Which infants should not receive intensive care?

Parents perceptions of withdrawal of life support treatment to newborn infants

The decision to withdraw life support challenges health care professionals and parents. Parents need to fulfil their role as parents, part of which involves difficult decision making. They desire to fully understand the care of their infant in order to help in this process. Parents work to a different time frame than health care professionals and therefore require detailed information and support to make decisions. Available approaches to care need to address ethical decisions regarding treatment, pain and suffering, quality of life and decisions to move from active to palliative care. Communication requires an investment of time, repeated discussions and a compassionate approach by health care professionals to educate parents in order for them to make an informed decision. Follow-on care to help parents come to terms with the decisions they have made is a requirement of good practice.

Deaths in a neonatal intensive care unit: a 10-year perspective

OBJECTIVE

To examine changes in the characteristics and management of infants dying in a regional neonatal intensive care unit in 1987-1988 vs. 1997-1998.

SETTING

The level III Neonatal Intensive Care Unit (NICU) at Rikshospitalet, Oslo, Norway, handles both regional and national referrals.

DESIGN/METHODS

The study was retrospective and observational. Patients who died in the neonatal intensive care unit were identified using our own and the hospital's data records. Charts were reviewed by the principal author.

RESULTS

The mortality rate relative to admissions decreased significantly from 1987-1988 to 1997-1998 (6.9% vs. 3.4%, p <.0001). Infants who died in 1997-1998 were more mature and had higher birth weights than those who died in 1987-1988 (34.0 +/- 5.5 vs. 32 +/- 6.0 wks gestational age [mean +/- sd], p <.05; and 2,186 +/- 1,207 vs. 1,699 +/- 1,038 g, p <.05). There was a significantly higher proportion of infants with complex congenital malformations among those who died in 1997-1998 (54% vs. 28%, p <.005). Forgoing intensive care treatment was more commonly associated with the process of dying in 1997-1998 than 10 yrs earlier (63.5% vs. 22.8%, p <.0001). Parental involvement in the process leading to a decision to forgo life support was more frequently described in the charts from 1997-1998 (72.7% vs. 23.8%, p <.001). During the last time period, parents were also present at the time of death significantly more often.

CONCLUSIONS

The mortality rate of sick infants decreased significantly between 1987-1988 and 1997-1998, showing the improvements in neonatal intensive care during that decade. In 1997-1998, congenital malformations had become the leading cause of death. Parental involvement in life-and-death questions seems to have become the rule, and almost two thirds of neonatal intensive care unit deaths followed a decision to forgo life support.

Attitudes of parents and health care professionals toward active treatment of extremely premature infants

OBJECTIVES

To compare the attitudes of neonatologists, neonatal nurses, the parents of extremely low birth weight (ELBW) children, and the parents of normal birth weight children toward saving infants of borderline viability and who should be involved in the decision-making process and to compare physicians' and nurses' estimates of the proportion of infants who are born at various gestational ages with regard to survival, morbidity, and treatment.

METHODS

A questionnaire was given to 169 parents of ELBW children and 123 parents of term children, who were part of a longitudinal study of the outcome of ELBW infants. A similar questionnaire was completed by 98 Canadian neonatologists and 99 neonatal nurses.

RESULTS

Physicians tended to be more optimistic than nurses regarding the probability of survival and freedom from serious disabilities and would recommend to parents life-saving interventions for their child at earlier gestational ages. A significant majority of parents believed that attempts should be made to save all infants, irrespective of condition or weight at birth, compared with only 6% of health professionals who endorsed this. In contrast to parents, health professionals believed that economic costs to society should be a factor in deciding whether to save an ELBW infant. However, health professionals did not believe that the economic status of the parents should be a factor, although the stress of raising an infant with disabilities should be. Most respondents believed that the parents and physicians should make the final decision but that other bodies, such as ethics committees or the courts, should not.

CONCLUSION

Health care professionals must recognize that their attitudes toward saving ELBW infants differ from those of parents. Parents, whether of term or extremely premature children, are more in favor of intervening to save the infant irrespective of its weight or condition at birth than are professionals. It therefore is imperative that there be joint decision making, combining the knowledge of the physician with the wishes of the parents.

The role of parents in end-of-life decisions in neonatology: physicians' views and practices

OBJECTIVE

End-of-life decisions for newborn infants are usually made with the consent of parents as well as physicians, but may occasionally involve disagreement about which decision is in the best interest of the child. Our study was aimed at providing an empirical background for the ethical discussion on the parent's versus the physician's role in decision-making.

