b
22    
 Range 0–4.437,38,41,48  85–10033,37,38,41,46,48  0–5529,34,48,49,56  
 Exception 5127  4927  — 
23    
 Range 4–4728,38,41,48,55  57–81.938,41,48,55  11–4034,48,49,56  
 Exception 8527  1527  9754  
24    
 Range 38–9916,25,32,33,36,38,40,41,48,55  2–27.232,38,41,46,48,55  2–7834,48,49,56  
 Exception — 6332  — 
25    
 Range 85.4–10038,41,48,55  0–4.238,41,48,55  0–1034,49,56  
 Exception 63 and 6547  — — 
26    
 Range 95–10038,41,48,55  0–138,41,48  0–134,49,56  
 Exception — — 2729  
27 100 yes38,48  0 no38,48  049,56  
GA, wkaResuscitation, %Nonresuscitation, %Threshold for Resuscitation, %b
22    
 Range 0–4.437,38,41,48  85–10033,37,38,41,46,48  0–5529,34,48,49,56  
 Exception 5127  4927  — 
23    
 Range 4–4728,38,41,48,55  57–81.938,41,48,55  11–4034,48,49,56  
 Exception 8527  1527  9754  
24    
 Range 38–9916,25,32,33,36,38,40,41,48,55  2–27.232,38,41,46,48,55  2–7834,48,49,56  
 Exception — 6332  — 
25    
 Range 85.4–10038,41,48,55  0–4.238,41,48,55  0–1034,49,56  
 Exception 63 and 6547  — — 
26    
 Range 95–10038,41,48,55  0–138,41,48  0–134,49,56  
 Exception — — 2729  
27 100 yes38,48  0 no38,48  049,56  

—, not applicable.

a

GA refers to the number of complete wk of gestation. For example, a GA of 22 wk spans from 220 to 226.

b

Threshold for resuscitation refers to the lowest GA below which physicians would not resuscitate.

Attitudes According to GA

With only few exceptions, the 15 studies in which researchers investigated how physicians’ attitudes differ depending on GA reveal a clear trend: With increasing GA, physicians were more willing to resuscitate the EPIs, and with decreasing GA, they were less willing to resuscitate. Results from these studies are grouped according to GA (Fig 2).

FIGURE 2

Physicians’ attitudes toward resuscitation and nonresuscitation of EPIs. Some researchers report data on physicians’ attitudes toward both resuscitation and nonresuscitation. Such studies are represented by multiple dots.

FIGURE 2

Physicians’ attitudes toward resuscitation and nonresuscitation of EPIs. Some researchers report data on physicians’ attitudes toward both resuscitation and nonresuscitation. Such studies are represented by multiple dots.

GA 22 and 23 Weeks

The majority of physicians (85%–100%) would not resuscitate infants born at GA 22 weeks33,37,38,41,48; only 0% to 4.4% said they would.37,38,41,48 Even for infants born at GA 23 weeks, most physicians (57%–81.9%) still would not resuscitate,38,41,48,55 whereas more said that they would (4%–47%)28,38,41,48,55 compared with 22 weeks. One exception is the study by Arzuaga et al27 of North American physicians who identified themselves as Muslim: 51% and 85% would resuscitate at GA 22 and 23 weeks, respectively.

GA 24 Weeks

The percentage of physicians willing to resuscitate EPIs at GA 24 weeks varied widely, spanning from 38% to 99%.16,25,32,33,36,38,40,41,48,55 Similarly, 2% to 27.2% were unwilling to resuscitate.32,38,41,46,48,55 However, the study of physicians in 11 European countries32 found that the majority surveyed in the Netherlands (63%) would not resuscitate EPIs at this GA, whereas in the other 10 countries, between 82% and 96% would resuscitate.

GA 25 Weeks

The majority of physicians (85.4%–100%) would resuscitate at GA 25 weeks,38,41,48,55 whereas a minority (0%–4.2%) still would not.38,41,48,55 In only 1 study were different results reported.47 That study included a fictitious scenario in which a young married couple struggled over the resuscitation decision of their 25-week-old infant. Only 63% of pediatricians and 65% of obstetricians would resuscitate in this case.

