Death in neonatal intensive care

End-of-life care over four decades in a quaternary neonatal intensive care unit

AIM

Death in the neonatal intensive care unit (NICU) commonly follows a decision to withdraw or limit life-sustaining treatment. Advances in medicine have changed the nature of life-sustaining interventions available and the potential prognosis for many newborn conditions. We aimed to assess changes in causes of death and end-of-life care over nearly four decades.

METHODS

A retrospective review of infants dying in the NICU was performed (2017-2020) and compared with previous audits performed in the same centre (1985-1987 and 1999-2001). Diagnoses at death were recorded for each infant as well as their apparent prognosis and any withdrawal or limitations of medical treatment.

RESULTS

In the recent epoch, there were 88 deaths out of 2084 admissions (4.2%), a reduction from the previous epochs (132/1362 (9.7%) and 111/1776 (6.2%), respectively, for epochs 1 and 2). More than 90% of infants died after withdrawal of life-sustaining treatment, an increase from the previous two epochs (75%). There was a reduction in deaths from chromosomal abnormalities, complications related to prematurity and severe birth asphyxia.

CONCLUSIONS

There continue to be changes in both the diagnoses leading to death and approaches to withdrawal of treatment in the NICU. These may reflect ongoing changes in both prenatal and post-natal diagnostics as well as changing attitudes towards palliative care within the medical and wider community.

Infant mode of death in the neonatal intensive care unit: A systematic scoping review

OBJECTIVE

To characterize literature that describes infant mode of death and to clarify how limitation of life-sustaining treatment (LST) is defined and rationalized.

STUDY DESIGN

Eligible studies were peer-reviewed, English-language, and included number of infant deaths by mode out of all infant deaths in the NICU and/or delivery room.

RESULT

58 included studies were primarily published in the last two decades from North American and European centers. There was variation in rates of infant mode of death by study, with some showing an increase in deaths following limitation of LST over time. Limitation of LST was defined by the intervention withheld/withdrawn, the relationship between the two practices, and prior frameworks. Themes for limiting LST included diagnoses, low predicted survival and/or quality of life, futility, and suffering.

CONCLUSION

Limitation of LST is a common infant mode of death, although rates, study definitions, and clinical rationale for this practice are variable.

Moral equivalence theory in neonatology

This article explores the ethical concept of "the equivalence thesis" (ET), or the idea that withdrawing and withholding life sustaining treatments are morally equivalent practices, within neonatology. We review the historical origins, theory, and clinical rationale behind ET, and provide an analysis of how ET relates to literature that describes neonatal mode of death and healthcare professional and parent attitudes towards end-of-life care. While ET may serve as an ethical tool to optimize resource allocation in theory, its clinical utility is limited given the complexity of end-of-life care decisions.

Neonatal end-of-life decisions and ethical perspectives

End-of-life decisions are usually required when a neonate is at high risk of disability or death, and such decisions involve many legal and ethical challenges. This article reviewed the processes of ethical decision-making for severely ill or terminal neonates, considering controversial issues including the followings: (i) identifying primary decision makers, (ii) the role of law and guidelines, and (iii) changes in treatment controversy, law and regulations over twenty years in several European countries such as Switzerland, Germany, Italy, United Kingdom, France, the Netherlands, Sweden, and Spain. This review study conducted on accessible articles from PubMed, Google Scholar, Web of Science and Scopus databases. Based on two studies in 2016 and 1996, neonatologists reported that withholding intensive care, withdrawing mechanical ventilation or life-saving drugs, and involvement of parents in decision-makings have become more acceptable as time passes, indicative of trend change. Trend of physicians on how end the life of neonates, at risk of death, varies in different countries, and cultural factors, parents’ involvement in decisions and gestational age are factors considered in end-of-life decision-making. Future investigations continuously need to identify upcoming ethical aspects of proper decision-making.

Restriction of ongoing intensive care in neonates: a prospective study

OBJECTIVE

The purpose of this work was to record the current practice of restricting ongoing intensive care in severely ill newborns.

METHODS

This was a prospective observational study over a 30-month period of consecutive newborns for whom restriction of ongoing intensive care was taken into consideration, discussed, or decided on. A standardized form recorded patients' medical condition, the type of restriction decided on, parents' wishes, and their information level. The research was conducted in a neonatal unit of a level III university children's hospital, with no interventions.

RESULTS

Forty patients were enrolled, 25 were preterm, 21 had either a genetic defect or an inborn malformation. Restriction of ongoing intensive care was decided on for 32 patients with a great variety of specified recommendations. Thirty-six patients died during the observation period. In general, parents were well informed; however, their wishes concerning restriction of ongoing intensive care were unknown in approximately 25% of cases.

CONCLUSIONS

The decision-making process for restriction of ongoing intensive care is well established, but the role of parents needs to be defined.

Death in the neonatal intensive care unit: changing patterns of end of life care over two decades

BACKGROUND

Death remains a common event in the neonatal intensive care unit, and often involves limitation or withdrawal of life sustaining treatment.

OBJECTIVE

To document changes in the causes of death and its management over the last two decades.

METHODS

An audit of infants dying in the neonatal intensive care unit was performed during two epochs (1985-1987 and 1999-2001). The principal diagnoses of infants who died were recorded, as well as their apparent prognoses, and any decisions to limit or withdraw medical treatment.

RESULTS

In epoch 1, 132 infants died out of 1362 admissions (9.7%), and in epoch 2 there were 111 deaths out of 1776 admissions (6.2%; p<0.001). Approximately three quarters of infants died after withdrawal of life sustaining treatment in both epochs. There was a significant reduction in the proportion of deaths from chromosomal abnormalities, and from neural tube defects in epoch 2.

CONCLUSIONS

There have been substantial changes in the illnesses leading to death in the neonatal intensive care unit. These may reflect the combined effects of prenatal diagnosis and changing community and medical attitudes.

End-of-life decisions in neonatal intensive care: physicians' self-reported practices in seven European countries. EURONIC Study Group

BACKGROUND

The ethical issue of foregoing life-sustaining treatment for newborn infants at high risk of death or severe disability is extensively debated, but there is little information on how physicians in different countries actually confront this issue to reach end-of-life decisions. The EURONIC project aimed to investigate practices as reported by physicians themselves.

METHODS

The study recruited a large, representative sample of 122 neonatal intensive-care units (NICUs) by census (in Luxembourg, the Netherlands, and Sweden) or stratified random sampling (in France, Germany, the UK, Italy, and Spain) with an overall response rate of 86%. Physicians' practices of end-of-life decision-making were investigated through an anonymous, self-administered questionnaire. 1235 completed questionnaires were returned (response rate 89%).

FINDINGS

In all countries, most physicians reported having been involved at least once in setting limits to intensive care because of incurable conditions (61-96%); smaller proportions reported such involvement because of a baby's poor neurological prognosis (46-90%). Practices such as continuation of current treatment without intensification and withholding of emergency manoeuvres were widespread, but withdrawal of mechanical ventilation was reported by variable proportions (28-90%). Only in France (73%) and the Netherlands (47%) was the administration of drugs with the aim of ending life reported with substantial frequency. Age, length of professional experience, and the importance of religion in the physician's life affected the likelihood of reporting of non-treatment decisions.

INTERPRETATION

A vast majority of neonatologists in European NICUs have been involved in end-of-life limitation of treatments, but type of decision-making varies among countries. Culture-related and other country-specific factors are more relevant than characteristics of individual physicians or units in explaining such variability.