From "can we treat?" to "should we treat?": a narrative review on resuscitation limits at the threshold of viability

Background: Advances in perinatal and neonatal care have progressively lowered the threshold of viability and improved survival among extremely preterm infants (EPIs). However, this increase in survival has not consistently been accompanied by comparable improvements in neurological outcomes, which in a relevant proportion of cases remain poor. This discrepancy generates the ethical dilemma of deciding whether to proceed with active resuscitation at the margins of viability. Historically, decisions have relied heavily on gestational age (GA), yet this single parameter has proven insufficient. Purpose: This narrative review examines the conceptual and practical challenges in determining the limit of active resuscitation and explores how healthcare professionals and international scientific and bioethical committees have addressed this issue, as well as how families experience and cope with it. Results: Evidence demonstrates that multiple fetal and pregnancy-related factors significantly influence survival and long-term neurodevelopmental outcomes, outperforming GA alone. Simultaneously, clinicians and families are confronted with prognostic uncertainty, psychological burdens, and cognitive biases that complicate decision-making. In this context, shared decision-making emerges not as a simple transfer of information, but as an interpretative process centered on the newborn’s best interests. Conclusion: No universal gestational threshold can determine when resuscitation should or should not be initiated. Rather, the “limit” is best understood as a case-specific decision point, shaped by prognosis, parental values, ethical judgment, and clinical feasibility. Future efforts should focus not on eliminating the grey area, but on developing ethically grounded strategies for navigating it responsibly, compassionately, and with intellectual humility. (Table presented.)