GA 26 and 27 Weeks

Between 95% to 100% and 100%, respectively, would resuscitate EPIs at GA 26 weeks38,41,48,55 and GA 27 weeks.38,48 Few (0%–1% and 0%) would not resuscitate at GA 2638,41,48 or 27 weeks.38,48 

Attitudes According to Threshold for Resuscitation

In 6 studies, researchers investigated what physicians considered to be the lower GA threshold for resuscitation. None of the physicians surveyed would set the threshold below GA 22 weeks, and only rarely would they set the threshold above GA 24 weeks.

Most of the physicians surveyed set the resuscitation threshold between GA 22 weeks and GA 24 weeks. It ranged from 0% to 55% at 22 weeks,29,34,48,49,56 11% to 40% at 23 weeks,34,48,49,56 and 2% to 78% at 24 weeks.34,48,49,56 Whereas these studies varied greatly, in 1 study, 97% of physicians set the resuscitation threshold at GA 23 weeks.54 The authors of this study sampled opinions of 58 obstetricians and neonatologists practicing in 34 hospitals with NICUs in New York City.54 

Few physicians set the threshold above GA 24 weeks: 0% to 10% set the threshold at 25 weeks,34,49,56 0% to 1% at 26 weeks,34,49,56 and 0% at 27 weeks.49,56 Bell et al,29 analyzing the attitudes of 95 Romanian neonatologists, found that 27% of physicians set the resuscitation threshold at GA 26 weeks, below which they would refuse to resuscitate.

In 5 studies, researchers determined which week was selected on average as the threshold for resuscitation. In the majority of those studies, researchers set the mean threshold between GA 22 and 24 weeks35,43,45,51 with few exceptions. In the international study of Martinez et al,43 physicians in Japan set a lower threshold (GA 21–22 weeks), whereas physicians in Malaysia43 and South Africa50 set a higher threshold (GA 25 weeks).

In 13 studies, researchers investigated physicians’ attitudes toward parents’ requests to resuscitate or to not resuscitate their EPI. Some investigators examined attitudes according to GA, whereas others examined attitudes according to thresholds for accepting or refusing the parents’ requests (Table 7).

TABLE 7

Physicians’ Attitudes Toward Parents’ Resuscitation or Nonresuscitation Requests

GA, wkGeneral Attitudes Toward Parents’ RequestsThreshold for Accepting or Refusing Parents’ Requests
Refused Parents’ Nonresuscitation Request, %Refused Parents’ Resuscitation Request, %Accepted Parents’ Nonresuscitation Request, %Youngest GA for Refusing Parents’ Nonresuscitation Request, %Oldest GA for Accepting Parents’ Nonresuscitation Request, %Youngest GA for Accepting Parents’ Resuscitation Request, %Oldest GA for Refusing Parents’ Resuscitation Request, %
22 131; exception: 4427  4231  — Range: 0–126,56  052,53  Range: 12–2126,52,53  4056  
23 Range: 7–4331,33; exception: 4627  731  9842  Range: 5–1526,56  Range: 37–6152,53  Range: 60–8426,52,53  3056  
24 5331  131  Range: 65–9416,25,36,40,42; exception: 6–4032  Range: 27–2926,56  Range: 30–5052,53  Range: 3–1526,52,53  956  
25 Range: 41–6131,42  031  2442  Range: 30–5026,56  Range: 6–1352,53  Range: 0–226,52,53  256  
26 Range: 64–8231,42  031  — Range: 15–2326,56  Range: 0–352,53  026,52,53  256  
27 6431  031  — Range: 1–226,56  — — 056  
GA, wkGeneral Attitudes Toward Parents’ RequestsThreshold for Accepting or Refusing Parents’ Requests
Refused Parents’ Nonresuscitation Request, %Refused Parents’ Resuscitation Request, %Accepted Parents’ Nonresuscitation Request, %Youngest GA for Refusing Parents’ Nonresuscitation Request, %Oldest GA for Accepting Parents’ Nonresuscitation Request, %Youngest GA for Accepting Parents’ Resuscitation Request, %Oldest GA for Refusing Parents’ Resuscitation Request, %
22 131; exception: 4427  4231  — Range: 0–126,56  052,53  Range: 12–2126,52,53  4056  
23 Range: 7–4331,33; exception: 4627  731  9842  Range: 5–1526,56  Range: 37–6152,53  Range: 60–8426,52,53  3056  
24 5331  131  Range: 65–9416,25,36,40,42; exception: 6–4032  Range: 27–2926,56  Range: 30–5052,53  Range: 3–1526,52,53  956  
25 Range: 41–6131,42  031  2442  Range: 30–5026,56  Range: 6–1352,53  Range: 0–226,52,53  256  
26 Range: 64–8231,42  031  — Range: 15–2326,56  Range: 0–352,53  026,52,53  256  
27 6431  031  — Range: 1–226,56  — — 056  

—, not tested.

