title: Just, in time: ethical implications of serial predictions of death and morbidity for ventilated premature infants.
abstract: OBJECTIVE
  For a cohort of extremely premature, ventilated, newborn infants, we determined the power of either serial caretaker intuitions of "die before discharge" or serial illness severity scores to predict the outcomes of death in the NICU or neurologic performance at corrected age of 2 years.
  
  
  METHODS
  We identified 268 premature infants who were admitted to our NICU in 1999-2004 and required mechanical ventilation. For each infant on each day of mechanical ventilation, we asked nurses, residents, fellows, and attending physicians the following question: "Do you think this child is going to live to go home or die before hospital discharge?" In addition, we calculated illness severity scores until either death or extubation.
  
  
  RESULTS
  A total of 17,066 intuition profiles were obtained on 5609 days of mechanical ventilation in the NICU. One hundred (37%) of 268 profiled infants had > or = 1 intuition of die before discharge. Only 33 infants (33%) with an intuition of die actually died in the NICU. Of 48 infants with even 1 day of corroborated intuition of die in the NICU, only 7 (14%) were alive with both Mental Developmental Index and Psychomotor Developmental Index scores of > 69, and only 2 (4%) were alive with both Mental Developmental Index and Psychomotor Developmental Index Scores of > 79 at corrected age of 2 years. On day of life 1, the Score for Neonatal Acute Physiology II value for nonsurvivors (38.2 +/- 18.1) was significantly higher than that for survivors (26.3 +/- 12.7). However, this difference decreased steadily over time as scores improved for both groups.
  
  
  CONCLUSIONS
  Illness severity scores become progressively less helpful over time in distinguishing infants who will either die in the NICU or survive with low Mental Developmental Index/Psychomotor Developmental Index scores. Serial caretaker intuitions of die before discharge also fail to identify prospective nonsurviving infants. However, corroborated intuitions of die before discharge identify a subset of infants whose likelihood of surviving to 2 years with both MDI and PDI > 80 is approximately 4%.
authors.affiliation: Department of Pediatrics, MC 6060, University of Chicago, 5825 South Maryland Ave, Chicago, IL 60637, USA. wlm1@uchicago.edu
authors.forename: William
authors.initials: W
authors.lastname: Meadow
authors.forename: Joanne
authors.initials: J
authors.lastname: Lagatta
authors.forename: Bree
authors.initials: B
authors.lastname: Andrews
authors.forename: Leslie
authors.initials: L
authors.lastname: Caldarelli
authors.forename: Amaris
authors.initials: A
authors.lastname: Keiser
authors.forename: Johanna
authors.initials: J
authors.lastname: Laporte
authors.forename: Susan
authors.initials: S
authors.lastname: Plesha-Troyke
authors.forename: Madhu
authors.initials: M
authors.lastname: Subramanian
authors.forename: Sam
authors.initials: S
authors.lastname: Wong
authors.forename: Jon
authors.initials: J
authors.lastname: Hron
authors.forename: Nima
authors.initials: N
authors.lastname: Golchin
authors.forename: Michael
authors.initials: M
authors.lastname: Schreiber
mesh_terms: D001034:Apgar Score; D002423:Cause of Death; D015331:Cohort Studies; D002658:Developmental Disabilities / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D005865:Gestational Age; D006801:Humans; D052577:Infant, Extremely Low Birth Weight; D007231:Infant, Newborn; D007235:Infant, Premature, Diseases / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D007363:Intensive Care Units, Neonatal; D008297:Male; D009017:Morbidity / Q000639:trends*; D011237:Predictive Value of Tests; D011336:Probability; D012121:Respiration, Artificial / Q000009:adverse effects* / Q000941:ethics* / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis