Withdrawing and withholding treatment: comments on new guidelines.

A new practice framework for clinicians has recently been issued by the Royal College of Paediatrics and Child Health through their Ethics Advisory Committee. It deals with babies and children for whom intensive treatment may not be in their best interest. These are diYcult cases. Absolute certainty is rarely possible; there are inevitably issues of conscience and conflict, which add to the burden individuals carry. Do the RCPCH guidelines address the concerns of doctors and nurses at the cotside? Will they be of practical help? The guidelines are based on evidence from experts, and discussion by carefully selected focus groups, both useful ways to further thinking on a subject. But these methods lack the rigour of empirical data collected by scientific research. Does research evidence confirm expert opinion? If it does, the guidelines will carry greater weight. We looked at the RCPCH document in relation to the expressed concerns and stresses of staV who work in neonatal intensive care units. In a recent survey we carried out in depth interviews with 57 doctors and 119 nurses currently employed in six neonatal intensive care units in Scotland. The units were selected to reflect diVerent geographical, cultural, and social factors; the sample was stratified to represent all grades and levels of experience. In principle, the RCPCH guidelines do address most of the issues that concern clinicians, but we highlight five areas that warrant further discussion.