Categorizing neonatal deaths: a cross-cultural study in the United States, Canada, and The Netherlands.

Categorizing neonatal deaths: a cross-cultural study in the United States, Canada, and The Netherlands.

Verhagen AAE; Janvier A; Leuthner SR; Andrews B; Lagatta J; Bos AF; Meadow W

The Journal Of Pediatrics

2010

Female; Humans; infant; Male; United States; Intensive Care Units; Terminal Care; Canada; Netherlands; Cross-Cultural Comparison; Respiration; Neonatal; decision making; Newborn; gestational age; Artificial; Withholding Treatment/statistics & numerical data; Physician Assisted Dying PAD; decision making; Diseases/mortality; Diseases/mortality; Withholding Treatment/statistics & numerical data

OBJECTIVE: To clarify the process of end-of-life decision-making in culturally different neonatal intensive care units (NICUs). STUDY DESIGN: Review of medical files of newborns >22 weeks gestation who died in the delivery room (DR) or the NICU during 12 months in 4 NICUs (Chicago, Milwaukee, Montreal, and Groningen). We categorized deaths using a 2-by-2 matrix and determined whether mechanical ventilation was withdrawn/withheld and whether the child was dying despite ventilation or physiologically stable but extubated for neurological prognosis. RESULTS: Most unstable patients in all units died in their parents' arms after mechanical ventilation was withdrawn. In Milwaukee, Montreal, and Groningen, 4% to 12% of patients died while receiving cardiopulmonary resuscitation. This proportion was higher in Chicago (31%). Elective extubation for quality-of-life reasons never occurred in Chicago and occurred in 19% to 35% of deaths in the other units. The proportion of DR deaths in Milwaukee, Montreal, and Groningen was 16% to 22%. No DR deaths occurred in Chicago. CONCLUSIONS: Death in the NICU occurred differently within and between countries. Distinctive end-of-life decisions can be categorized separately by using a model with uniform definitions of withholding/withdrawing mechanical ventilation correlated with the patient's physiological condition. Cross-cultural comparison of end-of-life practice is feasible and important when comparing NICU outcomes.

2010-01

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