Elsevier

The Journal of Pediatrics

Volume 129, Issue 5, November 1996, Pages 661-666
The Journal of Pediatrics

Foregoing intensive care treatment in newborn infants with extremely poor prognoses:: A study in four neonatal intensive care units in the Netherlands,☆☆,

https://doi.org/10.1016/S0022-3476(96)70146-4Get rights and content

Abstract

Within the framework of the broader ethical discussion on end-of-life decision making in neonatology and the need to obtain more quantifiable data, we performed a multicenter study in four Dutch neonatal intensive care units. All infants who died in these units in 1993 were included in the study. Aside from cases in which foregoing treatment was not under discussion, cases in which death appeared inevitable (A cases) and cases in which foregoing treatment because of extremely poor prognosis was the decisive factor (B cases) were distinguished. A total of 181 neonatal deaths occurred. Thirty-five infants died even after full continuation of treatment. In 98 A cases and 48 B cases, which together represented 81% of all deaths, treatment was foregone either because the infants had no chance to survive or because of extremely poor prognoses. In these cases, the medical team ultimately achieved consensus of opinion, although in some instances several sessions were required. In three cases, the parents did not agree with the team advice. In one A case death appeared inevitable. In two B cases, the parents' wish to continue treatment was followed. In a large majority of B cases, the decisions to forego treatment were based on the presence of severe cerebral damage. In A cases there was no real choice because death appeared inevitable. However, in B cases neonatologists were obliged to determine whether continuation of treatment was justifiable or if withdrawal of treatment in view of extremely poor prognoses was preferred. (J Pediatr 1996;129:661-6)

Section snippets

METHODS

In 1993, 195,673 infants were born alive in the Netherlands. Of these infants, 3780 (1.9%) were admitted to the 10 Dutch level III neonatal intensive care units. Of the total admissions, 1284 (34%) occurred at the four participating units in this study. This study focuses on all infants who died in 1993 in these four units.

The infants were classified in six categories according to the report “Doen of Laten?” (”To do or not to do?”) of the Dutch Society of Paediatrics.7 The six categories and

RESULTS

This study is based on 181 neonatal cases. Gestational ages and birth weights for the study patients and for the total number of patients admitted at the four sites are reported in Table I. The lowest gestational age and birth weight groups were overrepresented in the study group. Table II lists the classification and treatment choices of the study cases. No cases involving the intentional and active termination of the patient's life (category 4 cases) occurred in this population.

DISCUSSION

The neonatal units involved in this study also conducted a study in 1990 of the 185 patient deaths in their units in that year.8 In that study, it was found that intensive care had not been started in 9% of the cases. In 31% of the cases intensive care had been withdrawn because of the absence of a realistic chance of survival. In 19% of the cases intensive care had been withdrawn because of extremely poor prognoses. In 40% of the cases, intensive treatment had been continued until the

Acknowledgements

We thank Douglas Brown, PhD, associate professor with the Louisiana State University School of Medicine, Department of Obstetrics and Gynecology, for his help in preparing this article.

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From the Department of Neonatology, Emma Children's Hospital Academic Medical Center, University of Amsterdam, Amsterdam, the Department of Pediatrics, University Hospital Leiden, Leiden, the Department of Neonatology, St. Joseph Hospital Veldhoven, Veldhoven, and the Department of Pediatrics, Neonatal Unit, University Hospital Nijmegen, Nijmegen, The Netherlands

☆☆

Reprint requests: Richard de Leeuw, MD, PhD, Academical Medical Center, University of Amsterdam, Emma Children's Hospital, Department of Neonatology, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands.

0022-3476/96/$5.00 + 0 9/21/75978

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