A framework for ethical decision making in neonatal intensive care.

UNLABELLED Intensive care for neonates with high risks of severe impairment and the possibility of a prolonged dying process represents a frequent ethical issue in neonatal units. The aim of this paper is to present a framework for structured decision making that has been developed in a neonatal intensive care unit and to demonstrate its impact on the healthcare team and on survival of critically ill neonates. This framework attempts to integrate the best interests of the infants and their parents, the possibilities of high-tech neonatal intensive care interventions, and the perspective of the nurses and doctors. An external evaluation of 84 sessions over 3 y revealed a beneficial effect on the quality of the decision-making process itself and on the quality of the teamwork in the unit. Survival time was shorter (median 2 d, interquartile range 1-7 d) in 26 infants that died after structured decision making compared with 26 controls matched for gestational age, malformation and intracranial haemorrhage (median 7 d, interquartile range 4-15 d). CONCLUSION The introduction of this framework for structured decision making involving doctors and nurses improved the quality of the teamwork. It shortened futile intensive care, and thereby suffering for both infants and parents.