Analgesia for Dying Infants Whose Life Support Is Withdrawn or Withheld

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Abstract
Objective. To determine the frequency of opiate analgesia administration to infants when life support is discontinued and to determine whether infant characteristics, such as birth weight and diagnosis, or the physician's reasons for discontinuing life support influence either the decision to provide opioid agents or the dosages administered. Methods. We reviewed all 165 deaths in a 3-year period at a university-based level III intensive care nursery. Of the 121 deaths attributable to withdrawal or withholding of mechanical ventilation and/or extracorporeal membrane oxygenation, we ascertained whether opioid analgesics (morphine sulfate [MS] or fentanyl) were administered either concurrent with or after life-support withdrawal and at what doses. We examined whether these end-of-life practices varied according to birth weight, diagnoses, and the reasons documented by the neonatologist for discontinuing life support. Results. Opioid analgesia was provided to 84% of infants as their life support was either withheld or withdrawn. Infants with necrotizing enterocolitis and major anomalies or chromosomal disorders were more likely to be given opiates than infants with other diagnoses. Birth weight was not different for infants who received opiates compared with those who were not given opiates. Opioid analgesia was provided to all 18 infants for whom physicians documented the patients' suffering as a reason to discontinue life support. Sixty-four percent of infants who received opiates were given doses in the usual pharmacologic range of 0.1 to 0.2 mg/kg MS. Of the 36 infants given more than 0.2 mg/kg MS, all but 2 were receiving ongoing treatment with opioid agents. Conclusions. In most cases of withholding or withdrawal of life support in critically ill infants, neonatologists provided opioid analgesia to these infants at the end of life, despite the potential respiratory depression of opioid agents in infants whose respiratory support is discontinued.