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Here is an uncomfortable word that in neonatal medicine we prefer not to use. We commonly use the term ‘withdraw care’—a terrible thing to say when we actually mean moving from intensive to palliative care. While some of us commonly use the term ‘palliative care’, we all accept that discontinuing intensive therapy usually—but not always—leads relatively soon to death. We smooth the path of palliation with medication to alleviate suffering—but we don’t kill, or at least we don’t intend to do so. Probably. Now Cuttini et al have grasped the nettle of euthanasia as a legalised entity, and explored how medical and nursing attitudes vary across 10 European countries to this possibility. They found very large differences in attitudes between different countries, with the Netherlands and France being outliers in the direction of active euthanasia, while the UK sits much closer to those countries like Germany and Lithuania, where there seems little enthusiasm either for active euthanasia or for changes in the law. I don’t know whether to regard their findings as positive or negative, reassuring or frightening, and maybe these rather emotive words are the wrong way to describe the data. What I am certain about is that any debate on euthanasia is inescapably emotive, and I am also sure that both the article itself, and the two commentaries on it, will stimulate a lot of electronic responses. However, some of the electronic responses will probably quote the well known lines from Clough’s ‘The Latest Decalogue’, and since many people do not know the context of the lines, or appreciate the sardonic irony with which the poem was written, I reproduce it in full below.
See page 19
The Latest Decalogue
Thou shalt have one God only; who
Would be at the expense of two?
No graven images may be
Worshipp’d, except the currency:
Swear not at all; for, for thy curse
Thine enemy is none the worse:
At church on Sunday to attend
Will serve to keep the world thy friend:
Honour thy parents; that is, all
From whom advancement may befall:
Thou shalt not kill; but need’st not strive
Officiously to keep alive:
Do not adultery commit;
Advantage rarely comes of it:
Thou shalt not steal; an empty feat,
When it’s so lucrative to cheat:
Bear not false witness; let the lie
Have time on its own wings to fly:
Thou shalt not covet; but tradition
Approves all forms of competition.
Arthur Hugh Clough (1819–1861)
STRESS, PAIN & THEIR RELIEF
I get uncomfortable when ‘Fetal and Neonatal’ seems to be entirely dominated by Neonatal, so it is with great personal satisfaction that I note that this issue has several papers that cross the Great Perinatal Divide. One of these is the paper by Gitau et al, who examined fetal stress responses to intrauterine transfusion. As the authors acknowledge, work such as this begs at least as many questions as it answers, and the focus on the hypothalamic-pituitary axis avoids the rather obvious questions – does it matter and what can we do about it? Pain does matter, of course, and it is also good to be able to carry a paper that should help us to use rationally a potentially important intravenous analgesic, propacetamol (a pro-drug of paracetamol). Allegaert and her colleagues have done a useful service in providing some data on which to base dose strategies, but we still await better methods of assessing the efficacy of analgesia in the neonate.
See pages 25 and 29
METHADONE AND BABIES
Knowing that the side effect profile of any opioid is very different in humans according to the degree of pain for which they are being treated, I have always wondered whether babies would react in the same way to withdrawal from opioids used for maternal analgesia as from the same drugs used in harm reduction programmes. Now we have something of an answer to this: Sharpe and Kuschel suggest that where mothers have received methadone as treatment for chronic pain, their infants have less withdrawal symptoms. But were many of the mothers on harm reduction programmes taking lots of other stuff, making their babies more symptomatic because of that? There’s a lot more we need to know about this increasingly prevalent problem.
See page 33
MEASURING INTRAPARTUM CARE, & CESDI 27/28
Pain and methadone are both fetal and neonatal problems—so is intrapartum care, and we have three takes on this in the current issue. First, we have an annotation that explores the challenges presented to neonatologists by the report from the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI), which published its investigation into the perinatal care of babies born at 27 and 28 weeks in 2003. Second, we have a research letter from Edinburgh that presents a solution for the problem of early thermal care for these babies, which was one of the issues highlighted in the report. Finally, we have a paper that tackles the thorny issue of the structure of perinatal care and its relation to stillbirth and neonatal death: it suggests that a more interventionist obstetric approach, and units that have more consultant input, seem to have better rates of stillbirth and neonatal death. In contrast, paediatric variables seemed to make little difference to neonatal outcomes. These data from Joyce et al complement those from confidential enquiry that have appeared in CESDI reports over the years.
See pages 14, 51 and 93
FINDING THE TIP OF THE LONG LINE – HUNTING THE SNARK?
So many attempts to find the tips of long lines, such variable success. We badly need to know where the tips are, and where they aren’t—but no one has come up with a foolproof way of achieving this. The approach reported by Evans et al seems to beat that from Odd et al, but as yet not many neonatal units have access to radiographic ‘soft copy’ as provided by computed radiography, so most of us struggle on with old technology such as plain radiographs, contrast enhancement, and ultrasound. If you are interested in the problem of not knowing what you are looking for, nor where to find it, you will want to re-read The Hunting of the Snark. To find it on the web, point your browser at http://etext.lib.virginia.edu/toc/modeng/public/CarSnar.html. Happy New Year.
See pages 41 and 44
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