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J Pain Symptom Manage. 2018 Mar;55(3):979-984.e2. doi: 10.1016/j.jpainsymman.2017.10.023. Epub 2017 Nov 10.

Survey on Neonatal End-of-Life Comfort Care Guidelines Across America.

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Neonatology Loma Linda University Children's Hospital, Loma Linda, California, USA. Electronic address:
Neonatology Loma Linda University Children's Hospital, Loma Linda, California, USA.
Center for Perinatal Biology Loma Linda University, Loma Linda, California, USA.
Clinical Ethics Loma Linda University Children's Hospital, Loma Linda, California, USA.
Bioethics Center Children's Mercy Hospital, Kansas City, Missouri, USA.



Infants of age less than one year have the highest mortality rate in pediatrics. The American Academy of Pediatrics published guidelines for palliative care in 2013; however, significant variation persists among local protocols addressing neonatal comfort care at the end-of-life (EOL).


The purpose of this study was to evaluate current neonatal EOL comfort care practices and clinician satisfaction across America.


After institutional review board approval (516005), an anonymous, electronic survey was sent to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine. Members of the listserv include neonatologists, neonatal fellow physicians, neonatal nurses, and neonatal nurse practitioners from across America (U.S. and Canada).


There were 346/3000 (11.5%) responses with wide geographic distribution and high levels of intensive care responding (46.1% Level IV, 50.9% Level III, 3.0% Level II). Nearly half (45.2%) reported that their primary institution did not have neonatal comfort care guidelines. Of those reporting institutional neonatal comfort care guidelines, 19.1% do not address pain symptom management. Most guidelines also do not address gastrointestinal distress, anxiety, or secretions. Thirty-nine percent of respondents stated that their institution did not address physician compassion fatigue. Overall, 91.8% of respondents felt that their institution would benefit from further education/training in neonatal EOL care.


Across America, respondents confirmed significant variation and verified many institutions do not formally address neonatal EOL comfort care. Institutions with guidelines commonly appear to lack crucial areas of palliative care including patient symptom management and provider compassion fatigue. The overwhelming majority of respondents felt that their institutions would benefit from further neonatal EOL care training.


Palliative care; end-of-life care; neonate; pain; perinatal

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