METHODS

We conducted face-to-face interviews with a stratified sample of pediatricians. The response rate was 99%. The most recent decisions in newborn infants to hasten death or not prolong life and the most recent cases in which such decisions were not made because either the parents or the physician objected were comprehensively discussed.

RESULTS

Decisions to hasten death or not prolong life were usually made after discussing it with parents and did not occur while parents were known to disagree. Situations in which an end-of-life decision was not made because parents did not consent predominantly involved infants with complications of prematurity (24%) or perinatal asphyxia (40%), whereas situations in which parents requested an end-of-life decision that was not acceded to by the pediatrician involved Down syndrome as the main diagnosis in 43% and as a concurrent diagnosis in 21%. Pediatricians afterwards often expressed feelings of discontent about situations in which there had been disagreement with parents.

CONCLUSIONS

The opinion of parents about which medical decision is in the best interest of their child is for pediatricians only decisive in case it invokes the continuation of treatment. The principle of preserving life is abandoned only when the physician feels sufficiently sure that the parents agree that such a course of action is in the best interest of the child.

Medical end-of-life decisions made for neonates and infants in the Netherlands

BACKGROUND

Advances in neonatal intensive care have lowered the neonatal death rate. There are still some severely ill neonates and infants, however, for whom the application of all possible life-prolonging treatment modalities may be questioned.

METHODS

We did two studies in the Netherlands. In the first we sent questionnaires to physicians who had attended 338 consecutive deaths (August-November, 1995) within the first year of life (death-certificate study), and in the second we interviewed 31 neonatologists or paediatric intensive-care specialists and 35 general paediatricians. The response rates were 88% and 99%, respectively.

FINDINGS

In the death-certificate study, 57% of all deaths had been preceded by a decision to forgo life-sustaining treatment; this decision was accompanied by the administration of potentially life-shortening drugs to alleviate pain or other symptoms in 23%, and by the administration of drugs with the explicit aim of hastening death in 8%. A drug was given explicitly to hasten death to neonates not dependent on life-sustaining treatment in 1% of all death cases. No chance of survival was the main motive in 76% of all end-of-life decisions, and a poor prognosis was the main motive in 18%. The interview study showed that parents had been involved in making 79% of decisions. The physicians consulted colleagues about 88% of decisions. Most paediatricians favoured formal review of medical decisions by colleagues together with ethical or legal experts.

INTERPRETATION

Death among neonates and infants is commonly preceded by medical end-of-life decisions. Most Dutch paediatricians seem to find prospects for survival and prognostic factors relevant in such decisions. Public control by a committee of physicians, paediatricians, ethicists, and legal experts is widely endorsed by paediatricians.

[Ethical decisions making in neonatal intensive care. Survey among nursing staff in 2 French centers]

A European Concerted Action, Euronic, has been set up to study the attitudes and self-reported practices of the staff working in neonatal intensive care units about parent's information and ethical decisionmaking. This paper presents the results of a preliminary qualitative survey conducted in two French units and including 23 physicians and nurses. The answers indicate that withdrawal of treatments are part of their practices. Parents are never directly involved in the decision-making process. The decision to withdraw life sustaining treatments generate psychological distress among the caregivers. Nurses consider that they are more emotionally involved with the baby and the parents. They express concerns about painful treatments and life-prolonging therapies. Most respondents believe that an ethical committee would be of little help in the decision-making process and that the actual legislation should not be modified as it gives obligation for more in-depth consideration of each case.

Foregoing intensive care treatment in newborn infants with extremely poor prognoses. A study in four neonatal intensive care units in The Netherlands

Within the framework of the broader ethical discussion on end-of-life decision making in neonatology and the need to obtain more quantifiable data, we performed a multicenter study in four Dutch neonatal intensive care units. All infants who died in these units in 1993 were included in the study. Aside from cases in which foregoing treatment was not under discussion, cases in which death appeared inevitable (A cases) and cases in which foregoing treatment because of extremely poor prognosis was the decisive factor (B cases) were distinguished. A total of 181 neonatal deaths occurred. Thirty-five infants died even after full continuation of treatment. In 98 A cases and 48 B cases, which together represented 81% of all deaths, treatment was foregone either because the infants had no chance to survive or because of extremely poor prognoses. In these cases, the medical team ultimately achieved consensus of opinion, although in some instances several sessions were required. In three cases, the parents did not agree with the team advice. In one A case death appeared inevitable. In two B cases, the parents' wish to continue treatment was followed. In a large majority of B cases, the decisions to forego treatment were based on the presence of severe cerebral damage. In A cases there was no real choice because death appeared inevitable. However, in B cases neonatologists were obliged to determine whether continuation of treatment was justifiable or if withdrawal of treatment in view of extremely poor prognoses was preferred.