Attitudes Toward Parental Requests According to GA

In 3 studies,27,31,42 physicians were asked whether they would refuse the parents’ request to resuscitate or not resuscitate their EPI, whereas in 6 studies, physicians were asked whether they would accept a nonresuscitation request.16,25,32,36,40,42 Regardless of the form of the question, the data clearly reveal that physicians were less willing to accept a nonresuscitation request as GA increased. Likewise, they were less likely to refuse a resuscitation request as GA increased. Similarly, as GA increased, physicians were more willing to deny a nonresuscitation request (Fig 3).

FIGURE 3

Physicians’ attitudes toward parents’ resuscitation or nonresuscitation requests. Some researchers report data on physicians’ attitudes toward both parents’ request for resuscitation and parents’ request for nonresuscitation. Such studies are represented by multiple dots.

FIGURE 3

Physicians’ attitudes toward parents’ resuscitation or nonresuscitation requests. Some researchers report data on physicians’ attitudes toward both parents’ request for resuscitation and parents’ request for nonresuscitation. Such studies are represented by multiple dots.

GA 22 Weeks

At GA 22 weeks, only 1% of physicians would refuse parents’ nonresuscitation request, whereas 42% would refuse a resuscitation request.31 By contrast, the Arzuaga et al27 study on the attitudes of Muslim physicians found that 44% of physicians would refuse parents’ nonresuscitation requests.

GA 23 Weeks

Seven percent to 43% of physicians would refuse a nonresuscitation request for EPIs,31,33 and 7% of physicians would refuse a resuscitation request at GA 23 weeks.31 In 1 study, researchers reported that 98% of physicians would accept a parental nonresuscitation request.42 Again, the Arzuaga et al27 report was an exception, with 46% of physicians refusing a nonresuscitation request.

GA 24 Weeks

In 1 study, 53% of physicians would refuse a parental nonresuscitation request, but only 1% would refuse a resuscitation request at GA 24 weeks.31 In other studies, researchers report that 65% to 94% of physicians would accept a nonresuscitation request.16,25,36,40,42 In the study of 11 European countries, only physicians who stated they would resuscitate EPIs were also asked whether they would accept a nonresuscitation request; 6% to 40% indicated that they would.32 

GA 25 Weeks

More physicians would refuse a nonresuscitation request (41%–61%) at GA 25 weeks.31,42 None of the physicians would refuse parents’ resuscitation requests,31 and only 24% of physicians would accept a nonresuscitation request.42 

GA 26 to 27 Weeks

The majority of physicians would refuse a nonresuscitation request for infants as old as GA 26 and 27 weeks; this ranged from 64% to 82%31,42 and 64%,31 respectively. None of the physicians would refuse parents’ resuscitation request in this range of GA.31 

Attitudes According to Threshold for Accepting or Refusing Parents’ Requests for Resuscitation or Nonresuscitation

This threshold was defined as the lowest GA at or below which resuscitation should be consistently withheld.56 For parental nonresuscitation requests of infants at GA 22 weeks, virtually no physician (0%–1%) considered this GA to be a threshold for refusing nonresuscitation requests.26,56 The percentage sharply increased to 30% to 50% of physicians setting the threshold at GA 25 weeks; the percentage decreased for those setting the threshold at 26 weeks.26,56 No physician considered GA 22 weeks as the oldest age for accepting nonresuscitation requests. The majority of physicians placed such a GA threshold at 23 weeks, with the percentage ranging from 37% to 61%.52,53 From GA 24 weeks, the percentage declines until reaching 0% again at 26 weeks.52,53 

In 3 studies,26,52,53 researchers sought to determine the lowest GA at which physicians would accept parents’ resuscitation requests. In those studies, 12% to 84% of the physicians set the minimum age for resuscitation between GA 22 and 23 weeks, with more physicians leaning toward 23 weeks as the lower limit for resuscitation. The percentage dropped as the GA of the infant increased, going from 3% to 15% for GA 24 weeks to 0% for GA 26 weeks. Among the neonatologists surveyed in Weiss et al,56 40% would refuse to resuscitate EPIs with a GA of 22 weeks, but 0% would refuse to resuscitate infants born at GA 27 weeks. The results of these studies indicate that the physicians surveyed seem to set the lower limit for resuscitation at GA 22 to 23 weeks and the upper limit for refusing to resuscitate between 24 and 25 weeks.

