Withholding and withdrawing of life sustaining treatment in the newborn

Initiating technology dependence to sustain a child's life: a systematic review of reasons

BACKGROUND

Decision-making in initiating life-sustaining health technology is complex and often conducted at time-critical junctures in clinical care. Many of these decisions have profound, often irreversible, consequences for the child and family, as well as potential benefits for functioning, health and quality of life. Yet little is known about what influences these decisions. A systematic review of reasoning identified the range of reasons clinicians give in the literature when initiating technology dependence in a child, and as a result helps determine the range of influences on these decisions.

METHODS

Medline, EMBASE, CINAHL, PsychINFO, Web of Science, ASSIA and Global Health Library databases were searched to identify all reasons given for the initiation of technology dependence in a child. Each reason was coded as a broad and narrow reason type, and whether it supported or rejected technology dependence.

RESULTS

53 relevant papers were retained from 1604 publications, containing 116 broad reason types and 383 narrow reason types. These were grouped into broad thematic categories: clinical factors, quality of life factors, moral imperatives and duty and personal values; and whether they supported, rejected or described the initiation of technology dependence. The majority were conceptual or discussion papers, less than a third were empirical studies. Most discussed neonates and focused on end-of-life care.

CONCLUSIONS

There is a lack of empirical studies on this topic, scant knowledge about the experience of older children and their families in particular; and little written on choices made outside 'end-of-life' care. This review provides a sound basis for empirical research into the important influences on a child's potential technology dependence.

Approaches to the initiation of life-sustaining technology in children: A scoping review of changes over time

Little is understood about the dynamic circumstances within which the initiation of technology dependence takes place in children. The aim of this scoping review was to identify the influences on the initiation of technology dependence and the issues that require further exploration and consideration. Scientific literature that directly or indirectly discussed the initiation of technology dependence in children was identified. A three-stage screening process of title and abstract scrutiny, full-text scanning and in-depth full-text reading resulted in 63 relevant articles from 1133 initially reviewed. These were then subjected to descriptive and thematic analysis. Articles ranged from the 1970s to the present, reflecting the evolution of ethical debates around the approaches to clinical practice and changes in cultural and societal attitudes. Three themes emerged: how technology alters the meaning of futile care, dissonance in the perspectives of decision makers and increasing support for joint decision-making. Only articles in English and predominantly from the clinician's rather than the patient's perspective were included. Societal and cultural factors as well as the structural, financial and cultural environment influence the initiation of technology dependence in children. However, to what extent these overt and implicit influences guide decision-makers in this field remains largely unknown.

Summary of the Key Concepts on How to Develop a Perinatal Palliative Care Program

Purpose of review: The aim of this study is to assess the most significant Perinatal Palliative Care (PnPC) development projects in the literature and summarize the shared key principles. Recent findings: PnPC is a new concept in neonatal intensive care approach. Advancements in perinatal diagnostics and medical technology have changed the landscape of the perinatal world. The threshold of viability continues to decrease, and diagnostic information is available earlier in pregnancy and more rapidly at the bedside; overall outcomes continue to improve. This rapid technological improvement brings ethical debates on the quality of life of patients with life-limiting and life-threatening conditions and the need to involve the family in the decision-making process, according to their wishes and cultural beliefs. Although the Perinatal Hospice concept was developed in the 1980s in the US, the first recommendations on how to develop a PnPC pathway were published in the early 2000s. We considered the most relevant position statements or guidelines on PnPC published in the last two decades. Some of them were more pertinent to pediatrics but still useful for the fundamental concepts and PnPC project's development. Summary: Health care providers and institutions are encouraged to develop PnPC programs, which have the goal of maximizing the quality of life of infants with non-curable conditions. These may generally include the following: a formal prenatal consultation; development of a coordinated birth plan between obstetrician, newborn care, and family; access to other neonatal and pediatric specialties, as needed; comfort palliative care during the prenatal, birth, and postnatal periods; and psychosocial and spiritual support for families, siblings, and staff.

Infants' best interests in end-of-life care for newborns

BACKGROUND AND OBJECTIVES

Pediatric bioethics presumes that decisions should be taken in the child's best interest. If it's ambiguous whether a decision is in the child's interest, we defer to parents. Should parents be permitted to consider their own interests in making decisions for their child? In the Netherlands, where neonatal euthanasia is legal, such questions sometimes arise in deciding whether to hasten the death of a critically ill, suffering child. We describe the recommendations of a national Dutch committee. Our objectives were to analyze the role of competing child and family interests and to provide guidance on end-of-life decisions for doctors caring for severely ill newborns.

METHODS

We undertook literature review, 7 consensus meetings in a multidisciplinary expert commission, and invited comments on draft report by specialists' associations.

RESULTS

Initial treatment is mandatory for most ill newborns, to clarify the prognosis. Continuation of treatment is conditional on further diagnostic and prognostic data. Muscle relaxants can sometimes be continued after withdrawal of artificial respiration without aiming to shorten the child's life. When gasping causes suffering, or protracted dying is unbearable for the parents, muscle relaxants may be used to end a newborn's life. Whenever muscle relaxants are used, cases should be reported to the national review committee.

CONCLUSIONS

New national recommendations in the Netherlands for end-of-life decisions in newborns suggest that treatment should generally be seen as conditional. If treatment fails, it should be abandoned. In those cases, palliative care should be directed at both infant and parental suffering. Sometimes, this may permit interventions that hasten death.

Review on Neonatal End-of-Life Decision-Making: Medical Authority or Parental Autonomy?

