TY - JOUR
T1 - Just, in Time
T2 - Ethical implications of serial predictions of death and morbidity for ventilated premature infants
AU - Meadow, William
AU - JoanneLagatta,
AU - Andrews, Bree
AU - LeslieCaldarelli,
AU - Keiser, Amaris
AU - Laporte, Johanna
AU - Plesha-Troyke, Susan
AU - Subramanian, Madhu
AU - Wong, Sam
AU - Hron, Jon
AU - Golchin, Nima
AU - Schreiber, Michael
PY - 2008/4
Y1 - 2008/4
N2 - OBJECTIVES. For a cohort of extremely premature, ventilated, newborn infants, we determined the power of either serial caretaker intuitions of "die before discharge" or serial illness severity scores to predict the outcomes of death in the NICU or neurologic performance at corrected age of 2 years. METHODS. We identified 268 premature infants who were admitted to our NICU in 1999-2004 and required mechanical ventilation. For each infant on each day of mechanical ventilation, we asked nurses, residents, fellows, and attending physicians the following question: "Do you think this child is going to live to go home or die before hospital discharge?" In addition, we calculated illness severity scores until either death or extubation. RESULTS. A total of 17 066 intuition profiles were obtained on 5609 days of mechanical ventilation in the NICU. One hundred (37%) of 268 profiled infants had ≥ 1 intuition of die before discharge. Only 33 infants (33%) with an intuition of die actually died in the NICU. Of 48 infants with even 1 day of corroborated intuition of die in the NICU, only 7 (14%) were alive with both Mental Developmental Index and Psychomotor Developmental Index scores of >69, and only 2 (4%) were alive with both Mental Developmental Index and Psychomotor Developmental Index Scores of >79 at corrected age of 2 years. On day of life 1, the Score for Neonatal Acute Physiology II value for nonsurvivors (38.2 ± 18.1) was significantly higher than that for survivors (26.3 ± 12.7). However, this difference decreased steadily over time as scores improved for both groups. CONCLUSIONS. Illness severity scores become progressively less helpful over time in distinguishing infants who will either die in the NICU or survive with low Mental Developmental Index/Psychomotor Developmental Index scores. Serial caretaker intuitions of die before discharge also fail to identify prospective nonsurviving infants. However, corroborated intuitions of die before discharge identify a subset of infants whose likelihood of surviving to 2 years with both MDI and PDI > 80 is approximately 4%.
AB - OBJECTIVES. For a cohort of extremely premature, ventilated, newborn infants, we determined the power of either serial caretaker intuitions of "die before discharge" or serial illness severity scores to predict the outcomes of death in the NICU or neurologic performance at corrected age of 2 years. METHODS. We identified 268 premature infants who were admitted to our NICU in 1999-2004 and required mechanical ventilation. For each infant on each day of mechanical ventilation, we asked nurses, residents, fellows, and attending physicians the following question: "Do you think this child is going to live to go home or die before hospital discharge?" In addition, we calculated illness severity scores until either death or extubation. RESULTS. A total of 17 066 intuition profiles were obtained on 5609 days of mechanical ventilation in the NICU. One hundred (37%) of 268 profiled infants had ≥ 1 intuition of die before discharge. Only 33 infants (33%) with an intuition of die actually died in the NICU. Of 48 infants with even 1 day of corroborated intuition of die in the NICU, only 7 (14%) were alive with both Mental Developmental Index and Psychomotor Developmental Index scores of >69, and only 2 (4%) were alive with both Mental Developmental Index and Psychomotor Developmental Index Scores of >79 at corrected age of 2 years. On day of life 1, the Score for Neonatal Acute Physiology II value for nonsurvivors (38.2 ± 18.1) was significantly higher than that for survivors (26.3 ± 12.7). However, this difference decreased steadily over time as scores improved for both groups. CONCLUSIONS. Illness severity scores become progressively less helpful over time in distinguishing infants who will either die in the NICU or survive with low Mental Developmental Index/Psychomotor Developmental Index scores. Serial caretaker intuitions of die before discharge also fail to identify prospective nonsurviving infants. However, corroborated intuitions of die before discharge identify a subset of infants whose likelihood of surviving to 2 years with both MDI and PDI > 80 is approximately 4%.
KW - Illness severity scores
KW - Informed consent
KW - Neonatal epidemiology
KW - Neonatal ethics
KW - Prognostication
KW - Score for neonatal acute physiology ii
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U2 - 10.1542/peds.2006-2797
DO - 10.1542/peds.2006-2797
M3 - Article
C2 - 18381538
AN - SCOPUS:42949083800
SN - 0031-4005
VL - 121
SP - 732
EP - 740
JO - Pediatrics
JF - Pediatrics
IS - 4
ER -