Search

Developments in legal and medical research concerning end-of-life decisions regarding severely suffering neonates in the Netherlands provide good cause for reflection on specific items of this issue. This article deals with the outcomes of the first national survey on end-of-life practice in Dutch Neonatal Intensive Care Units (NICUs) and examines the legal aspects of the use of medication as a part of this practice. The authors particularly reflect on the application of analgesics and sedatives on the one hand and neuromuscular blockers (NMBs) on the other hand. Furthermore, they focus on different elements of medicinal use such as indication, the moment of administering, dosage, effects of combinations of drugs, the relationship to the causation of death and (failures in) documentation.

Developments in legal and medical research concerning end-of-life decisions regarding severely suffering neonates in the Netherlands provide good cause for reflection on specific items of this issue. This article deals with the outcomes of the first national survey on end-of-life practice in Dutch Neonatal Intensive Care Units (NICUs) and examines the legal aspects of the use of medication as a part of this practice. The authors particularly reflect on the application of analgesics and sedatives on the one hand and neuromuscular blockers (NMBs) on the other hand. Furthermore, they focus on different elements of medicinal use such as indication, the moment of administering, dosage, effects of combinations of drugs, the relationship to the causation of death and (failures in) documentation.

Developments in legal and medical practice in the Netherlands give rise to questions regarding the legal position of the unborn child. This article provides an overview of these developments and argues--in view of developments in other countries--that current Dutch legislation regarding the unborn child is not up to date. In effect, the article challenges the idea that the actual legal protection of the unborn child under positive Dutch law can be considered proportionate, even sufficient. To support this view the author will show that abortion is not the only matter in which clarity as to the legal protection of the viable unborn child is required. This signalisation provides good cause to reconsider the Dutch perspective on the matter, thus offering a point of reference to countries with a similar interpretation of what constitutes an appropriate legal protection of the unborn child.

Background: Clinicians frequently administer analgesics and sedatives at the time of withholding or withdrawal of life-sustaining treatment in newborns. This practice might be regarded as intentionally hastening of death., Objective: To describe type, doses and reasons for administering medications as part of end-of-life decisions in the Dutch neonatal intensive care units., Design and Setting: We reviewed the medical files of 340 newborn deaths with a preceding end-of-life decision over a 12-month period to describe the use of analgesics, sedatives and/or neuromuscular blockers. The neonatologists of 147 of the 150 newborns with a preceding end-of-life decision based on the infant's poor prognosis were interviewed to obtain additional details about the use of medication., Results: Analgesics and sedatives were administered to 224 of 340 newborns before the end-of-life decision and to 292 newborns after the decision. The medication was increased in 94 of 289 newborns whose death was imminent and in 110 of 150 newborns with a poor prognosis. Reasons for the increase were treatment of pain and suffering, and in 4% of cases hastening of death. Reasons were undocumented in 55% of deaths. Neuromuscular blockers were administered in 16% of patients because they already received these agents or to stop or prevent gasping., Conclusions: Analgesics and sedatives are generally increased after the end-of-life decision to treat pain and suffering and rarely to hasten death. Neuromuscular blockers were administered in 16% of deaths. Medical files provide insufficient documentation of considerations leading to the increase of medication, which hinders (external) review.

Objective: To clarify the practice of end-of-life decision making in severely ill newborns., Design: Retrospective descriptive study with face-to-face interviews., Setting: The 10 neonatal intensive care units in the Netherlands from October 2005 to September 2006., Patients: All 367 newborn infants who died in the first 2 months of life in Dutch neonatal intensive care units. Adequate documentation was available in 359 deaths., Outcome Measures: Presence of end-of-life decisions, classification of deaths in 3 groups, and physicians' considerations leading to end-of-life decisions., Results: An end-of-life decision preceded death in 95% of cases, and in 5% treatment was continued until death. Of all of the deaths, 58% were classified as having no chance of survival and 42% were stabilized newborns with poor prognoses. Withdrawal of life-sustaining therapy was the main mode of death in both groups. One case of deliberate ending of life was found. In 92% of newborns with poor prognoses, end-of-life decisions were based on patients' future quality of life and mainly concerned future suffering. Considerations regarding the infant's present state were made in 44% of infants., Conclusions: Virtually all deaths in Dutch neonatal intensive care units are preceded by the decision to withdraw life-sustaining treatment and many decisions are based on future quality of life. The decision to deliberately end the life of a newborn may occur less frequently than was previously assumed.

Objective: To determine the frequency and background of conflicts about neonatal end-of-life (EoL) decisions., Methods: We reviewed the medical files of 359 newborns who had died during 1 year in the 10 Dutch NICUs and identified 150 deaths that were preceded by an EoL decision on the basis of the child's poor prognosis. The attending neonatologists of 147 of the 150 newborns were interviewed to obtain details about the decision-making process., Results: EoL decisions about infants with a poor prognosis were initiated mainly by the physician, who subsequently involved the parents. Conflicts between parents and the medical team occurred in 18 of 147 cases and were mostly about the child's poor neurologic prognosis. Conflicts within the team occurred in 6 of 147 cases and concerned the uncertainty of the prognosis. In the event of conflict, the EoL decision was postponed. Consensus was reached by calling additional meetings, performing additional diagnostic tests, or obtaining a second opinion. The chief causes of conflict encountered by the physicians were religious convictions that forbade withdrawal of life-sustaining treatment and poor communication between the parents and the team., Conclusions: The parents were involved in all EoL decision-making processes, and consensus was ultimately reached in all cases. Conflicts within the team occurred in 4% of the cases and between the team and the parents in 12% of the cases. The conflicts were resolved by postponing the EoL decision until consensus was achieved.

This paper describes the position of Dutch law concerning end-of-life decisions in neonatology consequent on rulings of the Dutch appeals court in two cases. The concept of a multidisciplinary assessment committee is explored. The European Convention on Human Rights in its articles 2 and 13 is relevant to this concept. The author provides a detailed discussion of the current situation and draws conclusions based on his perception of future developments in regulating thanatic practices in neonatology.