Moro, T., Kavanaugh, K., Okuno-Jones, S., & Vankleef, J. A. (2006). Journal of Perinatal and Neonatal Nursing, 20, 262-273.
It is well documented that recent advances in neonatal medicine have increased the sustainability of life and improved neonatal outcomes. However, it remains fact that more infants die in the first 27 days of life than any other period during childhood (Kochanek, Murphy, Anderson, & Scott, 2004) and that neonatal palliative care is rarely offered. This ambitious systematic review of 51 research articles published since 1996 using OVID, MEDLINE, PsychINFO, CINHAL, and PubMed yielded 10 articles that the authors reviewed for the purpose of synthesizing research on end-of-life care in neonates. A clear and concise literature review of the overview of palliative care and end-of-life care during the neonatal period preceded the presentation of the integrative review. The inclusion and exclusion criteria for article selection were not well described in the article. It was interesting to note that the authors stated that there are no universal standards for treating neonates at the end of life and did not cite the Catlin & Carter Neonatal-End-of-Life Palliative Care Protocol published in 2002. Findings of this study were summarized in four categories: practices of withdrawing or withholding life-sustaining treatment, pain management during ventilator withdrawal, parents and the decision-making process, and the dying process. Research has shown that there has been an increase in the number of neonates for whom treatment was either withdrawn or withheld and that most NICU deaths occurred after the decision to withdraw or withhold treatment. The use of palliative care services is low in the NICU despite the high number of deaths during the neonatal period. Research on pain management during ventilator withdrawal was inconsistent, ranging from a study that showed that most infants received pain management to another study that indicated that although pain management was given during ventilator withdrawal, it was rarely continued. Parental involvement with decision making during the neonatal period has been well researched (previously reviewed in this column) and has shown that parents are involved in the decisions to withdraw or withhold treatment but that their level of involvement varies and that their experiences and perceptions with providers during this period of tough decision making clearly have an impact on what they decide. Although the research shows that most parents are present when their infant dies, they are not well prepared for the dying process itself. These authors make a strong case for enhancing palliative care and end-of-life services in the NICU, arguing that the use of such services would go a long way to solving issues related to inconsistent pain management and parental decision making and support. They concluded with the recommendation that palliative care services should be offered as soon as life-sustaining treatment has been initiated, regardless of anticipated outcomes.
Judy Beal
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