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Decisions to withhold treatment
THE LANCET
Decisions to withhold treatment Life, Death and Decisions Doctors and Nurses Reflect on Neonatal Practice Hazel McCaffey, Peter Fowler. Altrincham, UK: Books for Midwives Press. 1996. Pp 294. £18.95. ISBN 1-898507-55-4.
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Vol 350 • September 27, 1997
from members of staff that emphasise a particular point. To aid in the interpretation of these vignettes, the grade and number of years of experience of the person is given. The impact of these characteristics are, however, left to the reader to decide—for example, whether there is consistency with regard to the level of experience or grade in approach to this important area. Before discussing these issues in depth, the authors honestly state limitations of their research. The “one off ” nature of each interview meant they were bounded by time. They were unaware of how many, if any, of the nurses declined to take part. The respondents for various reasons may not have been totally honest at the interview—for example, if they wished to create a particular impression. The authors’ results should also be interpreted in the knowledge that the researchers themselves may unwittingly have influenced their results since they felt able to explore particular statements in an individualised fashion. To the interviewee, the more vivid recollections would stand out, and episodes equally as important, but perhaps less traumatic, might not have been
Anne Greenough Department of Child Health, King’s College School of Medicine and Dentistry, Denmark Hill, London SE5 9RS, UK
Royal Victoria Hospital
adly, despite advances in neonatal intensive care, about 10% of babies admitted to a tertiary neonatal intensive-care unit die. Some, born very prematurely, may succumb only hours after birth, whereas others survive for many months, ultimately dying from complications related to premature birth or congenital anomalies. In some cases, intensive care has been withdrawn. Whenever the sad event occurs, the baby deserves to die with dignity and to be pain free. The family must be fully supported. No matter what has led ultimately to the child’s death this is a stressful time for all involved, and whether one is the parent or an involved professional, one would wish any decision-making process to be undertaken with a consistent and sympathetic approach. Although, caring for dying patients rightly has received more attention in nurses’ and doctors’ education and there is a growing literature on this subject, this change is in marked contrast to the issues surrounding withdrawal of care. Hazel McCaffey and Peter Fowler’s Life, Death and Decisions is, therefore, welcome. In their book, doctors and nurses reflect on the neonatal practice of withdrawing or withholding treatment. The authors report their findings of a descriptive survey in which in-depth discussions took place with the staff of neonatal units of four university-based hospitals and of two district general hospitals in the UK. Over a period of about 2 weeks in each unit, the neonatal consultants, as many other doctors as possible, and qualified nurses selected by their team leader so an appropriate balance of grades was achieved, were interviewed. Tape-recorded, face-toface interviews were then carried out with individual staff. In total 119 nurses (1 in 3 of the total nursing population) and 57 (79%) doctors were interviewed. The purpose was to explore the thinking and practice among doctors and nurses in relation to decision-making in cases where withdrawal or withholding of treatment were possible options. McCaffey and Fowler then explore aspects of the decision-making practice. These include a focus on the law, current policies and practices, roles and responsibilities, conflicts, parental involvement, support, and education. Each chapter is illustrated by vignettes
thought worthy of description; this could alter the balance of the text. Although summaries of the doctors and nurses were given, unless one is well aware of other centres’ practice and perhaps even which units were involved, it is difficult to know whether these data could be generalised to the whole of the UK or whether in some cases, problems documented might have been due to the result of particular geographical or local issues. Nevertheless, I was impressed by the honesty of the answers of many of the professionals who recognised their own limitations. As a consultant on a neonatal intensive care unit for more than 10 years, my take-home message was a reconfirmation that with such difficult decisions, it is important to have the family and all the members of the team fully aware and understanding the decisionmaking process. This book will make interesting reading to professionals involved in neonatal intensive care; it emphasises that issues around the decision-making process regarding withdrawing treatment justify further attention. Relevant teaching personnel will wish to have access to this text from their reference library.
The Royal Victoria Hospital, Belfast, Northern Ireland, began life as the Belfast Dispensary and Fever Hospital in 1797, a result of several name changes, alterations, and locations. This drawing (1901) by the architect William Henman shows the hospital as originally designed for its most recent major refurbishment when it was rebuilt in 1903. Viewed from the south, it shows projecting bays and individual balconies. The hospital is about to undergo more changes during its bicentennial year. (Taken from The Royal Victoria Hospital, Belfast: A History 1797–1997. Richard Clarke. Belfast: Blackstaff Press. 1997. Pp 304. £20. ISBN 0-85640-601-5.)
