PEDIATRICS Vol. 89 No. 1 January 1992, pp. 119-122
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Facing Tragic Decisions With Parents in the Neonatal Intensive Care Unit: Clinical Perspectives

Michael S. Jellinek MD1, Elizabeth A. Catlin MD2, I. David Todres MD2, and Edwin H. Cassem MD3

1 From the Psychiatry Service and Children's Service, Massachusetts General Hospital, Boston
2 From the Children's Service and Division of Neonatal and Pediatric Intensive Care, Massachusetts General Hospital, Boston
3 From the Psychiatry Service, Massachusetts General Hospital, Boston

Withdrawing a neonate's life supports and limiting resuscitation efforts are among the most complex, tragic, and stressful decisions faced by parents and physicians. There is an extensive body of literature discussing ethical and legal implications of such decisions.1-8 There is also a substantial body of literature on parental grieving, the risks of long-term depression and family dysfunction,9-12 and the inevitable stress on the pediatric team when dealing with critically ill infants.13-20 However, despite all that has been written, our own review has found little that addresses the clinical and psychological questions that the physician and family must face together during the several intense and intimate meetings where they actually decide to withdraw life support or limit resuscitation efforts. These questions will be most relevant for the senior members of the neonatal intensive care unit (NICU) team and should be part of the training of pediatric house officers, although the underlying principles are relevant to many of the decisions made by a pediatrician and family. For the purposes of this discussion we will assume that the appropriate legal and ethical standards are being observed in terms of the substance of the decision and will focus on the clinical process of physician-family decision making. We expect that technology will necessitate ongoing revisions of the legal/ethical guidelines but that the clinical goals of decision making will remain interpersonal, intimate, humane, respectful, and sensitive to long-term emotional concerns.

The clinical context is loss. Grief replaces the family's hopes for a happy, healthy baby, their expectations of bringing a new baby into their home, and the dreams that come with raising this child.

Submitted on June 17, 1991
Accepted on August 20, 1991




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