In 10 studies, researchers investigated possible correlations between physicians’ demographic characteristics and their attitudes toward resuscitation, nonresuscitation (n = 8),26,30,32,34,38,41,49,51 and parents’ requests for resuscitation and nonresuscitation (n = 2).27,42 

Demographic Characteristics and Attitudes Toward Resuscitation

In 2 studies, researchers found a statistically significant correlation between physicians’ specialty and their attitudes. Obstetricians were more likely to recommend resuscitation for very young EPIs than neonatologists34 and pediatricians.41 Only De Leeuw et al32 found a statistically significant correlation between attitudes and physicians’ parental status and religiosity. Physicians with children and physicians who were religious were more willing to resuscitate EPIs. Partridge et al51 found a significant correlation with physicians’ age and work setting. Older physicians and those working in private hospitals set higher GA thresholds for resuscitation. Finally, Arzuaga and Meadow26 found a statistically significant correlation between physicians’ attitudes and different abortion legislations. US physicians working in states prohibiting abortion after GA 23 weeks were less likely to think that resuscitation should be mandatory at GA 24 weeks (Table 8).

TABLE 8

Correlations Between Physician Demographics, Non–Case-Related Variables, and Physicians’ Attitudes Toward Resuscitation and Nonresuscitation

AgeSexHas ChildrenReligiosityPro-choice Versus Pro-lifeYears of ExperienceHealth Care SpecialtyLevel of NICUPublic Versus Private HospitalAbortion Law
Arzuaga and Meadow26  — — — NS NS — — — — P < .05 
Charafeddine et al30  NS NS NS NS — NS — NS — — 
De Leeuw et al32  — — P = .05 P = .008 — NS — — — — 
Geurtzen et al34  NS — — — — NS P = .028 — — — 
Khan et al38  — — — — — — NS — — — 
Lavin et al41  — — — — — — 22 wk: P = .0003; 23 wk: P = .0008a — — — 
Partridge et al49  NS NS — — — NS — NS NS — 
Partridge et al51  P = .02 — NS NS NS — — — P = .01 — 
AgeSexHas ChildrenReligiosityPro-choice Versus Pro-lifeYears of ExperienceHealth Care SpecialtyLevel of NICUPublic Versus Private HospitalAbortion Law
Arzuaga and Meadow26  — — — NS NS — — — — P < .05 
Charafeddine et al30  NS NS NS NS — NS — NS — — 
De Leeuw et al32  — — P = .05 P = .008 — NS — — — — 
Geurtzen et al34  NS — — — — NS P = .028 — — — 
Khan et al38  — — — — — — NS — — — 
Lavin et al41  — — — — — — 22 wk: P = .0003; 23 wk: P = .0008a — — — 
Partridge et al49  NS NS — — — NS — NS NS — 
Partridge et al51  P = .02 — NS NS NS — — — P = .01 — 

NS, no significant correlation found or no numerical data reported; —, not tested.

a

Statistical correlations between specialty and attitudes have been tested and reported according to the different GAs.

In several studies, researchers found that physicians’ years of experience,30,32,34,49 sex,30,49 identification as pro-choice or pro-life,26,51 and level of NICU30,49 did not have a significant impact on physicians’ attitude toward resuscitating EPIs (Table 8).

Impact of Physicians’ Characteristics on Attitudes Toward Parental Requests

Arzuaga et al27 analyzed whether different measures of religiosity influenced Muslim physicians’ decision to accept nonresuscitation requests from parents. A higher frequency of Quran reading was associated with a higher likelihood of resuscitating an EPI against parents’ requests for infants at GA 22 weeks (odds ratio [OR]: 7.6; P < .001) and 23 weeks (OR: 4.55; P = .003).27 In addition, a higher attendance at congregational worship services was associated with a higher probability of resuscitating an EPI against parents’ request for infants at GA 23 weeks (OR: 5.3; P = .006). Lavoie et al42 observed a statistically significant correlation between physicians’ willingness to accept a parental request and physicians’ personal experience with disability. Physicians having personal experience with disabled persons were more likely to accept parents’ request to not resuscitate (90% vs 71%; P = .01). No significant correlations were found with age, sex, country, years of practice, and parental status.42 