Impact of extremely immature infants on neonatal services

The impact of very immature infants on neonatal services was examined within the United Kingdom. The Trent Health Region was used as a geographically defined population. Data were obtained on all infants weighing less than 1501 g at birth and all infants born before 32 weeks gestation between 1991-93. Information relating to length of stay, duration of ventilation, and survival was documented. Only one of 49 infants born before 24 weeks gestation survived. However, 75% of this group were ventilated. Most of the remaining infants died before 48 hours of age. A similar pattern was also seen in infants of 24 and 25 weeks gestation. Infants under 24 weeks gestation comprised 1.5% of all ventilated infants and consumed 2.14% of the total neonatal ventilator days for the region. It is concluded that the United Kingdom operates a conservative policy towards infants born before 24 weeks gestation and as a result resources expended on them are limited.

Death in neonatal intensive care

The aim of this study was to review the frequency of decisions to withdraw treatment from neonates who had died in a large neonatal intensive care unit, the reasons for these decisions, and the procedures followed. A 12 month retrospective review of medical and nursing records was undertaken. There were 67 deaths; treatment was withdrawn from 52 infants who were dead or dying, from 9 infants on the basis of a severe congenital abnormality, and from 6 infants with severe acquired brain damage. The decision-making process and the management of treatment withdrawal are reviewed. It is concluded that withdrawal of treatment resulting in death occurs frequently in the neonatal intensive care service of National Women's Hospital, Auckland, New Zealand, but is usually a recognition of the inevitable. Truly elective withdrawal of treatment is uncommon in the immature infant, but does occur in the context of multiple abnormalities or severe birth asphyxia, where it follows a formal procedure.

Outcome of infants born preterm, with special emphasis on extremely low birthweight infants

The outcome of extremely low birthweight (ELBW) infants has been reviewed from published articles and up-to-date data from Japan. The mortality rate of these infants declined significantly from over 90% to below 50% after the introduction of intensive care in the 1970s, but the incidence of major neurological sequelae remained steady at around 20%. Similarly, the incidence of major neurological sequelae did not increase along with the decrement of birthweight, although the mortality rate increased significantly. Long-term follow-up of ELBW children until school age has revealed poor school performance in spite of the absence of major neurological sequelae and the attainment of average intelligence quotient scores. Physical growth is retarded initially but generally catches up by the age of 8-9 years. In Japan, the neonatal mortality rate of ELBW infants declined from 56% in 1981 to 25% in 1989 with an increased birth rate of ELBW infants. In ELBW infants cared for at Tokyo Women's Medical College during 1984-90, the survival rate was 112 out of 134 (84%) and the incidence of major neurological sequelae was 15 out of 87 (17%) at 1-8 years old. The viability limit of ELBW infants has been discussed based on recent data. As a result of the rapid progress of medical care of ELBW infants, their viability limit as defined in the Eugenic Protection Law in Japan was amended from 24 completed weeks of gestation to 22 completed weeks in 1991.

The ethics of cardiopulmonary resuscitation. II. Medical logistics and the potential for good response

Mismatches between provision of paediatric cardiopulmonary resuscitation (CPR) and potential to benefit are examined. Deficiencies are most likely to occur in peripheral maternity units but futile CPR is more common in emergency departments where the child is unknown. Decision making in individual cases is best retained by the medical profession for the sake of the child and family. American style intervention by the legislature is likely to dissipate scarce resources and perhaps harm infants not capable of benefiting.

The ethics of cardiopulmonary resuscitation. I. Background to decision making

Futile cardiopulmonary resuscitation (CPR) may prevent humane care of the dying child and deprive parents of the opportunity to express their love, grief, and dedication at a critical moment, while appropriate and successful CPR may restore intact their child. Attempted resuscitation of corpses or children with terminal illness indicates inadequate knowledge, discrimination, and decision making. CPR is a medical procedure applicable to certain medical problems; weighing up the risks and benefits in each individual case is a medical function that is constrained by the law and must take full note of patient and family preferences, but cannot be governed by them and should not be over-ruled by laws based on complex but different cases. Time limits on occasions may curtail the full process of consultation and decision making. Applications of skills and resources in the right time and place requires understanding of the medical logistics and study of the potential for good outcome.

