End-of-Life After Birth: Death and Dying in a Neonatal Intensive Care Unit

Department of Pediatrics, University of Chicago, Chicago, Illinois, United States
PEDIATRICS (Impact Factor: 5.3). 01/2005; 114(6):1620-6. DOI: 10.1542/peds.2004-0447
Source: PubMed

ABSTRACT In canonical modern bioethics, withholding and withdrawing medical interventions for dying patients are considered morally equivalent. However, electing not to administer cardiopulmonary resuscitation (CPR) struck us as easily distinguishable from withdrawing mechanical ventilation. Moreover, withdrawing mechanical ventilation from a moribund infant "feels" different from withdrawing mechanical ventilation from a hemodynamically stable child with a severe neurologic insult. Most previous descriptions of withdrawing and withholding intervention in the neonatal intensive care unit (NICU) have blurred many of these distinctions. We hypothesized that clarifying them would more accurately portray the process of end-of-life decision-making in the NICU.
We reviewed the charts of all newborn infants who had birth weight >400 g and died in our hospital in 1988, 1993, and 1998 and extracted potential ethical issues (resuscitation, withdrawal, withholding, CPR, do-not-resuscitate orders, neurologic prognosis, ethics consult) surrounding each infant's death.
Using traditional definitions, roughly half of all deaths in our NICU in 1993 and 1998 were associated with "withholding or withdrawing." In addition, by 1998, >40% of our NICU deaths could be labeled "active withdrawal," reflecting the extubation of infants regardless of their physiologic instability. This practice is growing over time. However, 2 important conclusions arise from our more richly elaborated descriptions of death in the NICU. First, when CPR was withheld, it most commonly occurred in the context of moribund infants who were already receiving ventilation and dopamine. Physiologically stable infants who were removed from mechanical ventilation for quality-of-life reasons accounted for only 3% of NICU deaths in 1988, 16% of NICU deaths in 1993, and 13% of NICU deaths in 1998. Moreover, virtually none of these active withdrawals took place in premature infants. Second, by 1998 infants, who died without CPR almost always had mechanical ventilation withdrawn. Finally, the median and average day of death for 100 nonsurvivors who received full intervention did not differ significantly from the 78 nonsurvivors for whom intervention was withheld.
In our unit, a greater and greater percentage of doomed infants die without ever receiving chest compressions or epinephrine boluses. Rather, we have adopted a nuanced approach to withdrawing/withholding NICU intervention, providing what we hope is a humane approach to end-of-life decisions for doomed NICU infants. We suggest that ethical descriptions that reflect these nuances, distinguishing between withholding and withdrawing interventions from physiologically moribund infants or physiologically stable infants with morbid neurologic prognoses, provide a more accurate reflection of the circumstances of dying in the NICU.

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    • "Withdrawal of life support is a frequent occurrence in newborn intensive care. In many units the majority of deaths follow decisions to withhold or withdraw treatment (Roy et al. 2004; Singh et al. 2004; Verhagen et al. 2009a; Wilkinson et al. 2006). There are two different contexts for decisions. "
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    The American Journal of Bioethics 02/2011; 11(2):20-32. DOI:10.1080/15265161.2010.540060 · 2.45 Impact Factor
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    • "Administration of drugs with the intent of hastening the end of an infant's life was, however, reported only by Dutch (47 per cent) and French (73 per cent) physicians. (See also Barton and Hodgman 2005; Devictor et al. 2001; Hentschel et al. 2006; Singh et al. 2004; Verhagen et al. 2007; Wall and Partridge 1997.) De Leeuw et al. (2000) presented more than 3400 nurses and more than 1400 physicians from 11 European countries with a vignette describing the case of a 24 week gestational age infant with a birth weight of 560g and an Apgar score of 1 at 1 minute. "
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    Monash bioethics review 09/2010; 20(2):14.1-24. DOI:10.1007/BF03351524
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