In 19 studies, researchers investigated the influence of case-related factors on physicians’ attitudes toward resuscitation and nonresuscitation (n = 17)* and parents’ requests for resuscitation and nonresuscitation (n = 6).30,33,46,52,53,57 

Impact of Case-Related Factors on Attitudes Toward Resuscitation

Singh et al55 classified case-related factors as 2 categories: patient-related factors (eg, condition at birth) and non–patient-related factors (eg, resource allocation). Using the same classification, we identified a trend: although physicians considered patient-related factors to be important contributors in the decision to resuscitate, non–patient-related factors were rarely considered important contributors to the decision-making.

The main factors influencing physicians’ attitudes toward resuscitation or nonresuscitation were EPIs’ medical condition at birth,26,42,48,52,53,55 presence of congenital anomalies,34,42,43,45,49 probability of death or survival,30,43,45,46,52,53,55 probability of future disability,30,52,53 parents’ wishes,26,30,43,45,48,49 and quality of life.43,49,57 

The factors that were deemed less relevant in the decision-making process were emotional or financial burden to the family,43,45,46,52,53 health care resource allocation,43,45,46,49,55,57 and fear of litigation.43,45,46,49,55 Only in the study of Lebanese neonatologists’ attitudes30 did researchers find that health care resource allocation was ranked second as an influencing factor. Authors of another study found that fear of litigation was an important, although subtle, factor that influenced physicians’ decision to resusciate.28 

Finally, in 3 studies, researchers found that maternal characteristics can also influence physicians’ attitudes toward resuscitation. In Kunkel et al,39 parity, planned pregnancy, and race had a statistically significant impact on physicians’ willingness to resuscitate an EPI. Similarly, in 2 studies in which physicians were asked to give opinions on 2 scenarios in which EPIs’ characteristics remained constant but maternal characteristics (eg, age, marital status, parity) varied, maternal characteristics were found to significantly affect physicians’ willingness to resuscitate.44,47 

Impact of Case-Related Factors on Attitudes Toward Parental Requests

A number of studies observed that physicians were willing to resuscitate an EPI, even against parents’ requests, in cases in which resuscitation would be clearly beneficial or when parents were unsure about resuscitation.30,33,52,53 In 2 studies, researchers reported that parental influence is limited when there is a high likelihood of bad or good outcomes, especially at GA 22 and 25 weeks.46,57 

The results of this systematic review reveal that the GA at birth of EPIs greatly influences physicians’ attitudes toward resuscitation and nonresuscitation and accepting or refusing parents’ requests for or against resuscitation. Physicians’ willingness to resuscitate, to accept parents’ resuscitation requests, and to refuse parents’ nonresuscitation requests increases with increasing GA. This trend is consistent with the majority of clinical practice guidelines, which advise comfort care at GA 22 weeks and active treatment at GA 24 to 26 weeks.18,59,60 

Our results confirm other research18 that physicians’ views on resuscitation and on parents’ requests to resuscitate or not vary greatly when analyzing the 23-to-24-week GA period, constituting a “gray zone” of uncertainty. This uncertainty reflects a lack of consensus among physicians. Guidelines vary widely for infants born in the GA 23-to-24-week range compared with other GAs.18,59 Guidelines also tend to endorse a more individualized approach to treatment rather than advising strict resuscitation or nonresuscitation efforts.18,59,61 The existence of the gray zone is also supported by our finding that individual physicians’ GA threshold for initiating resuscitation is typically placed between GA 22 and 24 weeks.

We found 2 exceptions to these trends.27,32 First, De Leeuw et al32 reported that Dutch physicians are less willing to resuscitate an EPI of GA 24 weeks than physicians from other European countries. This is consistent with 1992 Dutch guidelines stating that the resuscitation threshold is a GA of 26 weeks.62 In 2010, the Netherlands developed new guidelines advising active treatment from GA 24 weeks.63 This recommendation may have contributed to a greater willingness to resuscitate at this GA. Indeed, according to Geurtzen et al,34 78% of the physicians surveyed set the resuscitation threshold at GA 24 weeks. Second, Arzuaga et al27 reported that Muslim physicians had a greater willingness to resuscitate EPIs at GA 22 and 23 weeks, even against parental requests for nonresuscitation. Physicians’ greater religiosity was associated with a greater willingness to resuscitate. De Leeuw et al32 also confirmed these results.

