van der Heide A, van der Maas P J, van der Wal G, de Graaff C L, Kester J G, Kollée L A, de Leeuw R, Holl R A
Department of Public Health, Erasmus University Rotterdam, Netherlands.
Lancet. 1997 Jul 26;350(9073):251-5. doi: 10.1016/S0140-6736(97)02315-5.
Advances in neonatal intensive care have lowered the neonatal death rate. There are still some severely ill neonates and infants, however, for whom the application of all possible life-prolonging treatment modalities may be questioned.
We did two studies in the Netherlands. In the first we sent questionnaires to physicians who had attended 338 consecutive deaths (August-November, 1995) within the first year of life (death-certificate study), and in the second we interviewed 31 neonatologists or paediatric intensive-care specialists and 35 general paediatricians. The response rates were 88% and 99%, respectively.
In the death-certificate study, 57% of all deaths had been preceded by a decision to forgo life-sustaining treatment; this decision was accompanied by the administration of potentially life-shortening drugs to alleviate pain or other symptoms in 23%, and by the administration of drugs with the explicit aim of hastening death in 8%. A drug was given explicitly to hasten death to neonates not dependent on life-sustaining treatment in 1% of all death cases. No chance of survival was the main motive in 76% of all end-of-life decisions, and a poor prognosis was the main motive in 18%. The interview study showed that parents had been involved in making 79% of decisions. The physicians consulted colleagues about 88% of decisions. Most paediatricians favoured formal review of medical decisions by colleagues together with ethical or legal experts.
Death among neonates and infants is commonly preceded by medical end-of-life decisions. Most Dutch paediatricians seem to find prospects for survival and prognostic factors relevant in such decisions. Public control by a committee of physicians, paediatricians, ethicists, and legal experts is widely endorsed by paediatricians.
新生儿重症监护技术的进步降低了新生儿死亡率。然而，仍有一些重症新生儿和婴儿，对他们而言，应用所有可能的延长生命的治疗方式可能会受到质疑。
我们在荷兰开展了两项研究。第一项研究中，我们向在1岁以内连续处理338例死亡病例（1995年8月至11月）的医生发放问卷（死亡证明研究），第二项研究中，我们访谈了31名新生儿科医生或儿科重症监护专家以及35名普通儿科医生。回复率分别为88%和99%。
在死亡证明研究中，所有死亡病例中有57%在之前做出了放弃维持生命治疗的决定；做出该决定的同时，23%的病例使用了可能缩短生命的药物以缓解疼痛或其他症状，8%的病例使用药物的明确目的是加速死亡。在所有死亡病例的1%中，明确给不依赖维持生命治疗的新生儿使用药物以加速死亡。在所有临终决定中，76%的主要动机是没有生存机会，18%的主要动机是预后不良。访谈研究显示，79%的决定有家长参与。医生就88%的决定咨询了同事。大多数儿科医生赞成由同事以及伦理或法律专家对医疗决定进行正式审查。
新生儿和婴儿死亡之前通常会做出医疗临终决定。大多数荷兰儿科医生似乎认为生存前景和预后因素在这类决定中很重要。儿科医生广泛认可由医生、儿科医生、伦理学家和法律专家组成的委员会进行公共监督。