Should we resuscitate? Ethical dilemmas

Over a 2-year period, there were 312 perinatal deaths. A total of 144 (46.2%) of these deaths were due to lack of or delayed resuscitation at birth. This group comprised 45 infants with multiple congenital abnormalities, 31 with severe birth asphyxia, 25 with meningomyelocele, 20 with infections and 15 with kernicterus. Taking the decision not to resuscitate may be difficult, perplexing and agonizing for the families and health professionals. The decision may be easier if one can prognosticate as to intact survival and development. The physician, though he is not God, has to be firm and decisive--if intact survival or satisfactory developmental outcome is very unlikely, then ther is probably no need to resuscitate.

International perspectives on treatment choice in neonatal intensive care units

Over the past 25 years, neonatal intensive care units (NICUs) have been established throughout the industrialized world and in some Third World nations to provide sophisticated medical interventions for critically ill newborns. This paper discusses the four major factors affecting treatment choices for newborns with disabilities or at risk for disabilities: the availability of resources, societal attitudes toward medical interventions and life with disabilities, the roles of physicians, parents and other decision-makers, and the role of the law. Much has been written on the bioethical issues surrounding such treatment as it is practiced in the United States, including analysis by social scientists; however, little has been written on how those issues are perceived and dealt with in most other nations, and very little comparative research has been conducted. The author provides an international perspective on the bioethical issues involved by comparing U.S. practice, which has received much attention, with a generalized commentary on practices in other parts of the world, which have received less examination. The nations surveyed include Australia, Brazil, Britain, Canada, China, France, India, Israel, Japan, the Netherlands, Poland, Sweden, and West Germany. The value of further comparative research is discussed in order to encourage others to do such research.

Changing outcome of extremely premature infants (less than or equal to 26 weeks' gestation and less than or equal to 750 gm): survival and follow-up at a tertiary center

Management of extremely premature infants is controversial because limits of viability are not established. From 1981 to 1987, 175 infants were admitted to the neonatal intensive care unit at Minneapolis Children's Medical Center with gestational ages less than or equal to 26 weeks and birth weights less than or equal to 750 gm. To assess current prognosis and to analyze trends over time, survival data and developmental characteristics of surviving infants were reviewed. During the study period, antenatal obstetric management was assertive, with liberal indications for tocolysis and expectant management for preterm prolonged membrane rupture, with the goal of delivery of infants in a nonasphyxiated condition. Ninety-one percent of infants were inborn and were managed aggressively after birth with full neonatal support. Survival increased from 21% in 1981-1982 to greater than 50% in 1986-1987 and occurred as early as 23 weeks' gestation. Seventy-one percent of all deaths occurred within 48 hours of birth, and late death (greater than 28 days) was uncommon. At follow-up, 23% of survivors were impaired, a proportion that remained relatively constant during the study period. Improvements in survival were not associated with an increased proportion of impaired infants. Survival with good outcome is attainable at gestational ages and birth weights previously considered nonviable. For obstetricians, neonatologists, and parents, knowledge of such current data can play an important role in making appropriate management decisions for both mother and infant.

Long-term outcome of pre-term infants

Recent advances in neonatal intensive care have resulted in significant improvements in the neonatal mortality rate in very low-birth-weight infants. Although there has been some decline in the prevalence of impairments, there are concerns that the improved survival rate may result in handicapped infants who would not have survived in an earlier era. This paper addresses the current survival and morbidity for very low-birth-weight infants and discusses the role of the family physician in meeting the new challenges in continuing care presented by these infants.

Attitudes of Australian neonatal paediatricians to the treatment of extremely preterm infants

A questionnaire survey was carried out to identify areas of consensus or disagreement in the attitudes and practices of Australian neonatal paediatricians with regard to the treatment of extremely preterm infants. Considerable variation was found in the estimated chances of survival and disability among respondents. The majority of neonatal paediatricians advocated prompt resuscitation and initiation of neonatal intensive care at birth, although all believed life-support treatment should be withdrawn in those instances where medical complications develop resulting in near certainty of death or life with total incapacity. The predominant view was for parents to be involved in the decision-making process for withdrawal of life-support and for the neonatal intensive care policy to be made known to the parents. Information from this survey which raised concerns included the variability in the estimate of the potential for survival, the lack of relevance of the law to everyday practices in the neonatal intensive care units, the small minority of respondents who felt that life-and-death decisions should be made by medical staff alone, and the reluctance of some neonatal paediatricians to inform parents about the policies of their unit.

