End‐of‐life opioid administration on neonatal and pediatric intensive care units: Nurses' attitudes and practice

Garten, Lars; Daehmlow, Steffen; Reindl, Tobias; Wendt, Anke; Münch, Annette; Bührer, Christoph

doi:10.1016/j.ejpain.2011.03.009

Cited by 19 publications

(13 citation statements)

References 28 publications

(28 reference statements)

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“…These findings are contradictory to those of Garten et al who demonstrated that 75% of NICU nurses surveyed believe that regular pain assessment should be performed throughout the dying process. 23 Furthermore, NICU nurses strongly believe that providing pain relief should be a priority during the dying process. 24 Lack of documentation may have partly been a function of the flurry of activities surrounding the infant’s entry into EOL care.…”

Section: Discussionmentioning

confidence: 99%

Medical Record Documentation and Symptom Management at the End of Life in the NICU

Fortney

Steward

2015

Advances in Neonatal Care

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Purpose In neonates, the course of illness is often unpredictable and symptom assessment is difficult. This is even truer at the end-of-life (EOL). Time to death can take minutes to days, and ongoing management of the infant is needed during the time between discontinuation of life-sustaining treatment and death to ensure the infant remains free of pain and suffering. The symptoms experienced by neonates as they die, as well as best ways to treat those symptoms, are understudied. The purpose of this study was to examine symptoms exhibited by neonates at the EOL and the treatments utilized to manage those symptoms as documented in the medical record during the last 24 hours of life. Subjects The sample included 20 neonates who died at a large children’s hospital Design This was an exploratory, descriptive study. Methods Descriptive data, such as diagnosis, on-going therapy at time of treatment withdrawal or withholding, pharmacologic and non-pharmacologic interventions associated with treatment withdrawal, time of treatment withdrawal and death, age at time of death, signs and symptoms exhibited during EOL care, and pain scores, was abstracted from the infant’s medical record. Main Outcome Measures Inadequate documentation in the medical record resulted in missing data that made it not possible to fully explore aspects of symptom management during the last 24 hours of life, however some important results were found. Principal Results Importantly, this study showed a difference in the way neonates approach the EOL period. Other findings were that most infants in the study received pain medication even though pain scores were infrequently documented and drug dosages varied across infants. Finally, documentation of non-pharmacologic interventions utilized at the EOL was also lacking.

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Section: Discussionmentioning

confidence: 99%

Medical Record Documentation and Symptom Management at the End of Life in the NICU

Fortney

Steward

2015

Advances in Neonatal Care

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“…The second classification system used was based upon classifications of (neonatal) intensive care patients by Garten et al ( 14 ), Stephens et al ( 15 ), and Verhagen et al ( 16 ):…”

Section: Methodsmentioning

confidence: 99%

Prevalence and Characteristics of Neonatal Comfort Care Patients: A Single-Center, 5-Year, Retrospective, Observational Study

et al. 2018

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Objective: To investigate the prevalence and characteristics of neonates with life-limiting or life-threatening conditions who receive care focused exclusively on comfort.Methods:Retrospective chart review of all newborn infants admitted to a level III perinatal center within a 5 year period.Results:1,777 of 9,878 infants (18.0%) had life-limiting or life-threatening conditions. 149 (1.5% of all neonates) were categorized as comfort care patients with death being anticipated within hours to weeks. 34.2% of comfort care patients suffered from conditions specific to the neonatal period, 28.9% were preterm infants at the limit of viability, and 22.8% were patients with congenital complex chronic conditions. In 80.5% of all comfort care patients treatment goals were re-directed toward a comfort-care-only regimen only once that life-prolonging therapies were demonstrated to be unhelpful. 136/149 comfort care patients (91.3%) died in hospital, while 13 (8.7%) were discharged home or into a hospice. Median age at death for comfort care patients was 3 days after birth (interquartile range 1–15.5 days), and delivery room death immediately after birth occurred in 37 patients (27.2%).Conclusions: The vast majority of neonatal comfort care patients died in the hospital during the first week of life. However, almost one in 10 comfort care patients were discharged to home or hospice, suggesting that planning transition out of the NICU should be routinely discussed for all infants receiving comfort care.

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“…Other studies similarly found that there was no difference in birth weight or gestational age in whether or not infants received medications for symptoms as part of EOL care and that the vast majority of patients who died in the delivery room did not receive opioids (39). A study of 171 neonates at a level III NICU showed that 27.5% did not receive opioids or benzodiazepines for EOL care (17).…”

Section: Pharmacological Managementmentioning

confidence: 99%

“…Historically, providers have been hesitant to administer medications, specifically opioids and benzodiazepines, out of concern that they will hasten death. This concern of providing medications that have respiratory depression as a side effect in a medically fragile neonate has led to inadequate treatment of symptoms (39). However, there is a commonly accepted ethical notion known as the principle of double-effect which states that an action is justifiable if the nature of the act is good, the good effects are the intended effects as opposed to the bad effects, and that the good effects outweigh the bad given the circumstances (20,47).…”

Section: Pharmacological Managementmentioning

confidence: 99%

Neonatal End-of-Life Symptom Management

Cortezzo

Meyer

2020

Front. Pediatr.

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Purpose of review: Despite advances in technology and treatment options, over 15,000 neonates die each year in the United States. The majority of the deaths, with some estimates as high as 80%, are the result of a planned redirection of care or comfort measures only approach to care. When curative or life-prolonging interventions are not available or have been exhausted, parents focus on preserving quality of life and eliminating needless suffering. Parents hope their child will have a peaceful death and will not feel pain. A significant component of end-of-life care is high quality symptom evaluation and management. It is important that neonatal providers are knowledgeable in symptom management to address common sources of suffering and distress for babies and their families at the end-of-life (EOL). Recent findings: Medically complex neonates with life-threatening conditions are a unique patient population and there is little research on end-of-life symptom assessment and management. While there are tools available to assess symptoms for adolescents and adults, there is not a recognized set of tools for the neonatal population. Nonetheless, it is widely accepted that neonates experience significant symptoms at end-of-life. Most commonly acknowledged manifestations are pain, dyspnea, agitation, and secretions. In the absence of data and established guidelines, there is variability in their clinical management. This contributes to provider discomfort and inadequate symptom control. Summary: End-of-life symptom assessment and management is an important component of neonatal end-of-life care. While there remains a paucity of studies and data, it is prudent that providers adequately manage symptoms. Likewise, it is important that providers are educated so that they can effectively guide families through the dying process by discussing disease progression, physical changes, and providing empathetic support. In this review, the authors make recommendations for non-pharmacological and pharmacological management of end-of-life symptoms in neonates.

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End‐of‐life opioid administration on neonatal and pediatric intensive care units: Nurses' attitudes and practice

Cited by 19 publications

References 28 publications

Medical Record Documentation and Symptom Management at the End of Life in the NICU

Medical Record Documentation and Symptom Management at the End of Life in the NICU

Prevalence and Characteristics of Neonatal Comfort Care Patients: A Single-Center, 5-Year, Retrospective, Observational Study

Neonatal End-of-Life Symptom Management

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