Withdrawal of life sustaining treatment in children in the first year of life

Objective: Since the enactment of the Texas Advance Directives Act of 1999, the Memorial Hermann Hospital Medical Appropriateness Review Committee (MARC) MARC reviewed six cases of children in the first year of life, three from the Neonatal ICU and three from the Pediatric ICU. We aimed to describe the characteristics of these patients and the role of the MARC in this process. Study Design: A single reviewer retrospectively reviewed the cases for patient diagnoses, demographics, related ethical issues and the actions of the MARC. Result: Each of the six patients required life-sustaining therapy, and each patient had a Do Not Resuscitate order on the chart. The MARC determined that it would be appropriate to withdraw life-sustaining support in four of the cases and to continue support in two of the cases. Five of the patients died in the hospital before discharge: two after discontinuation of support, one during the 10-day waiting period, and two died on full support after the Committee determined that continued treatment was medically appropriate. One patient was transferred to another hospital during the 10-day waiting period. Conclusion: These cases document the application of the TADA/MARC process in infants, even in circumstances where care was withdrawn without concurrence of the family. We found the MARC process to demand a very high degree of certainty of diagnosis and prognosis to determine continuation of care to be inappropriate. We conclude that the MARC promoted communication and provided additional protections to patients, families, physicians and staff.