Infant Doe Regulations and the Absolute Requirement to Use Nourishment and Fluids for the Dying Infant

Dilemmas in Intensive Care Medicine: An Ethical and Legal Analysis

The high-technology medicine available in today's intensive care setting not only provides near miraculous benefits for some patients, but it also creates new and troublesome ethical and legal dilemmas for patients and practitioners. Standards for access to and discharge from the intensive care unit, "do not resuscitate" orders, determination of death, organ retrieval, advanced directives, decision-making capacity, and substantive and procedural guidelines for termination of treatment in incompetent patients are among the problems. Those issues, along with the emerging question of withholding nutrition and fluids, are discussed in this article.

Forgoing medically provided nutrition and hydration in pediatric patients

Discussion of the ethics of forgoing medically provided nutrition and hydration tends to focus on adults rather than infants and children. Many appellate court decisions address the legal propriety of forgoing medically provided nutritional support of adults, but only a few have ruled on pediatric cases that pose the same issue.

The cessation of nutritional support is implemented most commonly for patients in apermanent vegetative state(often referred to aspersistent vegetative state(hereinafter “PVS”)). An estimated 4,000 to 10,000 American children are in the permanent vegetative state, compared to 10,000 to 25,000 adults. Yet the dearth of literature, case reports, and court decisions suggests that physicians and families of pediatric patients stop medically provided nutrition or seek court orders much less frequently.

Moral, Ethical, and Legal Issues in the Intensive Care Unit

The United States Supreme Court's recent ruling in Cruzan and Congress' passage of the Patient Self-Determination Act of 1990 are part of the expanding legal and ethical concerns affecting medicine. These changes force us to examine not only issues in termination of treatment and advanced directives, but questions of medical futility and the quandary of how to pay for beneficial but costly new technologies. These problems indicate the need for more vigorous intensive care unit admission and discharge criteria and for policies on appropriate care of patients. We review these developments and propose approaches to such issues as do not resuscitate orders, requests for “futile” treatments, brain death, organ retrieval, advanced directives, and decision making for competent and incompetent patients.

The management of children with spinal dysraphism

Improvements in technology have dramatically increased the survival of children with spinal dysraphism. Because this complex condition affects multiple organ systems as well as the psychosocial functioning of the child and family, these children require care from a host of specialists in order to achieve optimum functioning. This article reviews the pathophysiology and discusses the current management of the medical and psychosocial effects of spinal dysraphism. It also briefly discusses strategies for intervention, long-term outcomes, and some controversies regarding care and screening.