Should we resuscitate extremely premature babies? An interview with Dr Sara Hamilton – Consultant Paediatrician

By Anne Tan

Dr Sara Hamilton

Dr Sara Hamilton

It was 5pm on a Tuesday evening when I apprehensively popped my head into the doctor’s office on the paediatric unit where Dr Hamilton said I would be able to find her. The room was bustling with activity as the doctors on the day shift were handing over to the night team. Leaning against the wall I tried not to stand in anyone’s way. As the handover drew to a close, the lady sitting in the middle of all the activity wondered aloud where the medical student who was supposed to interview her was. Hearing this I quickly spoke up to say I was present.

The topic of our interview (and TMS Features for Jan 2015) was inspired by a ‘debate’ that I attended at University College London, which Dr Hamilton participated in. The ‘debate’ was about whether or not we should resuscitate extremely premature (gestation of <26 weeks) babies. I thought it was interesting that the session was sold to medical students as a ‘debate’ rather than a ‘lecture’. It is as if the medical school was subtly acknowledging that this is a controversial issue and the material discussed should not be taken as ‘truth’ in the way most other medical facts are disseminated to us in lectures.

To make the session more interactive, a poll was conducted before any speeches were made. During this poll, it was found that a vast majority of medical students present voted in favour of resuscitating extremely premature babies. After the vote, four different doctors delivered prepared speeches on the subject. Interestingly enough, the post speech vote was in favour of not resuscitating extremely premature babies. How did this happen?

Current UK Law: The Nuffield council recommends that babies born before or at 22 weeks should not be routinely resuscitated or receive intensive care. Babies born between 22 and 23 weeks should not usually receive intensive care unless parents make a request and doctors agree. Babies born between 24 and 25 weeks should normally receive intensive care, unless the parents and the doctors agree that there is no hope of survival, or if the level of suffering outweighs the baby's interest in continuing to live. Intensive care should normally be given to babies born after 25 weeks, because they have a sufficiently high chance of surviving and low risk of developing severe disability.

Current UK Guidelines:
The Nuffield council recommends that babies born before or at 22 weeks should not be routinely resuscitated or receive intensive care. Babies born between 22 and 23 weeks should not usually receive intensive care unless parents make a request and doctors agree. Babies born between 24 and 25 weeks should normally receive intensive care, unless the parents and the doctors agree that there is no hope of survival, or if the level of suffering outweighs the baby’s interest in continuing to live. Intensive care should normally be given to babies born after 25 weeks, because they have a sufficiently high chance of surviving and low risk of developing severe disability.

I actually believe Dr Hamilton’s speech may have something to do with it, despite the fact she did not intend for it to. In fact, when pushed to give her personal view on the matter she said that she did ‘not feel strongly about’ the matter. She simply pointed out that the more premature the babies are, the more likely they are to have severe mental and physical disability should they survive the resuscitation and leave neonatal Intensive Care Unit alive. She argues that as a society, it is more important that we ‘commit’ to every baby we resuscitate and ensure we give them the necessary support to cope with their disability.

Her views are perhaps shaped by her special interest in caring for children with chronic conditions such as sickle cell anaemia and oncology. Dr Hamilton is a consultant paediatrician who is currently the lead clinician on the Hospital @ Home scheme run jointly by University College Hospital and Whittington Hospital.  As part of this program, Dr Hamilton cares for paediatric patients with complex needs from their home with the aid of technology on a ‘virtual ward’.

Dr Hamilton knows well the difficulties parents face when raising a child with complex needs and she feels strongly that the most vulnerable children are not getting the care they need. It is unfortunate that good integrated care from hospital to community to special needs education is not a reality for many children as it is still too much of a post code lottery.

With such a zeal for children who need long term support, Dr Hamilton spent most of her speech at the ‘debate’ arguing for that society needed to be make more provisions for these children. I think, without intending to, her portrayal of the reality that children with disability live is what caused students to change their mind about resuscitating extremely premature babies. I think many students felt that by resuscitating these extremely premature babies we were purposefully prolonging the lives of children who have severe disability, inflicting upon them a ‘poor quality of life’ and making them a ‘burden’ on their families and society.

When discussing this issue with Dr Hamilton at the interview she was quick to clarify that not all extremely premature babies who are resuscitated end up with severe disability. With increased insight into how to care for these little ones, we are better able to ensure that despite being born early that these babies can still reach their full potential (statistics can be found at this link: http://www.epicure.ac.uk/).

Furthermore, Dr Hamilton believes that new techniques to help these babies are always on the horizon. She gave the example of how we have still not yet tapped into the brain’s plasticity (she also has a PhD in Neuroscience!) to help these babies develop more normally despite being born preterm.

Baby in handHowever despite these developments there is still no guarantee that the baby you resuscitate will survive and do well. She says the difficulty is that in these stressful emergencies it is hard for parents and doctors to make an informed decision. She believes the best thing to do at the moment is to resuscitate the baby when they are born but be willing to make ‘brave decisions about the withdrawal of treatment’ later on. She says it has to be a ‘dynamic dialogue (between doctors and parents) as situation evolves’.

Does this acknowledgment that we can withdraw treatment later on imply that we should not provide the best treatment available for babies that have disability? New technology brings new situations but the questions are still the same.

What kind of life is worth living? How do we decide what is a good life?

I believe that many young, able bodied and intelligent people (like most medical students) would think that a life with cerebral palsy or trisomy 21 is miserable and it would be better to not live at all. Yet is that always the reality? Is it perhaps more a question of attitude and perspective?

Dr Hamilton shared that one of the most charming (and sometimes even flirtatious!) patient she has is a 19 year old boy who is non-verbal and wheelchair bound. He was born after only 23 weeks in utero and developed Cerebral Palsy as a consequence of his prematurity. People did not expect him to survive his first birthday yet 100 people were in attendance for his 18th.

 

 

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