Our results revealed that physicians deem non–patient-related factors less relevant than patient-related factors in helping them decide whether to resuscitate EPIs. However, these non–patient-related factors were studied only superficially. Complicating the picture is that self-reported attitudes may be subject to social desirability bias28; thus, physicians’ attitudes summarized here may not correspond to their actual behavior in practice. Researchers investigating the variability of physicians’ attitudes influenced by non–patient-related factors found that maternal characteristics39,44,47 and fear of litigation28 greatly affected physicians’ attitudes. We also found that certain physicians’ demographic characteristics also have an impact, suggesting that an interplay of various factors, rather than GA alone, influences physicians’ attitudes. Therefore, physicians’ attitudes in this area should be viewed as a multifaceted phenomenon. This is in accordance with a subset of the ethical literature affirming that consideration of GA alone is not sufficient in deciding whether to resuscitate EPIs.64,68 In fact, GA is just 1 of the many factors that can influence the prognosis.65 Moreover, GA estimates are imprecise, having a margin of error of 2 weeks; thus, basing a decision solely on GA carries the risk of not resuscitating viable infants.66,68 

The majority of included studies (n = 23) included questionnaires structured around GA as the variable of interest. Doing so implies that GA is the primary factor directing the decision-making process. This leads to a reductionist approach in determining physicians’ attitudes toward resuscitation or nonresuscitation decisions. The majority of questionnaires used in the included studies were composed of yes or no and multiple-choice questions. Choosing from a set of predetermined answers also contributed to an oversimplified description of reality. Physicians’ attitudes were described as being either for or against resuscitation at the given GAs without investigating the reasoning behind the attitudes further.

Quantitative methodologies are well suited to reveal general attitudinal tendencies, but the rigid structure of quantitative assessment instruments also blurs a full description of the complexities behind such attitudes. Therefore, they are best complemented with qualitative research to gain in-depth insight into the multifaceted reality,69 such the reasons behind physicians’ attitudes toward resuscitation. Only 1 qualitative study57 emerged from our literature search, confirming the urgency for more qualitative research in the field.

Some limitations must be noted. First, the inclusion of solely English-language articles may mean that results of some relevant studies may have been overlooked, potentially limiting the generalizability of our results. Second, only 1 study set in a low-income country44 (Mongolia) was included, which may have further limited the generalizability of the results and introduced cultural bias. Third, because only 1 qualitative study emerged in our search, the nuanced reality behind physicians’ attitudes remains obscure.

The main strength of our review resides in the large number of eligible studies originating from 27 countries spread across the globe. Thus, our review is based on data extracted from a wide variety of cultures and legislative systems. In addition, a significant number of studies provided direct information on the main themes of the review: attitudes toward resuscitation and nonresuscitation (n = 19), attitudes toward parents’ resuscitation and nonresuscitation requests (n = 13), and demographic (n = 11) and case-related (n = 20) influencing factors. Finally, physicians’ attitudes on resuscitation of EPIs were examined from different perspectives, leading to a focused description of physicians’ attitudes.

Our results reveal that a diverse group of physicians believe that EPIs should not be resuscitated at GA 22 weeks, whereas they should always be resuscitated from GA 25 weeks. Our results confirm that the gray zone of uncertainty is 23 to 24 weeks for resuscitation attitudes. Although the included studies are focused on GA, we suggest that an interplay of factors, rather than the GA alone, influences physicians’ attitudes, highlighting the lack of understanding of the complex and nuanced reality behind the attitudes toward resuscitation of EPIs.

Ms Cavolo contributed to the study design, screened the bibliographic search results, reviewed all included articles, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Gastmans contributed to the study design, screened search results, reviewed all included studies, reviewed the manuscript, and provided mentorship; Dr Dierckx de Casterlé contributed to the study design, reviewed the manuscript, and provided mentorship; Dr Naulaers critically reviewed the manuscript for important clinical intellectual content and provided mentorship; and all authors approved and are accountable for the final manuscript as submitted.

*

Refs 26,28,30,34,39,4244,4649,52,53,55,57.

FUNDING: Funded by a grant from the Research Foundation (Flanders).

     
  • CASP

    Critical Appraisal Skills Programme

  •  
  • EPI

    extremely premature infant

  •  
  • GA

    gestational age

  •  
  • OR

    odds ratio

  •  
  • PRISMA

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.