Decisions to withdraw life support in the neonatal intensive care unit

The History of Ethical Decision Making in Neonatal Intensive Care

Neonatal ethics has focused on 2 questions: is withholding potentially live-saving treatment from neonates ethically justified? and if so, who has the authority to decide? This article details how these questions developed and provides a description of the possible answers. In the first section, we review a selection of seminal articles by noted authors in the fields of ethics, medicine, and law. The second section provides a detailed account of the development of the Baby Doe Regulations and the impact they had on neonatal ethics, with particular attention to the emergence of the Best Interest Standard as a guideline for decision making. In the last section, we review the landmark position statements by the American Academy of Pediatric (AAP), and the focus on evidence-based decision making. We conclude that forgoing life-saving treatment is ethically justified. However, this requires a rigorous evidence-based process and is limited by the Best Interest Standard. The second question is more difficult to answer, but we feel that in light of legal limitations, physicians acting as both the infant advocate and a proxy for the state, decide what falls in the range of acceptable treatment options, with the parents free to choose within that range.

End-of-life decision making by adolescents, parents, and healthcare providers in pediatric oncology: research to evidence-based practice guidelines

Participating in end-of-life decisions is life altering for adolescents with incurable cancer, their families, and their healthcare providers. However, no empirically developed and validated guidelines to assist patients, parents, and healthcare providers in making these decisions exist. The purpose of the work reported here was to use three sources (the findings of three studies on decision making in pediatric oncology, published literature, and recommendations from professional associations) to develop guidelines for end-of-life decision making in pediatric oncology. The study designs include a retrospective, descriptive design (Study 1); a prospective, descriptive design (Study 2); and a cross-sectional, descriptive design (Study 3). Settings for the pediatric oncology studies included a pediatric catastrophic illness research hospital located in the Midsouth (Studies 1 and 2); and that setting plus a children's hospital in Australia and one in Hong Kong (Study 3). Study samples included 39 guardians and 21 healthcare providers (Study 1); 52 parents, 10 adolescents, and 22 physicians (Study 2); and 43 parents (Study 3). All participants in the studies responded to six open-ended questions. A semantic content analysis technique was used to analyze all interview data. Four nurses independently coded each interview; interrater reliability per code ranged from 68% to 100% across studies. The most frequently reported influencing factors were "information on the health and disease status of the patient," "all curative options having been attempted," "trusting the healthcare team," and "feeling support from the healthcare provider." The agreement across studies regarding influencing factors provides the basis for the research-based guidelines for end-of-life decision making in pediatric oncology. The guidelines offer assistance with end-of-life decision making in a structured manner that can be formally evaluated and individualized to meet patient and family needs.

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.

[Ethical decisions making in neonatal intensive care. Survey among nursing staff in 2 French centers]

A European Concerted Action, Euronic, has been set up to study the attitudes and self-reported practices of the staff working in neonatal intensive care units about parent's information and ethical decisionmaking. This paper presents the results of a preliminary qualitative survey conducted in two French units and including 23 physicians and nurses. The answers indicate that withdrawal of treatments are part of their practices. Parents are never directly involved in the decision-making process. The decision to withdraw life sustaining treatments generate psychological distress among the caregivers. Nurses consider that they are more emotionally involved with the baby and the parents. They express concerns about painful treatments and life-prolonging therapies. Most respondents believe that an ethical committee would be of little help in the decision-making process and that the actual legislation should not be modified as it gives obligation for more in-depth consideration of each case.

Psychological Aspects of Life Support

Psychologists have done little research on the psychological aspects of life support. Research in other areas of psychology has produced results applicable to the life support situation, however. The results of directly and indirectly applicable research indicate that both patients and their intimates suffer less psychological distress if those who have a close positive relationship with the patient maintain emotional closeness to the patient and participate in making decisions concerning life support. Decisions to end treatment are difficult because ending treatment changes the social structure and identity of the survivors. Death is less stressful if the death comes at the right time of life, and the process of dying is neither too long nor too short. People feel less distress if they have appropriate information concerning the situation and have some control.

The parents' perspective: ethical decision-making in neonatal intensive care

Ethical debate abounds in the literature relative to treatment decisions for the high risk neonate in the intensive care nursery. A systematic examination of the parents' perspective is missing. To fill this existing gap, the ethical dimension of care was explored with 32 families of high risk newborns from a Level III nursery, using a moral conflict interview guide in order to describe their perspective. A concept of the medicalization of parenting appears to best reflect the parents' view of ethical decision-making responsibility. This concept evolved through the parents' reflection on conflict naming, content of decision-making, context of decision-making, information sharing and perception of infant status. These concerns differ profoundly from those of health professionals, philosophers, theologians and others active in this debate who cite lower limits of viability, iatrogenic effects of treatment, use of multiple invasive procedures, and the role of paternalism as ethical issues.

International perspectives on treatment choice in neonatal intensive care units

Over the past 25 years, neonatal intensive care units (NICUs) have been established throughout the industrialized world and in some Third World nations to provide sophisticated medical interventions for critically ill newborns. This paper discusses the four major factors affecting treatment choices for newborns with disabilities or at risk for disabilities: the availability of resources, societal attitudes toward medical interventions and life with disabilities, the roles of physicians, parents and other decision-makers, and the role of the law. Much has been written on the bioethical issues surrounding such treatment as it is practiced in the United States, including analysis by social scientists; however, little has been written on how those issues are perceived and dealt with in most other nations, and very little comparative research has been conducted. The author provides an international perspective on the bioethical issues involved by comparing U.S. practice, which has received much attention, with a generalized commentary on practices in other parts of the world, which have received less examination. The nations surveyed include Australia, Brazil, Britain, Canada, China, France, India, Israel, Japan, the Netherlands, Poland, Sweden, and West Germany. The value of further comparative research is discussed in order to encourage others to do such research.

Parental voices in the sea of neonatal ethical dilemmas

Ethical debate in neonatal intensive care centers around the lower limits of viability, the use of multiple invasive procedures, and the role of paternalism. The parents' perspective has been addressed infrequently. This report will focus on the parents' statements as obtained through predischarge in-depth interviews with 32 families, each with a high-risk infant(s). Discussion will include a summary of the range of parental perceptions during two major periods of time: preadmission to the NICU and the NICU experience itself. Some possible nursing implications will be drawn that reflect a sensitive response to these parental perceptions.

Selecting neonatal ethics

Nontreatment of handicapped newborns has disturbed American society, prompting heated debate and new attempts by government at regulation. Robert Weir's new book reviews the elements of this controversy as argued by concerned doctors, lawyers and ethicists. Unfortunately, we do not know the magnitude or scope of the problem. We know little about how often or under what circumstances physicians practice nontreatment. In discussing the issues, Weir and others have paid inadequate attention to medical uncertainty. The inability to accurately predict outcome makes clinical judgment harder than most philosophers and others acknowledge. Many legal arguments are outdated. The concept of personhood Weir and ethicists invoke confounds decision making. Complex or uncertain medicomoral dilemmas will not be resolved more easily by ethics committees. This procedural solution to a substantive quandry creates new problems. More attention must be paid to patients' current and future suffering when deciding whether to treat severely handicapped infants.

Follow-up of families of neonates in whom life support was withdrawn

Grieving patterns and psychosocial functioning were studied in 20 families who had participated in a decision-making conference regarding withdrawal of support of their newborn in the neonatal intensive care unit and for whom the life support had been withdrawn. Prolonged grieving was reported by one father and pathologic grieving by one grandmother. In the majority of families, grieving patterns and psychosocial functioning were similar to those of other families whose newborns have died.