The contribution of withholding or withdrawing care to newborn mortality

We sought to determine the contribution of withholding or withdrawing care to neonatal mortality in our hospital over a 10-year period from 1993 through 2002.

Although not initiating or withholding intensive care for certain newborns has been practiced openly for the past 25 years, little information has been published concerning the results of these practices on neonatal mortality.

All infants who were born in our hospital and remained in the hospital until their death were evaluated for the care they received at the time of birth and near the time of their death. The contribution of not initiating care or withdrawing care to the neonatal mortality rates in our hospital was determined. Information was obtained directly from the patients' charts as well as the neonatal database and monthly neonatal mortality and morbidity review. Other information, if needed, was obtained from the monthly ethics committee reviews of all nursery deaths. Information was collected relating to birth weight, gestational age, diagnosis, time of death, and year of death. Hospital and neonatal unit protocols were evaluated to determine how closely they were followed.

During the 10-year period, 380 deaths (0.8%) of a total of 47820 live births occurred in our hospital. Care was not initiated or was withdrawn in close to 72% of those deaths; total care until death occurred in 28%. Total care for infants who died over the 10-year period decreased markedly as care not initiated or care withdrawn increased. Most of this increase in not initiating care and in withdrawal of care was in the smaller of the extremely low birth weight infants.

The majority of nursery deaths of infants born in our hospital occurred as the result of selected noninitiating of care or as a result of withdrawing care in infants not responding or considered to have a futile outcome. Only slightly more than one quarter of the infants received total care until the time of death.