Analgesics, sedatives and neuromuscular blockers as part of end-of-life decisions in Dutch NICU's

A A Eduard Verhagen ^1*, Josef H H M Dorscheidt ², Bernadette Engels ¹, Joep H Hubben ² and Pieter J Sauer ¹

¹ University Medical Centre Groningen, Dept of Paediatrics, Netherlands
² University Medical Centre Groningen, Dept of Health Sciences, Section of Health Law, Netherlands

^* To whom correspondence should be addressed. E-mail: e.verhagen{at}bkk.umcg.nl.

Accepted 2 June 2009

Abstract

Background: Clinicians frequently administer analgesics and sedatives at the time of withholding or withdrawal of life-sustaining treatment in newborns. This practice might be regarded as intentionally hastening of death.

Objective: To describe type, doses and reasons for administering medications as part of end-of-life decisions in the Dutch NICU’s.

Design and setting: We reviewed the medical files of 340 newborn deaths with a preceding end-of-life decision over a 12 months period to describe the use of analgesics, sedatives and and/or neuromuscular blockers. The neonatologists of 147 of the 150 newborns with a preceding end-of-life decision based on the infant’s poor prognosis were interviewed to obtain additional details about the use of medication.

Results: Analgesics and sedatives were administered to 224 of 340 newborns before the end-of-life decision and to 292 newborns after the decision. The medication was increased in 94 of 289 newborns whose death was imminent and in 110 of 150 newborns with a poor prognosis. Reasons for the increase were treatment of pain and suffering and in 4% of cases hastening of death. Reasons were undocumented in 55% of deaths. Neuromuscular blockers were administered in 16% of patients because they already received these agents or to stop or prevent gasping.

Conclusions: Analgesics and sedatives are generally increased after the end-of-life decision to treat pain and suffering and rarely to hasten death. Neuromuscular blockers were administered in 16% of deaths. Medical files provide insufficient documentation of considerations leading to the increase of medication, which hinders (external) review.