Limitation et arrêt des thérapeutiques actives en néonatologie

Vidal, Magalie; Jacquot, Aurélien; Mesnage, Renault; Milési, Christophe; Lemaitre, Alexandre; Cabirou, S.; Perotin, V.; Picaud, Jean Charles; Cambonie, Gilles

doi:10.1016/s0929-693x(10)70187-1

Cited by 5 publications

(6 citation statements)

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“…Based on these decisions, the main method applied to discontinue therapy was termination of mechanical ventilation associated with sedation [4, 25]. Almost 95% of patients received analgesia at the time of death, which is higher than the rates reported in the literature [12, 16, 19, 25]. This medication has evolved over the years, with hypnotics increasingly associated with morphine.…”

Section: Discussionmentioning

confidence: 99%

“…Even if this law supports a true culture and politics of palliative care, certain issues still remain unclear, especially concerning the pediatric population. The introduction of the LWAT file, in response to the legal requirements, is a guide and support for health professionals, enabling them to better document the decision-making processes [25, 27]. In our cohort, use of the LWAT file did not have an effect on newborn age at death, which could have fundamentally challenged the very definition of the palliative approach, i.e., to avoid causing death and preserve the best possible QoL until death.…”

Section: Discussionmentioning

confidence: 99%

“…Nevertheless, Cremer et al [28] have noted certain weaknesses concerning the transmission of such medical information, which for example does not enable exchange between the professionals concerned. From the beginning of the pediatric care process, parental advice is increasingly collected [25, 27, 29–31]; parents thus act as spokespeople and protectors of the best interest of their child (to assert autonomy). Encouraging the parents to express themselves and integrating them into the healthcare process guarantees trust and strengthens their sense of parenthood.…”

Section: Discussionmentioning

confidence: 99%

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Formal procedure to facilitate the decision to withhold or withdraw life-sustaining interventions in a neonatal intensive care unit: a seven-year retrospective study

2018

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BackgroundNeonatal deaths are often associated with the complex decision to limit or withdraw life-sustaining interventions (LSIs) rather than therapeutic impasses. Despite the existence of a law, significant disparities in clinical procedures remain. This study aimed to assess deaths occurring in a Neonatal Intensive Care Unit (NICU) and measure the impact of a traceable Limitation or Withdrawal of Active Treatment (LWAT) file on the treatment of these newborns.MethodsIn this monocentric retrospective study, we reviewed all consecutive neonatal deaths occurring during two three-year periods among patients in the NICU at the North Hospital of Marseille: cohort 1 (from 2009 to 2011 without the LWAT file) and cohort 2 (from 2013 to 2015 after introduction of the LWAT file). Newborns included were: gestational age over 22 weeks, birth weight over 500 g, and admission and death in the same NICU. Deaths were categorized according to the classification described by Verhagen et al.: 1) children who died despite cardiopulmonary resuscitation (CPR) (no withholding nor withdrawing of LSIs), (2) children who died while the ventilator, without CPR (no withdrawing of LSIs, but CPR withheld), (3) children who died after LSIs were withdrawn, or (4) LSIs were withheld.Results193 deaths were analyzed: 77 in cohort 1 and 116 in cohort 2. 50% of deaths followed the decision to limit or stop life-sustaining interventions. The mean age at death did not differ between the two cohorts (p = 0.525). An increase in the mortality rate after life-sustaining interventions were withdrawn was observed. The number of multidisciplinary decision meetings was statistically higher in cohort 2 (32.5% versus 55.2% p = 0.002), which were most often prompted due to neurological pathologies, with an increase in parental advice concerning the management of their child (p = 0.026). Even if the introduction of this file did not have an effect on patient age at death, it was significantly associated with a better understanding of end-of-life conditions (p = 0.019), including medication used to sedate and comfort the patient.ConclusionsIntroduction of the LWAT file seems imperative to develop a personalized healthcare strategy for each child and situation.Electronic supplementary materialThe online version of this article (10.1186/s12904-018-0329-x) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Formal procedure to facilitate the decision to withhold or withdraw life-sustaining interventions in a neonatal intensive care unit: a seven-year retrospective study

