Medical audit in neonatal care

A system of medical audit on a neonatal unit based on the primary reason for admission may be used alongside the more conventional type of audit of mortality and morbidity by birthweight and gestation using a diagnostic classification of disease. The method provides a more accurate description of all babies admitted to a neonatal unit and thus a more comprehensive measure of work undertaken.

[Ethics problems in neonatal medicine]

In view of the recent advances in reanimation of the newborn infant, parents, physicians and nursing staff have now to face the ethical dilemma of the quality of the surviving infant with severe brain damage which excludes a further normal development. The author discusses the situation of an infant with trisomy 21 and a total intestinal atresia: a surgical intervention leads to a living human being with a severe mental, and physical handicap; a non-intervention will let the newborn die even if he could be saved. The decision has to be made with the parents in agreement with the nursing staff, but without involving a policy making outside committee.

The physically handicapped child--is active management justified?

Deformities can either be congenital in origin or acquired after an accident or particularly after extensive surgery for malignant disease. Many congenital anomalies, especially if associated with Down syndrome, or when major residual handicaps are anticipated, raise the ethical question of whether or not to treat them initially. The effect of major handicaps on the child, family and society are discussed. Certain congenital anomalies can now be prevented by amniocentesis and termination of pregnancy in the high-risk group, and some of the acquired deformities can also be prevented to a certain extent. Lastly, some aspects of the legal situation are mentioned.

The first year of life. Some congenital abnormalities

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Deciding the care of severely malformed or dying infants

Suffering patients (when able), grieving families and compassionate physicians have always sought the least detrimental alternative while deciding care in the face of tragedy. Modern medical technology has brought great benefits to patients but has blurred traditional concepts of life and death and created new dilemmas for practising doctors. While this technology has given doctors great control over living and dying, their dominance in critical decision making is being challenged. More and more their decisions are liable to public and legal scrutiny, intense publicity by the news media and exploitation by lobbyists with opposing aims. Increasing pressure of this kind may deflect the physician form his primary responsibility to patients and their families. For infants with gross malformations or a distressing terminal illness we believe that the parents and their doctors must be allowed primary decisional power even if the chosen course of action involves the death of the infant. Choices for death should be permitted but only after suitable family and professional consultation. Some general guidelines are suggested. As these situations are so varied and so complex, much latitude in decision-making should be expected and tolerated.