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Outcomes of Preterm Infants following Discussions about Withdrawal or Withholding of Life Support
Jennifer James1, David Munson1, Sara B DeMauro1
1Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA.
Insights
Postnatal discussions about withdrawal or withholding of life-sustaining therapy (WWLST) occurred in 15.4% of infants. Survivors of these discussions experienced poor outcomes, including higher rates of neonatal morbidities and neurodevelopmental impairment.
Area of Science:
- Neonatal research
- Clinical ethics
- Perinatal medicine
Background:
- Withdrawal or withholding of life-sustaining therapy (WWLST) discussions are critical in neonatal care.
- Understanding the frequency and outcomes of these discussions is essential for improving care for extremely preterm infants.
Purpose of the Study:
- To determine the incidence of postnatal WWLST discussions.
- To identify factors associated with WWLST discussions and subsequent therapy withdrawal.
- To evaluate the outcomes of infants surviving WWLST discussions.
Main Methods:
- Retrospective review of registry data from 18 NICHD Neonatal Research Network centers.
- Inclusion of infants born at 22-28 weeks gestation surviving >12 hours (2011-2013).
- Regression analysis to identify factors associated with WWLST discussions and outcomes.
Main Results:
- WWLST discussions occurred in 15.4% of 3434 infants, more frequent in earlier gestations (27.0% at 22-24 weeks vs. 5.6% at 27-28 weeks).
- Factors associated with discussions included male sex, lower gestational age, small for gestational age, congenital anomalies, sepsis, brain injury, and necrotizing enterocolitis.
- Of 406 infants with ensuing WWLST, only 5 survived to discharge; 47% survived to discharge if intensive care continued after discussion. Survival after WWLST discussion was linked to higher neonatal morbidities and neurodevelopmental impairment.
Conclusions:
- Significant center variations exist in WWLST discussions, particularly for infants ≤24 weeks gestation.
- Infants surviving WWLST discussions exhibit poor outcomes, highlighting the need for careful consideration and support.
Objectives:
To describe the frequency of postnatal discussions about withdrawal or withholding of life-sustaining therapy (WWLST), ensuing WWLST, and outcomes of infants surviving such discussions. We hypothesized that such survivors have poor outcomes.
Study Design:
This retrospective review included registry data from 18 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Infants born at 22-28 weeks of gestation who survived >12 hours during 2011-2013 were included. Regression analysis identified maternal and infant factors associated with WWLST discussions and factors predicting ensuing WWLST. In-hospital and 18- to 26-month outcomes were evaluated.
Results:
WWLST discussions occurred in 529 (15.4%) of 3434 infants. These were more frequent at 22-24 weeks (27.0%) compared with 27-28 weeks of gestation (5.6%). Factors associated with WWLST discussion were male sex, gestational age (GA) of ≤24 weeks, birth weight small for GA, congenital malformations or syndromes, early onset sepsis, severe brain injury, and necrotizing enterocolitis. Rates of WWLST discussion varied by center (6.4%-29.9%) as did WWLST (5.2%-20.7%). Ensuing WWLST occurred in 406 patients; of these, 5 survived to discharge. Of the 123 infants for whom intensive care was continued, 58 (47%) survived to discharge. Survival after WWLST discussion was associated with higher rates of neonatal morbidities and neurodevelopmental impairment compared with babies for whom WWLST discussions did not occur. Significant predictors of ensuing WWLST were maternal age >25 years, necrotizing enterocolitis, and days on a ventilator.
Conclusions:
Wide center variations in WWLST discussions occur, especially at ≤24 weeks GA. Outcomes of infants surviving after WWLST discussions are poor.
Trial Registration:
ClinicalTrials.gov: NCT00063063.
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