Analgesics, sedatives and neuromuscular blockers as part of end-of-life decisions in Dutch NICUs

Background: Clinicians frequently administer analgesics and sedatives at the time of withholding or withdrawal of life-sustaining treatment in newborns. This practice might be regarded as intentionally hastening of death. Objective: To describe type, doses and reasons for administering medications as part of end-of-life decisions in the Dutch neonatal intensive care units. Design and setting: We reviewed the medical files of 340 newborn deaths with a preceding end-of-life decision over a 12-month period to describe the use of analgesics, sedatives and/or neuromuscular blockers. The neonatologists of 147 of the 150 newborns with a preceding end-of-life decision based on the infant's poor prognosis were interviewed to obtain additional details about the use of medication. Results: Analgesics and sedatives were administered to 224 of 340 newborns before the end-of-life decision and to 292 newborns after the decision. The medication was increased in 94 of 289 newborns whose death was imminent and in 110 of 150 newborns with a poor prognosis. Reasons for the increase were treatment of pain and suffering, and in 4% of cases hastening of death. Reasons were undocumented in 55% of deaths. Neuromuscular blockers were administered in 16% of patients because they already received these agents or to stop or prevent gasping. Conclusions: Analgesics and sedatives are generally increased after the end-of-life decision to treat pain and suffering and rarely to hasten death. Neurornuscular blockers were administered in 16% of deaths. Medical files provide insufficient documentation of considerations leading to the increase of medication, which hinders (external) review.