Wall S N, Partridge J C
Department of Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA.
Pediatrics. 1997 Jan;99(1):64-70. doi: 10.1542/peds.99.1.64.
To determine the frequency of selective nontreatment of extremely premature, critically ill, or malformed infants among all infant deaths in a level III intensive care nursery (ICN) and to determine the reasons documented by neonatologists for their decisions to withdraw or withhold life support.
This was a descriptive study based on review of the medical records of all 165 infants who died at a university-based level III ICN during 3 years. We determined whether each death had occurred despite the use of all available technologies to keep the infant alive or whether these were withheld or withdrawn, thereby leading to the infant's death. We also determined whether neonatologists documented either "futility" or "quality of life" as a reason to limit medical interventions.
One hundred sixty-five infants died among the 1609 infants admitted during the study period. One hundred eight infant deaths followed the withdrawal of life support, 13 deaths followed the withholding of treatment, and 44 deaths occurred while infants continued to receive maximal life-sustaining treatment. For 90 (74%) of the 121 deaths attributable to withholding of withdrawal of treatment, physicians cited that death was imminent and treatment was futile. Quality-of-life concerns were cited by the neonatologists as reasons to limit treatment in 62 (51%). Quality of life was the only reason cited for limiting treatment for 28 (23%) of the 121 deaths attributable to withholding or withdrawal of treatment.
The majority of deaths in the ICN occurred as a result of selective nontreatment by neonatologists, with few infants receiving maximal support until the actual time of death. Neonatologists often documented that quality-of-life concerns were considered in decisions to limit treatment; however, the majority of these decisions were based on their belief that treatment was futile. Prospective studies are needed to elucidate the determinants of neonatologists' practice decisions of selective nontreatment for marginally viable or damaged infants.
确定在三级重症监护病房（ICN）所有婴儿死亡中，对极早产、危重症或畸形婴儿进行选择性不治疗的频率，并确定新生儿科医生记录的决定撤销或 withhold 生命支持的原因。
这是一项描述性研究，基于对3年内一所大学附属三级ICN所有165例死亡婴儿的病历审查。我们确定每例死亡是在使用所有可用技术维持婴儿生命的情况下发生的，还是这些技术被 withhold 或撤销从而导致婴儿死亡。我们还确定新生儿科医生是否将“无意义”或“生活质量”记录为限制医疗干预的原因。
在研究期间收治的1609例婴儿中有165例死亡。108例婴儿死亡是在生命支持被撤销后发生的，13例死亡是在治疗被 withhold 后发生的，44例死亡发生在婴儿继续接受最大程度维持生命治疗期间。在121例因 withhold 或撤销治疗导致的死亡中，有90例（74%）医生认为死亡即将来临且治疗无意义。新生儿科医生将生活质量问题作为限制治疗的原因的有62例（51%）。在121例因 withhold 或撤销治疗导致的死亡中，有28例（23%）将生活质量作为限制治疗的唯一原因。
ICN中的大多数死亡是由于新生儿科医生的选择性不治疗导致的，很少有婴儿在实际死亡前接受最大程度的支持。新生儿科医生经常记录在限制治疗的决定中考虑了生活质量问题；然而，这些决定中的大多数是基于他们认为治疗无意义的信念。需要进行前瞻性研究以阐明新生儿科医生对边缘存活或受损婴儿进行选择性不治疗的实践决定的决定因素。
