- Non-Initiation and Discontinuation of Resuscitation
- Family Communication, Comfort Care, and Team Wellbeing
Non-Initiation and Discontinuation of Resuscitation
Not every neonatal resuscitation should be started. Not every one that starts should continue. This module addresses both decisions and how to communicate them to families.
The content reflects current ILCOR guidance and acknowledges that institutional policy and jurisdictional law vary. AMC does not provide legal advice, and providers should defer to their institutional ethics committees and legal counsel on specific cases.
Non-initiation of resuscitation
Non-initiation ( the decision not to begin resuscitative interventions at birth) is appropriate in specific clinical circumstances where resuscitation is either futile or inconsistent with the family's informed wishes. Current guidance identifies three categories where non-initiation may be appropriate (Table 18):
Category | Threshold | Notes |
|---|---|---|
| Confirmed lethal anomaly | Anencephaly, confirmed bilateral renal agenesis (Potter sequence), confirmed trisomy 13 or 18 with family consent | Requires prenatal diagnosis and pre-birth family discussion |
| Extreme prematurity | Below 22 weeks gestation | No reported survival at this gestational age; non-initiation generally appropriate |
| Periviable range with family refusal | 22-24 weeks gestation, following thorough antenatal counselling | Parental values are central; resuscitation may be withheld with informed parental refusal |
The decision not to initiate resuscitation must never be made unilaterally by a single provider in the delivery room without prior discussion. Where a lethal anomaly or extreme prematurity is identified prenatally, the antenatal counselling process should establish the agreed approach before delivery. Where the situation is uncertain or unexpected, resuscitation should begin while the team assesses the situation and initiates the family communication process.
Discontinuation of resuscitation
The decision to discontinue ongoing resuscitation is distinct from non-initiation and is made when resuscitation has been adequate and continuous but has not produced return of spontaneous circulation after a defined period.
Current guidance identifies asystole persisting for 20 minutes despite continuous and adequate resuscitation as the threshold beyond which survival is unlikely and severe neurological impairment in any survivor is expected. At this point, discontinuation of resuscitation is a reasonable clinical decision, made in discussion with the team and communicated to the family.
The 20-minute threshold is not an absolute rule. Clinical judgement applies, such as factors including the cause of arrest, adequacy of resuscitation, and specific clinical response patterns, which may inform the decision. The threshold should be understood as a guideline that triggers the team discussion, not an automatic stop point.
The decision to discontinue resuscitation should never be made by the team leader alone. It requires team discussion, documentation of the resuscitation timeline, and as timely communication with the family as the situation allows.
The uncertainty zone - 22-24 weeks gestation
Births between 22 and 24 weeks gestation represent the most ethically complex scenario in neonatal resuscitation. Survival is possible but not reliably predicted, and survival with significant morbidity is substantially more common than intact survival. There is no single correct answer, and the decision framework must center the family's values and informed preferences alongside the clinical evidence.
Providers working in this gestational age range should be familiar with their institution's periviability guidelines, which typically provide gestational-age and weight-specific survival data. These data should be presented to families in antenatal counselling in plain language, without false certainty in either direction.
Medically reviewed by: Kim Murray, RN, MS., Medical Educator
