Analgesics, sedatives and neuromuscular blockers as part of end-of-life decisions in Dutch NICUs.
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.


METHODS
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.
Verhagen
A A E
AA
Department of Paediatrics, Beatrix Children's Hospital/ University Medical Centre Groningen, 9700 RB Groningen, the Netherlands. e.verhagen@bkk.umcg.nl
Dorscheidt
J H H M
JH
Engels
B
B
Hubben
J H
JH
Sauer
P J
PJ
D000700:Analgesics / Q000008:administration & dosage*; D001291:Attitude of Health Personnel; D003657:Decision Making; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000175:diagnosis / Q000188:drug therapy; D007363:Intensive Care Units, Neonatal; D015931:Intensive Care, Neonatal / Q000379:methods; D018447:Medical Futility; D009426:Netherlands; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage*; D010146:Pain / Q000188:drug therapy; D010166:Palliative Care / Q000379:methods*; D011379:Prognosis; D012189:Retrospective Studies; D013315:Stress, Psychological / Q000188:drug therapy; D028761:Withholding Treatment
D000700:Analgesics; D006993:Hypnotics and Sedatives; D009466:Neuromuscular Blocking Agents