[Making ethical decision of limiting vital support to critical newborns]

To know the cause of death and the criteria used in the vital support limitation decisions in the critical newborn who eventually died.

A retrospective review of the medical records for all newborns who died in the NICU between 1987-1994 was performed. The following actions were defined: total vital support, do not resuscitate order (DNR), vital support withdrawal (VSW).

The mortality rate in the NICU was 7.3% (55/753), with a neonatal mortality rate of 2.98 per thousand live births. Medical records of 53 patients were reviewed. In 67.9% of the patients (36/53; p < 0.001) the therapeutical effort was limited. The most frequent way of action was the VSW (35.8%) and the support most frequently interrupted was mechanical ventilation (89%). DNR was established in 32%. Only 42% of the parents were involved in the decision making process to limit support. In three patients (6%), there was evidence of disagreement between the medical team and the family and the parents of two opting for a more aggressive care. In the three cases, the family determined the course of action. In general, the decision of support limitation was justified based on "bad prognosis". Retrospectively, the criteria were: not viable (11%), eminent death (14%), no response to treatment (22%) and quality of life judgments (53%).

It is very frequent to take decisions on vital support limitation in neonates when they are in a critical situation. We consider that the individual evaluation of each patient's prognosis, combined with standards of ethical criteria, the "child's best interest" and the "potential for relation", pondered in a rational way, constitute an adequate guideline for making conflictive ethical decisions together with the child's parents.