967
Decisions to withhold treatment Life, Death and Decisions Doctors and Nurses Reflect on Neonatal Practice Hazel McCaffey, Peter Fowler. Altrincham, UK: Books for Midwives Press. 1996. Pp 294. £18.95. ISBN 1-898507-55-4.
S
Vol 350 • September 27, 1997
from members of staff that emphasise a particular point. To aid in the interpretation of these vignettes, the grade and number of years of experience of the person is given. The impact of these characteristics are, however, left to the reader to decide—for example, whether there is consistency with regard to the level of experience or grade in approach to this important area. Before discussing these issues in depth, the authors honestly state limitations of their research. The “one off ” nature of each interview meant they were bounded by time. They were unaware of how many, if any, of the nurses declined to take part. The respondents for various reasons may not have been totally honest at the interview—for example, if they wished to create a particular impression. The authors’ results should also be interpreted in the knowledge that the researchers themselves may unwittingly have influenced their results since they felt able to explore particular statements in an individualised fashion. To the interviewee, the more vivid recollections would stand out, and episodes equally as important, but perhaps less traumatic, might not have been
Anne Greenough Department of Child Health, King’s College School of Medicine and Dentistry, Denmark Hill, London SE5 9RS, UK
Royal Victoria Hospital
adly, despite advances in neonatal intensive care, about 10% of babies admitted to a tertiary neonatal intensive-care unit die. Some, born very prematurely, may succumb only hours after birth, whereas others survive for many months, ultimately dying from complications related to premature birth or congenital anomalies. In some cases, intensive care has been withdrawn. Whenever the sad event occurs, the baby deserves to die with dignity and to be pain free. The family must be fully supported. No matter what has led ultimately to the child’s death this is a stressful time for all involved, and whether one is the parent or an involved professional, one would wish any decision-making process to be undertaken with a consistent and sympathetic approach. Although, caring for dying patients rightly has received more attention in nurses’ and doctors’ education and there is a growing literature on this subject, this change is in marked contrast to the issues surrounding withdrawal of care. Hazel McCaffey and Peter Fowler’s Life, Death and Decisions is, therefore, welcome. In their book, doctors and nurses reflect on the neonatal practice of withdrawing or withholding treatment. The authors report their findings of a descriptive survey in which in-depth discussions took place with the staff of neonatal units of four university-based hospitals and of two district general hospitals in the UK. Over a period of about 2 weeks in each unit, the neonatal consultants, as many other doctors as possible, and qualified nurses selected by their team leader so an appropriate balance of grades was achieved, were interviewed. Tape-recorded, face-toface interviews were then carried out with individual staff. In total 119 nurses (1 in 3 of the total nursing population) and 57 (79%) doctors were interviewed. The purpose was to explore the thinking and practice among doctors and nurses in relation to decision-making in cases where withdrawal or withholding of treatment were possible options. McCaffey and Fowler then explore aspects of the decision-making practice. These include a focus on the law, current policies and practices, roles and responsibilities, conflicts, parental involvement, support, and education. Each chapter is illustrated by vignettes
thought worthy of description; this could alter the balance of the text. Although summaries of the doctors and nurses were given, unless one is well aware of other centres’ practice and perhaps even which units were involved, it is difficult to know whether these data could be generalised to the whole of the UK or whether in some cases, problems documented might have been due to the result of particular geographical or local issues. Nevertheless, I was impressed by the honesty of the answers of many of the professionals who recognised their own limitations. As a consultant on a neonatal intensive care unit for more than 10 years, my take-home message was a reconfirmation that with such difficult decisions, it is important to have the family and all the members of the team fully aware and understanding the decisionmaking process. This book will make interesting reading to professionals involved in neonatal intensive care; it emphasises that issues around the decision-making process regarding withdrawing treatment justify further attention. Relevant teaching personnel will wish to have access to this text from their reference library.
The Royal Victoria Hospital, Belfast, Northern Ireland, began life as the Belfast Dispensary and Fever Hospital in 1797, a result of several name changes, alterations, and locations. This drawing (1901) by the architect William Henman shows the hospital as originally designed for its most recent major refurbishment when it was rebuilt in 1903. Viewed from the south, it shows projecting bays and individual balconies. The hospital is about to undergo more changes during its bicentennial year. (Taken from The Royal Victoria Hospital, Belfast: A History 1797–1997. Richard Clarke. Belfast: Blackstaff Press. 1997. Pp 304. £20. ISBN 0-85640-601-5.)
967