As advances in medical technology are constantly re-defining the lower limit of newborn viability, the practice of withholding/withdrawing treatment in neonatal care is increasingly prevalent. Now more than ever, physicians working in neonatal intensive care units have to constantly face the ethical dilemma of terminating the neonates' life support, sometimes against the parents' desire. Traditionally and legally, parents have the duty to make decisions on behalf of their infants because they are the ones to whom the consequences matter the most. Physicians, on the other hand, often claim for themselves the role of the child's advocate, with the growing acceptance of the patient's “best interest” standard as the guiding principle. In this mini literature review, the authors examined the issue of medical authority versus parental autonomy in neonatal end-of-life (EoL) decision-making and found that consultations with parents were made in the majority (79–100%) of cases. Furthermore, conflicts between doctors and family were shown to occur quite frequently due to barriers to effective communication such as strong religious convictions and disagreements within medical team members. Only by encouraging active parental participation and overcoming some of these barriers, physicians and the patient's family could arrive at an ethically sound EoL decision.

Conflicts about end-of-life decisions in NICUs in the Netherlands

OBJECTIVE

To determine the frequency and background of conflicts about neonatal end-of-life (EoL) decisions.

METHODS

We reviewed the medical files of 359 newborns who had died during 1 year in the 10 Dutch NICUs and identified 150 deaths that were preceded by an EoL decision on the basis of the child's poor prognosis. The attending neonatologists of 147 of the 150 newborns were interviewed to obtain details about the decision-making process.

RESULTS

EoL decisions about infants with a poor prognosis were initiated mainly by the physician, who subsequently involved the parents. Conflicts between parents and the medical team occurred in 18 of 147 cases and were mostly about the child's poor neurologic prognosis. Conflicts within the team occurred in 6 of 147 cases and concerned the uncertainty of the prognosis. In the event of conflict, the EoL decision was postponed. Consensus was reached by calling additional meetings, performing additional diagnostic tests, or obtaining a second opinion. The chief causes of conflict encountered by the physicians were religious convictions that forbade withdrawal of life-sustaining treatment and poor communication between the parents and the team.

CONCLUSIONS

The parents were involved in all EoL decision-making processes, and consensus was ultimately reached in all cases. Conflicts within the team occurred in 4% of the cases and between the team and the parents in 12% of the cases. The conflicts were resolved by postponing the EoL decision until consensus was achieved.

What can we learn from the experiences of consultants around the time of a child's death?

AIMS

To describe how paediatric consultants report dealing with child and neonatal deaths as part of their daily work.

BACKGROUND

Paediatric consultants are involved with children and their families facing death through illness. This study focused on consultant's involvement around the time of death including: decision making and its associated difficulties, talking to parents and the use of coping strategies. Consultants with more than 5 years experience were asked what experience has taught them and consultants with less that 5 years experience were asked what they felt was the biggest change from being a registrar.

METHODS

Following Multicentre Research Ethics Committee (MREC) approval a pre-piloted self-administered questionnaire (with one reminder) was sent to 100 of the paediatric consultants within the South West Region.

RESULTS

There was a 61% response rate. Most consultants had experienced a variety of opinions when talking to parents about when to withdraw or withhold life sustaining treatment. Uncertainty (39%) and disagreement (44%) made decision making difficult. Discussion with colleagues (41%), 'honesty and time with parents' (28%) and planning or 'stage managing' talking with parents (38%) were well used strategies to deal with this. New consultants find responsibility and decision making the biggest change from being a registrar.

CONCLUSIONS

We can learn much from the experiences of consultants around the time of a child's death. Their approach during resuscitation and withdrawal or withholding life sustaining treatment describes many strategies that have been developed to ease the often complex decision-making process. Although consultants have built up personal support networks and individual coping strategies many recognize that these are not all encompassing and some harbour unresolved feelings of grief. Enabling health professionals to genuinely care, 'giving oneself totally yet preserving oneself totally' remains a challenge.

Parental religious affiliation and survival of premature infants with severe intraventricular hemorrhage

OBJECTIVE

To evaluate the association between parents' ethnic/religious affiliation (secular Jewish, religious Jewish, ultra-orthodox Jewish, Muslim Arabs) and survival of premature infants with severe intraventricular hemorrhage (IVH).

STUDY DESIGN

Survival of 102 infants (birth weight<or=1500 g) born at the Hadassah hospitals in Jerusalem from 1 January 1996 through 31 December 2005, who sustained severe IVH and who survived over 48 h, was assessed in relation to their parents' ethnic/religious affiliation and accounting for relevant clinical and demographic variables.

RESULT

There were 38 cases of demise among 72 infants with IVH grade IV (52.8%), and 4 among 30 infants with IVH grade III (13.3%). In a multivariate logistic regression analysis accounting for relevant perinatal variables, the odds for mortality compared to the reference Arab group was significantly lower only with regard to ultra-orthodox patients (odds ratio, OR=0.06; 95% confidential interval, CI=0.00 to 0.80; P=0.033). In a logistic and in the Cox stepwise regression analyses with religion as forced in variable, comparing infants with IVH grade IV of religious and ultra-orthodox Jewish families with those of secular Jewish families, the OR/hazard ratio (HR) for mortality were OR=0.10; 95% CI=0.01 to 0.06; P=0.017, and HR=0.37; 95% CI=0.16 to 0.85; P=0.019, respectively. No significant difference between the groups was demonstrated when infants with IVH grade III were analyzed apart.

CONCLUSION

Parental religious affiliation may be influential on the outcome of premature infants with severe brain damage.