Abstract
Objective
To better understand the value of DNR orders for critically ill infants in the NICU.
Methods
A prospective mixed-methods approach was utilized including chart review of infants who died in a regional NICU over a twenty-six-month period and surveys of their neonatologists, neonatal fellows, and nurses.
Results
40 infants died during the study period and 120 staff surveys were completed. Infants with DNR orders were of a higher gestational age at birth and a higher chronological age at death. Nurses were more likely to perceive benefit from DNR orders than physicians. Medical staff recollection of the existence of DNR orders was not always accurate. Time and fear of adding unnecessary emotional burden to parents were identified as barriers to DNR order implementation. An advanced care planning model built on open communication instead of DNR order documentation was deemed the best approach.
Conclusion
Though DNR orders are beneficial for a subset of infants, DNR orders are likely not applicable for all infants who die in the NICU. More important is supportive, individualized communication between families and the medical team to ensure quality end-of-life care.
Impact
-
In the adult and pediatric ICU literature, DNR orders are associated with improved qualitative “good death” assessments and decreased familial decision regret. In the NICU, rates of DNR usage aren’t well reported and their overall utility is unclear.
-
Though DNR orders can help guide clinical decision making in the NICU and may be associated with higher quality ethical discussion, our data suggest that they are not applicable in all patient cases.
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We hope that this work will help guide approaches to end-of-life care in the NICU and underscore the importance of frequent, open communication between families and their medical team.
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Data availability
The complete qualitative and quantitative datasets generated and analyzed during this study are available from the corresponding author on reasonable request. Chart review data and partial survey data are included in this published article and its supplementary information files.
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Shannon Adams was responsible for interpreting the work and critically reviewing and revising the manuscript. Richard Tucker was responsible for the analysis and interpretation of data as well as critically reviewing the manuscript. Beatrice Lechner helped to conceptualize this project and was involved in the analysis and interpretation of data as well as drafting, critically reviewing and revising the manuscript. Katherine Redford contributed to the acquisition of data and interpretation of the work, as well as drafting and critically reviewing the manuscript. Randall Li contributed to the conception of the work, data acquisition and critically reviewing the manuscript. Ana Malfa was involved in data acquisition and critically reviewing the work. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
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Adams, S.Y., Redford, K., Li, R. et al. Utility of do-not-resuscitate orders for critically ill infants in the NICU. Pediatr Res 97, 707–713 (2025). https://doi.org/10.1038/s41390-024-03367-1
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DOI: https://doi.org/10.1038/s41390-024-03367-1
