Epidemiology and ethics in the NICU

No medical professional is obliged to provide futile care. To be useful, however, futility determinations must be prospective and accurate. We wondered how accurately the professionals who work in the neonatal intensive care unit (NICU) recognized futile medical care as they were providing it, day-to-day, infant-to-infant. To estimate the accuracy of futility prognostications, we prospectively surveyed doctors and nurses in a NICU on their assessment of whether babies would survive or die. We then determined the number of times professionals predicted that a baby would die, and noted the accuracy of these predictions. Overall, 802 infants were admitted to the NICU during this time period. We studied the 254 patients who received mechanical ventilation on at least one hospital day. Of the 254 ventilated patients, 55 (22%) died and 199 (78%) survived. Twentysix (13%) of the surviving infants survived after at least one day characterized by at least one estimate of 'death'. Indeed, eight infants survived despite having at least one hospital day in which ALL respondents predicted death. Whereas all respondents predicted survival in 78% of all patient days, these predictions were correct in 92%. On the other hand, all respondents predicted death at three consecutive days in 3% of all patient days and they were right in 82%. The percentages of correct predictions were considerably lower for the remaining cases in which the predictions were less uniform. It is concluded that many futility assessments in the NICU are inaccurate. If certainty about futility were the only criterion that can justify a decision to withhold or withdraw life-sustaining treatment in the NICU, these data would make such decisions virtually impossible. These data also suggest caution in legitimizing policies that allow physicians to unilaterally determine that treatment will be futile. There is no quick and easy technical solution to the problems of prognostication.