2018

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“…Based on a report from our department of an equivalent distribution of death rate occurring after a decision of WWLST or despite maximum care [ 9 ], and under the assumption of a 50% rate of parental anxiety or depression 5 months after the loss of their infant, 50 parents per group were needed to demonstrate a 20% difference in the rate of anxiety or depression in at least one of the parents according to death condition, with a power of 80% and p < 0.05. Given that the annual number of deaths in the department is about 40 and that the parental participation rate in the interview 3 months after infant death is about 60%, the recruitment period was set at 5 years.…”

Section: Methodsmentioning

confidence: 99%

“…Neonatal death in high-income countries is often preceded by end-of-life medical decisions [ 7 , 8 ]. A study conducted in the department of neonatal medicine of our institution showed that half the deaths occurred in this context [ 9 ]. The review of our practices indicated that they were in most cases in line with the ethical and legal framework in our country [ 10 ], however it did not assess how parents and caregivers felt about the decision to limit or withdraw treatment.…”

Section: Introductionmentioning

confidence: 99%

Context of a neonatal death affects parental perception of end-of-life care, anxiety and depression in the first year of bereavement

et al. 2023

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Background Neonatal death is often preceded by end-of-life medical decisions. This study aimed to determine whether the context of death − after a decision of withholding or withdrawing life-sustaining treatment (WWLST) or despite maximum care − was associated with subsequent risk of parental anxiety or depression. The secondary objective was to assess parents’ perceptions of end-of-life care according to death context. Methods Prospective single center observational study of all neonatal deaths in a neonatal intensive care unit over a 5-year period. Data were collected during hospitalization and from face-to-face interviews with parents 3 months after the infant’s death. Anxiety and depression were assessed using Hospital Anxiety and Depression Scale (HADS) questionnaires, completed by parents 5 and 15 months after death. Results Of 179 deaths, 115 (64%) occurred after the WWLST decision and 64 (36%) despite maximum care. Parental satisfaction with newborn care and received support by professionals and relatives was higher in the first condition. Sixty-one percent of parents (109/179) attended the 3-month interview, with the distribution between groups very close to that of hospitalization. The completion rates of the HADS questionnaires by the parents who attended the 3-month interview were 75% (82/109) at 5 months and 65% (71/109) at 15 months. HADS scores at 5 months were consistent with anxiety in at least one parent in 73% (60/82) of cases and with depression in 50% (41/82). At 15 months, these rates were, respectively, 63% (45/71) and 28% (20/71). Risk of depression at 5 months was lower after a WWLST decision (OR 0.35 [0.14, 0.88], p = 0.02). Explicit parental agreement with the WWLST decision had an equivocal impact on the risk of anxiety at 5 months, being higher when expressed during hospitalization, but not at the 3-month interview. Conclusions Context of death has a significant impact on the emotional experience of parents after neonatal loss, which underlines the importance of systematic follow-up conversations with bereaved parents.

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Soins palliatifs en néonatologie : analyse et évolution des pratiques sur 5ans dans un centre de niveau 3

Mazille

Litzler-Renault

Weider

et al. 2014

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Limitation et arrêt des thérapeutiques actives en néonatologie

Cited by 5 publications

References 3 publications

Formal procedure to facilitate the decision to withhold or withdraw life-sustaining interventions in a neonatal intensive care unit: a seven-year retrospective study

Formal procedure to facilitate the decision to withhold or withdraw life-sustaining interventions in a neonatal intensive care unit: a seven-year retrospective study

Context of a neonatal death affects parental perception of end-of-life care, anxiety and depression in the first year of bereavement

Soins palliatifs en néonatologie : analyse et évolution des pratiques sur 5ans dans un centre de niveau 3

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