The extremely low birthweight infant: ethical issues in treatment

Survival and disability rates of extremely low birthweight infants have significantly improved. Since it is impossible to give an accurate prognosis at the time of birth, all such live births should be resuscitated and curative treatment, including the use of life support measures when appropriate, promptly initiated. In the event that medical facts indicate curative efforts are futile or lack compensating benefit, they should be discontinued and palliative treatment, which provides symptomatic relief and comfort, should be introduced. The attending neonatologist has the primary role as advocate for the infant and medical advisor to the parents, while the parents act as surrogates for their infant. The shift in emphasis from curative to palliative treatment requires medical consensus among all those involved in the care of the infant and consent from the parents closely involved in this widely shared decision. The role of infant bioethics committees is one of advisor and consultant to this decision-making process. Legislation needs to uphold the primary prejudice in favour of life while conceding that discontinuation of curative treatment, which is no longer effective, and the provision of palliative treatment, are appropriate medical decisions in exceptional cases.

A classification of clinical paediatric research with analysis of related ethical themes

Different types of clinical research are associated with different degrees of risk and with varying utility. Usually classified as therapeutic or non-therapeutic, clinical research involving children necessitates a balance between the conflicts of intrusion into a group of vulnerable subjects, and the obvious advantages which such intrusion engenders. To understand better the potential ethical dilemmas of paediatric research the author has expanded the classification of such clinical research involving children. Five types of such research--preventive research, curative research, research to alleviate symptoms, studies to establish norms and baselines, and curiosity research--are discussed in the context of their ethical constraints, and the different ethical questions which confront workers operating in each of these different themes.

Periventricular haemorrhage and leukomalacia in extremely low birthweight infants

Forty (49%) of 82 extremely low birthweight (ELBW, less than 1000 g) infants had periventricular haemorrhage (PVH). Ten (12%) had germinal layer haemorrhage (GLH) alone, 16 (20%) had intraventricular haemorrhage (IVH) and 14 (17%) had intracerebral haemorrhage (ICH). Almost all the cases of PVH had developed by 4 days of age. Small-for-gestational age infants (12% of study population) had a significantly lower incidence and severity of PVH than appropriate-for-gestational age infants. Of 94 infants born between 23 and 28 weeks gestation, 45 (48%) had PVH. The PVH incidence was 60% in those of 23-26 weeks and 38% in those of 27-28 weeks. The hospital survival rate of ELBW infants was 69% in those without PVH and 43% in those with PVH; 70% in GLH alone; 50% in IVH and 14% in ICH. Three survivors developed post-haemorrhage hydrocephalus of whom two required ventriculoperitoneal shunting. Five survivors developed periventricular leukomalacia (PVL) evidenced by cysts identified between 3 and 7 weeks of age. A significant decrease in the incidence of PVH occurred over the study period (67% in 1982, 38% in 1983 and 33% in 1984). This decrease was seen for all grades of PVH. The reasons for this decreased incidence are still to be ascertained but this trend suggests that improvements in neonatal intensive care have the potential to improve the neurological outcome of more recent ELBW survivors.

Objectives and outcome of perinatal care

Great advances in perinatal care during the past two decades have been accompanied by reduced mortality rates in progressively lower birthweight groups. Continuing effort may be warranted by these improved results or by the need to preserve human life, yet rising costs in terms of disability, stress on parents and attendants, and financial resources raise questions about the value and justification of such effort. If rational policies are to be formulated for the future, accurate data based on planned population studies are essential. Perinatal care is only one of the determinants of outcome--environmental influences are also important and must be taken into account. Resources should be directed to improving the sociocultural environment as well as the standards of perinatal care.

Prognosis for babies born with fused eyelids

The overall mortality for babies referred to our unit with fused eyelids was 68.7%; but when severe skin bruising was present only one of 18 babies survived (5.6%). This compares with a survival rate of 75% for those not bruised at or soon after birth. Skin bruising invariably indicates a very poor prognosis in babies born with fused eyelids.

