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首页> 外文期刊>Pediatrics: Official Publication of the American Academy of Pediatrics >End-of-life after birth: death and dying in a neonatal intensive care unit.
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End-of-life after birth: death and dying in a neonatal intensive care unit.

机译：出生后的生命终止：新生儿重症监护病房的死亡和死亡。

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OBJECTIVE: In canonical modern bioethics, withholding and withdrawing medical interventions for dying patients are considered morally equivalent. However, electing not to administer cardiopulmonary resuscitation (CPR) struck us as easily distinguishable from withdrawing mechanical ventilation. Moreover, withdrawing mechanical ventilation from a moribund infant "feels" different from withdrawing mechanical ventilation from a hemodynamically stable child with a severe neurologic insult. Most previous descriptions of withdrawing and withholding intervention in the neonatal intensive care unit (NICU) have blurred many of these distinctions. We hypothesized that clarifying them would more accurately portray the process of end-of-life decision-making in the NICU. METHODS: We reviewed the charts of all newborn infants who had birth weight >400 g and died in our hospital in 1988, 1993, and 1998 and extracted potential ethical issues (resuscitation, withdrawal, withholding, CPR, do-not-resuscitate orders, neurologic prognosis, ethics consult) surrounding each infant's death. RESULTS: Using traditional definitions, roughly half of all deaths in our NICU in 1993 and 1998 were associated with "withholding or withdrawing." In addition, by 1998, >40% of our NICU deaths could be labeled "active withdrawal," reflecting the extubation of infants regardless of their physiologic instability. This practice is growing over time. However, 2 important conclusions arise from our more richly elaborated descriptions of death in the NICU. First, when CPR was withheld, it most commonly occurred in the context of moribund infants who were already receiving ventilation and dopamine. Physiologically stable infants who were removed from mechanical ventilation for quality-of-life reasons accounted for only 3% of NICU deaths in 1988, 16% of NICU deaths in 1993, and 13% of NICU deaths in 1998. Moreover, virtually none of these active withdrawals took place in premature infants. Second, by 1998 infants, who died without CPR almost always had mechanical ventilation withdrawn. Finally, the median and average day of death for 100 nonsurvivors who received full intervention did not differ significantly from the 78 nonsurvivors for whom intervention was withheld. CONCLUSIONS: In our unit, a greater and greater percentage of doomed infants die without ever receiving chest compressions or epinephrine boluses. Rather, we have adopted a nuanced approach to withdrawing/withholding NICU intervention, providing what we hope is a humane approach to end-of-life decisions for doomed NICU infants. We suggest that ethical descriptions that reflect these nuances, distinguishing between withholding and withdrawing interventions from physiologically moribund infants or physiologically stable infants with morbid neurologic prognoses, provide a more accurate reflection of the circumstances of dying in the NICU.
机译：目的：在规范的现代生物伦理学中，对垂死的患者保留和撤回医疗干预被认为在道德上是等同的。但是，选择不进行心肺复苏（CPR）使我们很容易与撤出机械通气区分开来。此外，从垂死的婴儿中撤出机械通气“感觉”不同于从血液动力学稳定的患有严重神经学损伤的儿童中撤出机械通气。先前对新生儿重症监护病房（NICU）撤回和扣留干预的大多数描述模糊了许多这些区别。我们假设澄清它们会更准确地描述NICU生命周期决策的过程。方法：我们回顾了所有出生体重> 400 g并于1988年，1993年和1998年在我院死亡的新生儿的图表，并提取了潜在的道德问题（复苏，停药，预扣，CPR，请勿进行复苏，神经系统的预后，请咨询道德规范），以了解每个婴儿的死亡情况。结果：按照传统的定义，在1993年和1998年我们重症监护病房死亡的大约一半与“扣留或退出”有关。另外，到1998年，我们40％以上的重症监护病房死亡可被标记为“主动戒断”，这反映了婴儿的拔管现象，无论其生理不稳定如何。随着时间的流逝，这种做法越来越多。但是，从我们对NICU中死亡的更详尽的描述中得出2个重要结论。首先，当停止进行心肺复苏术时，最常见的情况是在垂死的婴儿中接受通气和多巴胺治疗。由于生活质量原因而从机械通气中移出的生理稳定的婴儿仅占1988年NICU死亡的3％，1993年占NICU死亡的16％和1998年占NICU死亡的13％。而且，实际上，这些都不是早产儿主动退缩。其次，到1998年，没有CPR死亡的婴儿几乎总是撤回了机械通气。最后，接受全面干预的100名非幸存者的中位数和平均死亡天数与拒绝干预的78名非幸存者没有显着差异。结论：在我们的单位中，越来越多的注定死亡的婴儿没有受到胸部按压或肾上腺素推注而死亡。相反，我们采用了细微差别的方法来撤回/保留NICU干预，提供我们所希望的是为注定要患的NICU婴儿做出生命周期决定的人道方法。我们建议，反映这些细微差别的伦理学描述（从生理上垂死的婴儿或病态神经系统预后的生理上稳定的婴儿中扣留和撤回干预之间进行区分）可以更准确地反映新生儿重症监护病房的死亡情况。

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