Palliative care in neonates and unborn babies

Nicola Xiang, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

Palliative care has only recently become recognised as a speciality of its own right and in general, when we think of palliative care, we think of the elderly. However, it should be recognised that providing palliative support for young patients including neonates and unborn babies should be just as important.

The main problem with providing palliative care to neonates is determining eligibility. After all, how do you palliate an unborn baby who is not yet a living functioning member of society? It has however been shown that parents who undergo spontaneous and induced pregnancy losses undergo a grief reaction and require counselling in the long term. In some cases, palliation maybe an unexpected necessity. The EpiCure study showed that In pregnancies terminated at less than 22 weeks’ gestation, 4% of neonates show signs of life at birth, (1) a situation that may require palliation, if survival is prolonged.

In order to address some of these issues, a recent working report by the British Association of Perinatal Medicine focused on palliative care. Several points were highlighted:

  1. Holistic palliative care planning must begin with the identification and clear definition of pathology. (3)
  2. The diagnosis and prognosis must be agreed within the MDT and discussed with family.
  3. Family centred psychological, medical and social care must be given. Including in some cases allowing the pregnancy to proceed to term and delivery, providing sensitive ante-natal care and documenting formally any care plans.
  4. Post-partum, the neonatal team should be at hand and any resuscitation plans be agreed on previously.
  5. The family should be made aware that the baby may appear alive for sometime and the use of appropriate sedation and analgesia should be discussed.
  6. The benefits of a post-mortem to clarify pathology in advance of future pregnancies should be explained to the family.
  7. Help should be given with regards to registration of death, other documentation and emotional and psychological support continue to be provided by the perinatal bereavement services.

In conclusion, this working report has highlighted the need for guidance regarding the palliative care of neonates and unborn babies. It highlights that basic medical sense such as always maintaining open communication with family and staff and being sensitive and is needed in these instances. Such guidelines could provide valuable advancement for palliative perinatal care.

References: 

1. Wyldes M, Tonks A. Short communication: Termination of pregnancy for fetal anomaly: a population-based study 1995 to 2004. BJOG: An International Journal of Obstetrics & Gynaecology 2007;114(5):639-642.
doi: 10.1111/j.1471-0528.2007.01279.x

2. Kilby MD, Pretlove SJ, Bedford Russell AR. Multidisciplinary palliative care in unborn and newborn babies [Internet]. BMJ 2011 Apr;342Available from: http://www.bmj.com/content/342/bmj.d1808.short
doi: 10.1136/bmj.d1808

Story image from: Wikimedia Commons