Effect of neonatal periventricular haemorrhage on neurodevelopmental outcome

All 56 infants born between 23 and 28 weeks' gestation admitted to this hospital in 1981 were examined for periventricular haemorrhage with cerebral ultrasonography. Haemorrhage was diagnosed in 34 (61%)-12 (22%) had germinal layer haemorrhage, 18 (32%) had intraventricular haemorrhage, and four (7%) had intracerebral haemorrhage. The two year outcome of survivors with and without periventricular haemorrhage was compared to determine the effect on neurodevelopment. Only three (16%) of 19 infants with normal scans or germinal layer haemorrhages had evidence of major disability but nine (75%) of 12 infants with intraventricular or intracerebral haemorrhage had major disability. The mental and psychomotor performance on the Bayley scales of infant development was also significantly worse in the latter group. All three survivors with intracerebral haemorrhage had major disability. The continuation of life support treatment for extremely preterm infants who are at very high risk of severe handicap is a matter of increasing concern in neonatal intensive care. Our results show that if extensive periventricular haemorrhage, in particular intracerebral haemorrhage, occurs in this gestational group, extreme pessimism is warranted.

Evaluation of a one-year Swedish neonatal care population

A one-year population of 527 newborn infants treated in a Swedish neonatal unit was studied with regard to the effectiveness of the neonatal care in rate of normal survival and rate of handicaps at 3 years of age. The effectiveness could be accurately calculated in terms of survival rate being 84% and 98% of outborns and inborns respectively, and in terms of survivors without neurodevelopmental handicaps at 3 years of age being 90% and 97%, respectively. From available data on the cost of the neonatal care it could be estimated that the average annual costs for rehabilitation care for a light or moderately to a severely handicapped child were 5.8 to 11.2 times higher than in average per patient in-hospital costs during neonatal treatment. It is evident that skills in specialized neonatal care are indispensable for optimal outcome for very small low birthweight infants below 1500 g or born before 30(-32) weeks of gestation. However, in order to evaluate the return on expenditure for prevention of handicaps from the viewpoint of society adequate data on effectiveness of treatment as well as economic cost-efficiency are necessary for local and regional organization of neonatal care units.

Outcome in infants 501 to 1000 gm birth weight delivered to residents of the McMaster Health Region

The mortality and morbidity for all 255 live births of infants with birth weight 501 to 1000 gm and delivered to residents of a geographically defined region between 1977 and 1980 are reported. In all, 117 (46%) infants were discharged alive; there were four postdischarge deaths, and three infants were lost to follow-up. The mean birth weight and gestational age of the survivors was 850 +/- 118 gm and 27.1 +/- 2 weeks, respectively. Neurosensory handicaps were detected in 26 (24%) of 110 survivors followed for a minimum of 2 years corrected age. In addition, 29 (26%) infants had nonneurologic problems and 55 (50%) were considered apparently normal. Within 100 gm birth weight groups, survival improved significantly with increasing birth weight, but the handicap rate among survivors remained relatively constant. These figures are proposed for use in describing the current prognosis at birth for liveborn tiny infants from comparable unselected populations.

Survival and 2-year outcome of extremely preterm infants

The survival of 163 infants born within the hospital at 24-28 weeks gestation during a 4 1/2-year period and the morbidity in survivors at 2 years of age were reported. Hospital survival rates from 24-28 weeks at each week of gestation, excluding six infants with birth defects, were 36%, 32%, 57%, 70% and 74% respectively. The late outcome of children born at 24-26 weeks was compared with those born at 27-28 weeks. Of the 81 infants in the former group 46 (57%) died, nine (11%) survived with significant functional handicap and 26 (32%) were developing within the normal range. Of the 82 infants in the latter group, 28 (34%) died, eight (10%) survived with significant functional handicap and 46 (56%) were developing within the normal range. Although the mortality rate was significantly higher in the 24-26-weeks group, the physical disability and functional handicap rates in survivors were not statistically different between the two groups. Neither was developmental progress, as determined by psychological assessment, different.

The right to be allowed to die

The unbridled use of modern medical skills and technology in preserving life at all costs has stimulated interest in expressing a 'right to die' by the legally competent patient who is anxious to protect his autonomy. Some recent decisions by American courts are seen to threaten this 'right to die' of competent patients and imply that legally incompetent patients including children should not have this right under any circumstances, even when expressed on their behalf by guardians, nearest relatives or parents. It is argued that this is contrary to 'natural justice' as viewed by most people. It should be possible to develop procedures which are protective of the basic 'right to life' of the incompetent yet will recognise circumstances where they could be allowed to die. This paper was presented at the 1983 annual conference of the London Medical Group, 'Human Rights in Medicine'.