DEATH IN THE INTENSIVE-CARE NURSERY - PHYSICIAN PRACTICE OF WITHDRAWING AND WITHHOLDING LIFE-SUPPORT

Objective. To determine the frequency of selective nontreatment of ext remely premature, critically ill, or malformed infants among all infan t deaths in a level III intensive care nursery (ICN) and to determine the reasons documented by neonatologists for their decisions to withdr aw or withhold life support. Methods. This was a descriptive study bas ed on review of the medical records of all 165 infants who died at a u niversity-based level III ICN during 3 years. We determined whether ea ch death had occurred despite the use of all available technologies to keep the infant alive or whether these were withheld or withdrawn, th ereby leading to the infants death. We also determined whether neonato logists documented either ''futility'' or ''quality of life'' as a rea son to limit medical interventions. Results. One hundred sixty-five in fants died among the 1609 infants admitted during the study period. On e hundred eight infant deaths followed the withdrawal of life support, 13 deaths followed the withholding of treatment, and 44 deaths occurr ed while infants continued to receive maximal life-sustaining treatmen t. For 90 (74%) of the 121 deaths attributable to withholding of withd rawal of treatment, physicians cited that death was imminent and treat ment was futile. Quality-of-life concerns were cited by the neonatolog ists as reasons to Limit treatment in 62 (51%). Quality of life was th e only reason cited for limiting treatment for 28 (23%) of the 121 dea ths attributable to withholding or withdrawal of treatment. Conclusion s. The majority of deaths in the ICN occurred as a result of selective nontreatment by neonatologists, with few infants receiving maximal su pport until the actual time of death. Neonatologists often documented that quality-of-life concerns were considered in decisions to limit tr eatment; however, the majority of these decisions were based on their belief that treatment was futile. Prospective studies are needed to el ucidate the determinants of neonatologists' practice decisions of sele ctive nontreatment for marginally viable or damaged infants.