Enough is enough — when to stop neonatal care

Reorientation of care in the NICU

Where possible, both parents should be present whenever bad news is broken. Professional calm and carefully chosen words are essential. Staff must be aware of cultural and religious beliefs of the family, and should be cognizant of linguistic and educational capabilities. The unexpected collapse and death of an infant is rare but is exceptionally demanding on communication skills. Time must be given for the family to ask questions, and staff should acknowledge the tragedy and the uncertainty, but should convey a determination to discover the truth for the family. A predictable deterioration allows staff and family to work together towards a "guided consensus" over future management. Compassionate care involves time, comfort and dignity for the child and parents. It is crucial for the family to receive empathetic support from senior nursing and medical staff. Mementoes may help the grieving process. Necropsy may also play an important role in allowing the families to rebuild their lives.

Clinical aspects of neonatal death and autopsy

An autopsy carried out by a trained perinatal pathologist can provide parents and professionals with new information about the cause of a baby's death. It is extremely stressful for parents to be asked for autopsy authorisation. The request is also very demanding for the staff. The rates of neonatal autopsy have been declining since 1990 and, almost certainly, the adverse publicity surrounding the Alder Hey enquiry precipitated a further fall in authorisation rates. Only a re-establishment of trust between parents and professionals can reverse this trend. This trust is founded on excellent perinatal communication and clinical care. The child's death must be managed in the most empathetic way, with an understanding of bereavement and the grief support required. If the parents and professionals work together as a team, the parents should sense the commitment of staff to their family. They may then be more likely to understand the importance of autopsy and to provide authorisation.