An uncertain future? Counselling and decision-making around treatment withdrawal for newborn infants. Dominic Wilkinson 1,2,3 Affiliations:1. Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, UK. 2. Robinson Institute, Discipline of Obstetrics and Gynaecology, University of Adelaide, Australia. 3. John Radcliffe Hospital, Oxford, UK. Correspondence: Dr Dominic Wilkinson, Oxford Uehiro Centre for Practical Ethics, Suite 8, Littlegate House, St Ebbes St, Oxford, OX1 1PT, UK. Tel: +44 1865 286888, Fax: +44 1865 286886 Email: dominic.wilkinson@philosophy.ox.ac.uk Funding: DW was supported for this work by a grant from the Wellcome trust WT106587/Z/14/Z In this issue, Pal and colleagues from Cambridge describe a small cohort of infants with severe hypoxic-ischaemic brain injury.(1) These 8 infants survived for a prolonged period (weeks to years) after withdrawal of mechanical ventilation in intensive care despite the apparent belief of the infants’ clinicians that death was inevitable. Survival was not expected for these infants. But should it have been? How common is it for infants to survive after limitation of treatment? There are no prospective studies in neonatal intensive care to answer that question. In studies in adult intensive care, 4-7% of patients who had palliative withdrawal of mechanical ventilation survived to discharge from hospital.(2, 3) In contrast, in a prospective study in paediatric intensive care there were no survivors.(4) Our own recently published retrospective series identified survival to discharge in 28% of infants with severe brain injury in whom there had been discussions about potential limitation of treatment.(5) The chance of survival following withdrawal or withholding of treatment is likely to be influenced by a number of factors. One factor is the reason for treatment limitation. Infants who are moribund despite maximal intensive care, and having treatment withdrawn on the basis of imminent demise would be unlikely to survive. Infants who have treatment limited in the setting of poor neurological prognosis, in contrast, may not require high levels of intensive medical support, and consequently may survive when this is withdrawn. In our own study, ¾ of infants were Dzphysiologically stabledz at the time of discussions about treatment limitation.(5) In the Cambridge study, 5 of the 8 infants were minimally ventilated (in room air), or on non-invasive respiratory support.(1) Another factor may be the timing of decisions: earlier treatment withdrawal may be associated with a higher chance of death in patients with brain injury.(6) The median time for treatment withdrawal in the Cambridge study was day 7 after birth.(1) In our cohort, treatment limitations occurred earlier in infants who died (median day 1), than in infants who survived (median day 6, p<0.001, unpublished data). Finally, subsequent decisions, made after withdrawal of