Death in the Intensive Care Nursery: Physician Practice of Withdrawing and Withholding Life Support

Department of Pediatrics, Northwestern University, Evanston, Illinois, United States
PEDIATRICS (Impact Factor: 5.47). 02/1997; 99(1):64-70. DOI: 10.1542/peds.99.1.64
Source: PubMed


To determine the frequency of selective nontreatment of extremely premature, critically ill, or malformed infants among all infant deaths in a level III intensive care nursery (ICN) and to determine the reasons documented by neonatologists for their decisions to withdraw or withhold life support.
This was a descriptive study based on review of the medical records of all 165 infants who died at a university-based level III ICN during 3 years. We determined whether each death had occurred despite the use of all available technologies to keep the infant alive or whether these were withheld or withdrawn, thereby leading to the infant's death. We also determined whether neonatologists documented either "futility" or "quality of life" as a reason to limit medical interventions.
One hundred sixty-five infants died among the 1609 infants admitted during the study period. One hundred eight infant deaths followed the withdrawal of life support, 13 deaths followed the withholding of treatment, and 44 deaths occurred while infants continued to receive maximal life-sustaining treatment. For 90 (74%) of the 121 deaths attributable to withholding of withdrawal of treatment, physicians cited that death was imminent and treatment was futile. Quality-of-life concerns were cited by the neonatologists as reasons to limit treatment in 62 (51%). Quality of life was the only reason cited for limiting treatment for 28 (23%) of the 121 deaths attributable to withholding or withdrawal of treatment.
The majority of deaths in the ICN occurred as a result of selective nontreatment by neonatologists, with few infants receiving maximal support until the actual time of death. Neonatologists often documented that quality-of-life concerns were considered in decisions to limit treatment; however, the majority of these decisions were based on their belief that treatment was futile. Prospective studies are needed to elucidate the determinants of neonatologists' practice decisions of selective nontreatment for marginally viable or damaged infants.

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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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    ABSTRACT: Euthanasia is performed on occasion, even on newborns, but is highly controversial, and it is prohibited by law and condemned by medical ethics in most countries. To characterise and compare the judgments of lay persons, nurses, and physicians of the acceptability of actively ending the life of a damaged newborn. Convenience samples of 237 lay persons, 214 nurses, and 76 physicians in the south of France rated the acceptability on a scale of 0-10 of giving a lethal injection in 54 scenarios composed of all combinations of 4 within-subject factors: gestational age of 6, 7, or 9 months; 3 levels of severity of either perinatal asphyxia or of genetic disease; attitude of the parents about prolonging care unknown, favourable, or unfavourable; and decision made individually by the physician or collectively by the medical team. Overall ratings were subjected to cluster analysis and each cluster to analysis of variance and graphic representation. Lay persons (mean acceptability rating 4.29) were significantly more favourable to euthanasia than nurses (2.84), p < .005, or physicians (2.12), p < .005. Five clusters were found with different judgment rules, i.e., how the information was integrated. More physicians (30 per cent) than nurses (14 per cent), p < .01, or lay persons (11 per cent), p < .01, rated euthanasia as never, under any condition, acceptable. Most, however, asserted that it was increasingly acceptable as the factors combined to favour it, especially when the parents desired to stop treatment. More physicians (45 per cent) and nurses (46 per cent) than lay persons (21 per cent), p < .01, used a complex conjunctive rule (level of parent's attitude x level of severity of damage x consultation with team or not) rather than a simple additive rule. Unlike law and medical ethics, most of the lay persons, nurses, and physicians judged the acceptability of euthanasia as a function of the circumstances. Most health professionals combined the factors in a conjunctive (multiplicative), rather than additive, fashion in accordance with legislation for adults in The Netherlands and elsewhere that requires a set of criteria to be fulfilled before it is legitimate to end a patient's life.
    Preview · Article · Sep 2010 · Monash bioethics review
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    • "Birth asphyxia (more properly referred to as Hypoxic Ischaemic Encephalopathy or HIE) is a common reason for withdrawal of life-sustaining treatment in newborn intensive care. It is the commonest single cause of death in term newborn infants (The Consultative Council 2008; Verhagen et al. 2009), and the majority of such deaths follow decisions to limit or withdraw treatment (Wall and Partridge 1997; Pierrat et al. 2005; Verhagen et al. 2009). These decisions are often in practice particularly difficult and controversial (McHaffie and Fowlie 1996, 98). "
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    ABSTRACT: Birth asphyxia is the most common single cause of death in term newborn infants. The majority of deaths in developed countries follow decisions to withdraw intensive care. Recent technological advances, particularly the use of magnetic resonance imaging (MRI) of the brain, may affect the process of prognostication and decision-making. There is little existing evidence about how prognosis is determined in newborn infants and how this relates to treatment withdrawal decisions. An exploratory qualitative study was performed using in-depth semi-structured interviews with a sample of ten neonatologists from tertiary intensive care units in the UK. Participants were purposively selected to ensure a range of experience and type of unit. They were asked about the process of prognostication for infants with birth asphyxia and decisions about treatment withdrawal. Interviews were transcribed and thematically analysed. MRI played a significant role in decision-making about life-sustaining treatment for a number of clinicians. Clinicians did not identify particular ethical concerns related to MRI, though wider discussion revealed issues relating to uncertainty around predictions, the timing of prognostication and decision-making, and difficulty in predicting quality of life.
    Full-text · Article · Mar 2010 · Monash bioethics review
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    • "Further, it is well established legally that a medical team and the family can discontinue overly burdensome treatment [1] [2] [3]. Palliative care principles have made inroads into intensive care units, and some surveys of practice and physician attitudes toward withdrawing lifesustaining treatment have been published [4] [5]. Although there is little empiric research into the most effective way to withdraw ventilator support, there is now a body of literature that describes application of basic "
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    ABSTRACT: Withdrawing life-sustaining technologies requires all of the resources and concepts that the field of palliative care has to offer. By learning some fundamental principles of medical management at the time of withdrawal and by mastering a few communication techniques, pediatricians, neonatologists, and pediatric intensivists can dramatically improve the care provided to their patients at the end of life. Although we may argue in pediatrics if there is ever such a thing as a good death, we should all strive to ensure one that is free of suffering, and one that supports the family in moving down a path of healthy grief and recovery.
    Preview · Article · Nov 2007 · Pediatric Clinics of North America
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