Life and death decisions in the extremely preterm infant: What happens in a level III perinatal centre?

To describe resuscitation decisions and withdrawal of treatment practices in live-born infants at the extremes of prematurity at St Joseph's Health Care (London, Ontario).

A retrospective chart review was conducted on all neonatal deaths between 22 weeks, zero days' and 25 weeks, six days' gestational age over an eight-year period. Documentation concerning end-of-life discussions was subjected to thematic review to limit or withhold resuscitation or withdraw treatment.

Three hundred eighteen infants were delivered between 22 weeks, zero days' and 25 weeks, six days' gestational age. Of these, 21% of infants (67 of 318) were stillborn, 38% (121 of 318) were alive on discharge from hospital and 41% (130 of 318) died in the neonatal period. Of the live-born infants who did not survive to discharge, 34% (44 of 130) had no initial attempts at resuscitation. Withdrawal of life-sustaining treatment was the immediate cause of death in 84% of cases (61 of 73) in which the infant survived initial resuscitation. Documented parental rationale for withdrawal of treatment included "preventing pain and suffering", "not wanting (their baby) to die on a ventilator" and "poor quality of life". Families in which the mother identified as Catholic were more likely to withhold resuscitation and to withdraw life-sustaining treatment because death was imminent despite ongoing treatment. Non-Catholic families were more likely to withdraw life-sustaining treatment based on prediction of a poor long-term prognosis.

Decisions not to initiate resuscitation remain fairly common practice at the extremes of prematurity. The majority of deaths in those who survive initial resuscitative measures are secondary to withdrawal of treatment decisions made in the neonatal intensive care unit.