END-OF-LIFE DECISIONS FOR SURGICAL NEONATES - EXPERIENCE IN THE NETHERLANDS AND UNITED-STATES

Purpose: To characterize end-of-life decisions for surgical neonates a nd compare similarities and differences in practice between pediatric surgeons in The Netherlands and the United States. Methods: The author s evaluated the deaths of all neonates admitted to the surgical intens ive care unit (SICU) of two major children's hospitals: Sophia Childre n's Hospital (SCH) in The Netherlands and Columbus Children's Hospital (CCH) in the United States. Between January 1990 and July 1993, neona tal SICU admissions totaled 362 (SCH) and 125 (CCH). Neonates who died were classified as follows: group 1 = poor prognosis, expected death, and group 2 = good prognosis, expected survival. Results: The mortali ty rates were comparable for each SICU: 12% (SCH) and 14% (CCH). The a verage survival period was shorter in group 1 (1.5 days) than in group 2 (26.5 days). Criteria for assignment to group 1 differed, with ''ex pected poor quality of life'' used at SCH, and ''futility'' at CCH. Cr iteria for group 2 were similar and included significant postoperative complications. Although the percentages with a do-not-resuscitate (DN R) status were comparable (SCH, 51%; CCH, 55%), the application of the DNR order differed in each SICU. The majority of neonates at SCH had either withholding or withdrawal of life support, whereas no further e scalation in treatment was offered for infants with a DNR order at CCH . The average survival period after the DNR order was 4 days at SCH an d 7 days at CCH. Conclusion: DNR orders were used for more than half t he surgical neonates with critical illness. Criteria for DNR status an d implementation of patient care after the DNR order differed between the SICUs. Copyright (C) 1995 by W.B. Saunders Company.