Published online May 1, 2008
PEDIATRICS Vol. 121 No. 5 May 2008, pp. 1071-1072 (doi:10.1542/peds.2008-0273)

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LETTER TO THE EDITOR

Withdrawing Support for Withdrawing Support From Premature Infants With Severe Intracranial Hemorrhage

Taylor Sawyer, DO
University of Hawaii Program,
Tripler Army Medical Center/Kapiolani Medical Center for Women and Children,
Honolulu, HI 96859

To the Editor.—

The active withdrawal of life support from premature infants with severe intracranial hemorrhage based on quality-of-life (QoL) concerns is rare in the United States, occurring in <5% of cases in which care is actively withdrawn.¹ It does occur, however, and is potentially supported by the American Academy of Pediatrics statement "Noninitiation or Withdrawal of Intensive Care for High-Risk Newborns."² According to this statement, a decision to withdraw care may be justified for cases in which the "prognosis is uncertain but likely to be very poor and survival may be associated with a diminished quality of life for the child."²

A "diminished quality of life" is not defined in the statement, but 1 definition includes an evaluation of the child's level of cognitive ability. Rhoden defined an unacceptably poor QoL as one in which an individual "lacks potential for human interaction as a result of profound mental retardation."³ This definition is supported by many bioethicists and also the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research.³

A recent article by Bassan et al⁴ reported on the neurodevelopmental outcomes of a group of premature infants with the most severe form of intracranial hemorrhage grade IV intraventricular hemorrhage (IVH). The authors reported that despite a high overall incidence of motor and cognitive impairment, the vast majority of infants in their study retained the potential for human interaction, including 80% with adaptive social scores and 87% with adaptive communication scores within 2 SDs of normal.⁴ Their study represents the largest to date on the outcomes in infants with severe IVH and points to clear improvements compared with previous studies in the 1980s and 1990s.⁴

Given the results by Bassan et al and the recommendation that treatment decisions in the high-risk newborn should be "based on the best available data,"² I find it difficult to support the practice of actively withdrawing life support from premature infants on the basis of severe IVH and concerns for diminished QoL. Certainly there are cases in the NICU in which an infant with severe IVH becomes moribund as a result of either catastrophic IVH or other comorbidities. In these cases, a discussion with the family concerning the active withdrawal of support may be appropriate. However, on the basis of the findings of Bassan et al, a discussion to actively withdraw support from a clinically stable premature infant solely on the basis of severe IVH and QoL concerns may no longer be ethically justified.

FOOTNOTES

The views expressed here are those of the author and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US government.

REFERENCES

1. Singh J, Lantos J, Meadow W. End-of-life after birth: death and dying in a neonatal intensive care unit. Pediatrics. 2004;114 (6):1620 –1626[Abstract/Free Full Text]
2. American Academy of Pediatrics, Committee on Fetus and Newborn; Bell EF. Noninitiation or withdrawal of intensive care for high-risk newborns. Pediatrics. 2007;119 (2):401 –403[Abstract/Free Full Text]
3. Robertson J. Extreme prematurity and parental rights after Baby Doe. Hastings Cent Rep. 2004;34 (4):32 –39[Medline]
4. Bassan H, Limperopoulos C, Visconti K, et al. Neurodevelopmental outcome in survivors of periventricular hemorrhagic infarction. Pediatrics. 2007;120 (4):785 –792[Abstract/Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Sawyer, T. Search for Related Content PubMed PubMed Citation Articles by Sawyer, T. Related Collections Neurology & Psychiatry Social Bookmarking                         What's this?