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End of life decisions for newborns: an ethical and compassionate process?
  1. Brian S Carter
  1. Correspondence to Dr Brian S Carter, Department of Pediatrics, University of Missouri-Kansas City (UMKC) and Division of Neonatology & Bioethics Center, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; bscarter{at}cmh.edu

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In their report on neonatal death from Canada, Hellmann et al indicate a propensity for neonatologists to employ a consensus deriving process that engages both families and the neonatal intensive care unit (NICU) interdisciplinary team.1 This is certainly in alignment with the process of shared decision-making, a strategy espoused by the American Academy of Pediatrics, the Nuffield Council and others. To their credit, the authors excluded stillbirths and infants <500 g and/or <23 completed weeks of gestation, but included infants admitted to the NICU, who may have died elsewhere in the hospital or at home receiving palliative care.

Within Hellmann et al's report, three things stand out.

First, certainty in a poor prognosis was reported to be from moderate to absolute by 88% of physicians. Clinicians may occasionally be confronted by colleagues, staff members or families who ask, ‘How certain are you?’ The degree of certainty need not be absolute in order to make recommendations for implementing, or withdrawing, care.2 There is an often missed, or misread, notion of certainty that characterises physicians in the intensive care unit. We expect of ourselves relative certainty—as best discernible by available evidence—in a scientific sense as we go about diagnosing and treating critically ill newborns. Yet, our practice involves a practical application of knowledge coloured by our best understanding of evidence and outcome expectations based on our experiences and those shared by others. Can we prognosticate with certainty? No, not absolutely, but our Canadian colleagues may be more accepting of this reality than what is practiced in the USA.

Second, despite this …

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    Jonathan Hellmann Robin Knighton Shoo K Lee Prakesh S Shah on behalf of the Canadian Neonatal Network End of Life Study Group Wayne Andrews Antoine Payot Barbara Bullied Aaron Chiu Kimberly Dow Shaheen Doctor Kevin Coughlin Douglas D. McMillan Cecil Ojah Abraham Peliowski Bruno Piedboeuf Patricia Riley Thierry Dabowal John Watts Horacio Osiovich
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