End of life decisions in the NICU

End of life decisions are never easy. But deciding to withhold or withdraw treatment from children adds more layers of emotional and ethical complexity. “Treatment decisions are easier when an infant is clearly dying,” said Jonathan Hellman, MBBCh, The Hospital for Sick Children, University of Toronto, Canada, at the PAS meeting in Honolulu.

Decisions are harder when an infant might be saved but could live severely compromised by pain, disability, or both. Societal and cultural expectations are key. Eduard Verhagen, MD, JD, University Medical Center Groningen, Netherlands, noted that European practitioners limit intensive neonatal interventions based on fatal illness or neurologic prognosis.

But there are differences. Clinicians in some countries would not treat a 23-week baby; clinicians in other countries always treat a 23-week baby. In Belgium and Holland, physicians openly practice pediatric euthanasia after consultation with parents. “The Dutch attitude is that we know it is happening,” Dr. Verhagen said. “It is better to regulate and do it in the best manner possible than to leave it alone.” Standard practice is different in Japan. Masanori Tamura, MD, Saitama Medical University, Kawagoe, Japan, reported that extreme measures are routine, especially if parents concur. “American physicians look for consensus, said William Meadow, MD, University of Chicago Children’s Hospital.” Deciding when to treat or when to stop treating must be a joint decision between parents and care givers.

If both decide to not treat, the decision is made. If one says treat and the other says don’t treat, the only appropriate option is to treat.