No resuscitation and withdrawal of therapy in a neonatal and a pediatric intensive care unit in Canada C. Anthony Ryan, MB, MRCPI, MRCP(UK), FRCPC, Paul Byrne, MB, FRCPC, Susan Kuhn, MD, and Juzer Tyebkhan, MD From the Neonatal and Pediatric Intensive Care Units, University of Alberta Hospitals, and the Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada Study objective: To compare and contrast the modes of death in a neonatal (NICU) and a pediatric (PICU) intensive care unit. Design: Retrospective analysis of patient records. Subjects: All newborn infants and children (<17 years of age) who died in the NICU and PICU at the University of Alberta Hospitals, Edmonton, between Jan. I, 1990, to Dec. 31, 1991. Results: The mortality rate in the PICU was 8.7% (73/839) compared with 5.6% (75/1333) in the NICU (p = 0.007). Withdrawal of therapy was the most common cause of death in both units and occurred more commonly in the NICU (NICU = 69% vs PICU = 34%; p = 0.01). There were significantly more deaths as a result of failed cardiopulmonary resuscitation (CPR) in the PICU than in the NICU (29% vs 13%; p = 0.046). Death after no-CPR orders occurred with equal fre- quency in both units (NICU 17%; PICU 15%). Brain death accounted for 22% (16/ 87) of PICU deaths; no infant in the NICU was declared brain dead (p <0.05). When deaths resulting from brain death and failed CPR were excluded, there was no significant difference between the two units regarding withdrawal of therapy (NICU 80% vs PICU 69%) and no-CPR orders (NICU 20% vs PICU 30%), Conclusions: This study confirms that both withdrawal of therapy and no-CPR or- ders are part of current clinical practice in both the NICU and PICU settings. The ethical foundations and implications of these practices need further elabora- tion. (J PEDIATR 1993;123:534-8) Critical care physicians have been perceived, rightly or wrongly, as providers of aggressive medical care without technologic limits and perhaps with little consideration for the ethics of such treatments. However, reports from the United States, Great Britain, Holland, and Japan concern- ing withdrawal and limitation of life support in adult, l, 2 neonatal,3, 4, 5, 6 and pediatric intensive care units7, 8 con- firm that intensivists frequently consider the ethical impli- cations of the treatments that they provide. Rhoden 9 has Submitted for publication Feb. 26, 1993; accepted May 25, 1993. Reprint requests: C. Anthony Ryan, MB, Neonatal Intensive Care Unit, Royal Alexandra Hospital, 10240 Kingsway,Edmonton, Al- berta T5H 3V9, Canada. Copyright 91993 by Mosby-Year Book, Inc. 0022-3476/93/$1.00 + .10 9/20/48959 theorized on the international approaches to "end of life" strategies, and has suggested that Swedish physicians with- hold treatment when the statistical data suggest a grim prognosis ("statistical approach"); British physicians are more likely to initiate treatment and withdraw in the face of a deteriorating clinical situation ("individualized ap- CPR NICU PICU Cardiopulmonary resuscitation Neonatal intensive care unit Pediatric intensive care unit proach"); and the trend in the United States is to initiate treatment and continue until it is virtually certain that the infant will die ("waiting for near certainty"). In Japan, the senior staff member, after plenary discussions, arrives at a decision that is then communicated to the family.5 Limita- 534