Wednesday, November 19, 2008
Image via WikipediaPalliative care has not made inroads with American Neonatal Intensive Care Units (NICU) for many reasons: the increased use of technology in the NICU (more complex and specialized then an adult ICU), the usually 'closed' style of the NICU potentially excluding other specialists, the sensitivity issues with the parents/family when dealing with children, and the tremendous lack of pediatric palliative care specialists, let alone neonatal palliative care specialists.
(Is there anyone out there claiming to be a neonatal palliative care specialist? If so please let me know in the comments. You should be talking at every national palliative care meeting and pediatric meeting.)
An article in the November 2008 Pediatrics compares different NICU admission strategies for extremely preterm births (25 weeks and lower). This study is first of all important because it highlights the poor survival outcomes for this population and therefore the potential need for improved palliative care support in the NICU. Approximately 16% of births at or before 25 weeks survive hospitalization. Stratified survival rates were approximately 2% at 23 weeks, 14% at 24 weeks, and 29% at 25 weeks. There was no clarification about deaths that may have occurred immediately after discharge, as may happen in peri-natal hospice situations.
Mortality rates for extreme preterm births are not the key finding here and the researchers were looking at the differences in delivery room strategies in France versus the United Kingdom. In the introduction they propose three observed strategies:
"Wait until certain" (United States) - Admit to NICU until death is certain
"Statistical prognostic" (Sweden/France) - Withhold NICU care for preterm infants with probable poor outcomes
"Individual" (United Kingdom) - Admit to NICU and reassess treatment goals based on prognostic information
The percentage of stillbirths and deaths while in the delivery room was higher in France (72% - EPIPAGE study) compared tho the UK (56% - EPICure). And conversely, deaths in the NICU were statistically higher in the UK (45%) versus France (29%). The point of this is not that delivery rooms are awful in France but their NICU's are much better, or vice versa for the UK. It may have to do more with medical management approach and decision making since when looking at all survivors the studies were not statistically different, 16.5% for the UK, 15.8% for France.
And the difference of the mortality rate in the NICU is not wholly explained by change of goals from curative to palliative and the resulting withholding and/or withdrawing of life-sustaining treatments. In the UK NICU study 55% of infants died after discontinuation of intensive care compared to a non-statistically significant 47% in the French study.
It would be nice to see a similar study in adult ICU's or even oncology practices looking at various strategies and regional variations (similar to the Dartmouth Atlas?) but with the breadth of data these NICU studies have. The basic conclusions drawn from this comparison is:
"Wait until certain" - lower mortality rate, higher rate of impairment, high resource utilzation
"Statistical prognostic" - higher mortality rate, lower rate of impairment, low resource utilization
"Individual" - higher mortality rate, lower rate of impairment, medium resource utilization
The implication for policy makers and society is to determine which of these variables need to change to which degree to make one strategy more desired over another.
F. Bodeau-Livinec, N. Marlow, P.-Y. Ancel, J. J. Kurinczuk, K. Costeloe, M. Kaminski (2008). Impact of Intensive Care Practices on Short-Term and Long-term Outcomes for Extremely Preterm Infants: Comparison Between the British Isles and France PEDIATRICS, 122 (5) DOI: 10.1542/peds.2007-2976
One side note:
The discussion refers to an article demonstrating wide regional variations in end-of-life practices by neonatologists in Europe. This study found 73% of French neonatologists had administered medicines to deliberately hasten death at least once compared to 4% of British neonatologists. And British docs were more likely to have conversations about withholding or withdrawing curative/life-support therapies compared to French docs (91% to 73%)
Second side note:
Does this table look like there are some miscalculations here? It seems to be all those numbers on overall cognition should not be the same. Click for higher res pic.