Withdrawal of treatment

Published on 03/06/2015 by admin

Filed under Neonatal - Perinatal Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 1437 times

CHAPTER 30 Withdrawal of treatment

Mark Davies, David Cartwright

General principles

In certain circumstances it is considered appropriate to withdraw life support from an infant, or to not initiate life support. This will always be done with close collaboration between the consultant responsible for that baby’s care, the nursing and social work staff, and the baby’s parents; embracing the principles established at consensus conferences in New South Wales in 1986, 1989 and 1998, and the findings of the latest consensus conference held in Australia (published in 2006). [Lui K et al. Perinatal care at the borderlines of viability: a consensus statement based on a NSW and ACT consensus workshop. Med J Australia 2006;185(9):495–500.]

• Consideration must be given to the interests and wellbeing of the infant.

• The initiation or the prolongation of treatment is not necessarily in the best interests of the infant.

• The opinion of parents as to the best interests of the infant must be respected and accounted for.

• Society has the right to intervene when parents’ decisions are not clearly in the best interests of the infant.

• Resources are finite. There may be competing financial claims which are as vital to human life as is neonatal intensive care.

• Parents must be informed and consulted about all medical treatment or non-treatment regarding their newborn child.

• Appropriate follow-up is essential, including support for parents of disabled survivors and community services for such infants.

Non-initiation of life support

• Initiation of life support is inappropriate in infants born with lethal non-correctable malformations (such as anencephaly and confirmed trisomy 13 or 18).

If possible, this eventuality should be discussed with the parents before birth.

• There exists a discretionary zone (‘grey zone’) in neonatal practice. Within this zone, after considered discussion between parent and specialist caregivers, it would be acceptable and reasonable medical practice to not initiate life support for a newborn.

Informed discussion should commence before the birth.

• The location of the ‘grey zone’ boundaries are at 25⁺⁶ and 23⁺⁰ weeks.

— At 26⁺⁰ weeks and above, there is indication to treat unless there are exceptional circumstances.

— Below 23⁺⁰ weeks, resuscitation and active treatment are not appropriate.

• The decision whether to initiate treatment or not within the ‘grey zone’ will depend on the wishes of the parents and other factors such as the condition of the baby at birth and past obstetric history. Under these circumstances counselling should always include the option of not starting resuscitation and active treatment, and the potential consequences of active intervention.

• These ‘grey zone’ boundaries, it is appreciated, may be inappropriate in areas with no neonatal intensive care facilities and where transport may be impractical.

Withdrawal of treatment

It is reasonable and acceptable practice to withdraw treatment under certain circumstances. Where an infant is dependent on medical treatment for survival, it is reasonable and accepted practice to withdraw such treatment, after considered discussion between parent and specialist caregiver, in any one of the following situations:

1. There is a substantial probability of major disability if that treatment were to continue (very little chance of normal outcome).

2. Death is inevitable and imminent regardless of that treatment (i.e. treatment is futile).

3. Continued treatment cannot relieve pain and suffering believed to be intolerable.

Related

Pocket Notes on Neonatology 2e