Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units - 22/01/20

Doi : 10.1016/j.jpeds.2019.10.039

Jessica T. Fry, MD ^1,^2,^⁎ , Nana Matoba, MD, MPH ^1,², Ankur Datta, MD, MS ^1,², Robert DiGeronimo, MD ^3,⁴, Carl H. Coghill, MD ^5,⁶, Girija Natarajan, MD ^7,⁸, Beverly Brozanski, MD ^9,^10,^{^{∗
Current address: Department of Pediatrics, Washington University School of Medicine and Division of Newborn Medicine, St. Louis Children's Hospital, St. Louis, MO.}}, Steven R. Leuthner, MD, MA ^11,¹², Jason Z. Niehaus, MD ^13,¹⁴, Amy Brown Schlegel, MD ^15,¹⁶, Anita Shah, MD ¹⁷, Isabella Zaniletti, PhD ¹⁸, Thomas Bartman, MD, PhD ^15,¹⁶, Karna Murthy, MD, MSc ^1,², Kevin M. Sullivan, MD, MBA ^19,²⁰
on behalf of the
Children's Hospital Neonatal Consortium (CHNC)^21,^{^†}
List of Board members, participating sites, and site sponsors of the Children's Hospital Neonatal Consortium (CHNC) is available at www.jpeds.com (Appendix).
Jeanette Asselin, David Durand : (ex officio), Francine Dykes, Jacquelyn Evans : (Executive Director), Karna Murthy : (Chair), Michael Padula, Eugenia Pallotto, Theresa Grover, Anthony Piazza, Kristina Reber, Billie Short

¹ Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
² Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
³ Department of Pediatrics, University of Washington, Seattle, WA
⁴ Division of Neonatology, Seattle Children's Hospital, Seattle, WA
⁵ Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
⁶ Division of Neonatology, Children's of Alabama, Birmingham, AL
⁷ Department of Pediatrics, Wayne State University, Detroit, MI
⁸ Division of Neonatology, Children's Hospital of Michigan, Detroit, MI
⁹ Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
¹⁰ Division of Newborn Medicine, UPMC Children's Hospital, Pittsburgh, PA
¹¹ Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
¹² Division of Neonatology, Children's Hospital of Wisconsin, Milwaukee, WI
¹³ Department of Pediatrics, Indiana University, Indianapolis, IN
¹⁴ Division of Neonatology, Riley Hospital for Children, Indianapolis, IN
¹⁵ Department of Pediatrics, The Ohio State College of Medicine, Columbus, OH
¹⁶ Division of Neonatology, Nationwide Children's Hospital, Columbus, OH
¹⁷ Division of Neonatology, Children's Hospital of Orange County, Orange, CA
¹⁸ Children's Hospitals Association, Lenexa, KS
¹⁹ Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
²⁰ Division of Neonatology, Nemours/AI duPont Hospital for Children, Wilmington, DE
²¹ Children's Hospitals Neonatal Consortium, Kansas City, MO

^∗Reprint requests: Jessica T. Fry, MD, Division of Neonatology, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E Chicago Ave, Box 45, Chicago, IL, 60611.Division of NeonatologyAnn and Robert H. Lurie Children's Hospital of Chicago225 E Chicago Ave, Box 45ChicagoIL60611

Abstract

Objective

To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs).

Study design

We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6 hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation.

Results

Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28 weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death.

Conclusions

From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.

Le texte complet de cet article est disponible en PDF.

Keywords : Children's Hospitals Neonatal Consortium, Children's Hospitals Neonatal Database, neonatal intensive care, end-of-life care, neonatal death

Abbreviations : CHND, CNS, CPR, DNR, GI, NICU, WLST

Plan

Methods

Results

Discussion

	Detailed affiliations are available at www.jpeds.com.
	Portions of this study were presented at the Pediatric Academic Societies annual meeting, May 6-9, 2017 (San Francisco, California).
	K.M. is a Board member and Chair of the CHNC (Kansas City, MO). B.B. is a Board member of the CHNC. The other authors declare no conflicts of interest.

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Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units - 22/01/20

Abstract

Objective

Study design

Results

Conclusions

Plan

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