SPECIAL ARTICLE
Infants’ Best Interests in End-of-life
Care for Newborns
AUTHORS: Dick L. Willems, MD, PhD,a A.A. Eduard
Verhagen, MD, PhD, JD,b and Eric van Wijlick, MSC,c on
behalf of the Committee End-of-Life Decisions in Severely
Ill Newborns of the Royal Dutch Medical Association
aSection of Medical Ethics, Department of General Practice,
Academic Medical Centre/University of Amsterdam, Netherlands;
bDepartment of Pediatrics, University Medical Center Groningen,
University of Groningen, Groningen, Netherlands; and cRoyal
Dutch Medical Association, Utrecht, Netherlands
KEY WORDS
neonatal intensive care, clinical bioethics, end-of-life decisions,
palliative care
ABBREVIATIONS
DELN—the decision to deliberately end the life of newborns with
lethal drugs
EoL—end-of-life
KNMG—Royal Dutch Medical Association
NVK—Dutch Pediatric Society
Drs Willems and Verhagen conceptualized and designed the
study, carried out the initial analysis, coordinated and
supervised the data collection, drafted the initial manuscript,
and critically reviewed the manuscript; Mr van Wijlick carried
out the initial analyses, coordinated and supervised the data
collection, drafted the study, and critically reviewed and revised
the manuscript; and all authors approved the final manuscript
as submitted and agree to be accountable for all aspects of the
work.
www.pediatrics.org/cgi/doi/10.1542/peds.2014-0780
doi:10.1542/peds.2014-0780
Accepted for publication Jul 24, 2014
Address correspondence to A.A. Eduard Verhagen, MD, PhD, JD,
Department of Pediatrics, University Medical Center Groningen,
University of Groningen, PO Box 30.001, 9700 RB Groningen, the
Netherlands. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
abstract
BACKGROUND AND OBJECTIVES: Pediatric bioethics presumes that
decisions should be taken in the child’s best interest. If it’s ambiguous
whether a decision is in the child’s interest, we defer to parents. Should
parents be permitted to consider their own interests in making decisions
for their child? In the Netherlands, where neonatal euthanasia is legal,
such questions sometimes arise in deciding whether to hasten the death
of a critically ill, suffering child. We describe the recommendations of a
national Dutch committee. Our objectives were to analyze the role of competing child and family interests and to provide guidance on end-of-life
decisions for doctors caring for severely ill newborns.
METHODS: We undertook literature review, 7 consensus meetings in
a multidisciplinary expert commission, and invited comments on draft
report by specialists’ associations.
RESULTS: Initial treatment is mandatory for most ill newborns, to clarify
the prognosis. Continuation of treatment is conditional on further diagnostic and prognostic data. Muscle relaxants can sometimes be continued after withdrawal of artificial respiration without aiming to shorten
the child’s life. When gasping causes suffering, or protracted dying is
unbearable for the parents, muscle relaxants may be used to end a
newborn’s life. Whenever muscle relaxants are used, cases should be
reported to the national review committee.
CONCLUSIONS: New national recommendations in the Netherlands for
end-of-life decisions in newborns suggest that treatment should generally
be seen as conditional. If treatment fails, it should be abandoned. In those
cases, palliative care should be directed at both infant and parental
suffering. Sometimes, this may permit interventions that hasten
death. Pediatrics 2014;134:e1163–e1168
Copyright © 2014 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conflicts of interest to disclose.
PEDIATRICS Volume 134, Number 4, October 2014
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e1163
The care of severely ill newborns can be
extremely burdensome for both parents
and caregivers. When prospects are
hopeless, end-of-life (EoL) decisions have
to be taken with the utmost care. In this
article, EoL decisions are medical decisions with the effect, or the probable effect, that death is hastened. They include
the decision to withhold or withdraw lifesustaining treatment, the decision to
administer medication with a potentially
life-shortening effect to alleviate pain
and suffering, and the decision to deliberately end the life of newborns with
lethal drugs (DELN). The Dutch terminology for the latter decision differs
from that in North America and many
other countries: in the Netherlands, the
term “euthanasia” is used for situations
in which the patient can voluntarily request death. Because newborns and
children cannot make this voluntary
request, we use DELN for what others
would call neonatal euthanasia.
Building on previous reports, a commission of the Royal Dutch Medical
Association (KNMG) has issued new
recommendations for EoL decisions in
newborns, with the aim of reaching
a consensus that may be considered
normative within the Dutch medicolegal
context.1 We defined newborns as children up to age 1 year. In practice, however,
the report concerns mostly newborn infants up to age 28 days. This article
describes the recommendations developed
by the Commission and pays attention to
some of the contentious elements. The
authors were members of the Commission that wrote the recommendations.
In 1992, the Dutch Pediatric Society
(NVK) proposed a distinction between
newborns who have no chance of survival, and thosewho maysurvive, butwith
a very poor quality of life.2 Quality of life
was defined as a life of severe suffering,
dependent on medical technology, with
extremely restricted possibilities for communication and self-subsistence. In both
situations, the NVK considered withdrawing
e1164
life support to be justified. Five years
later, the Ministry of Health convened
a multidisciplinary commission to discuss the reporting of cases of DELN.
Among others, this commission introduced the idea that continuation of
treatment is conditional upon improvement (“life on approval”).3 This would
justify, or even demand, withdrawing
life support when the prognosis is
shown to be grim. In 2005, the NVK
adopted the so-called Groningen Protocol concerning the ending of life in
severely handicapped newborns, who
survive in severe suffering without any
prospect for improvement.4,5 If these
infants do not die after the withdrawal
of life support, the active ending of life
may be justified under the same conditions as stated in the Dutch euthanasia
law, obviously apart from the impossible
consent of the patient. Soon after, in
2006, the government decided to establish a commission of experts to assess
cases of DELN.
This commission, however, in 6 years
received just 1 report of DELN, whereas
previous studies had led to the expectation of ∼20 cases per year.6 This
discrepancy can be partly explained
by the implementation of a 20-week
ultrasound, which would lead to abortion in severe congenital anomalies,
but also it was suggested that pediatricians may have felt that the criteria
of the assessment committee were too
vague to give them the confidence to
report cases of DELN.
This undesirable situation was an important reason the KNMG asked a commission to provide guidance on EoL
decisions for doctors caring for severely
ill newborns.
On the basis of a thorough study of the
existing literature, the Commission,
consisting of experts in pediatrics,
nursing, ethics, and law, held 8 sessions,
drafting a report. This draft was then
commented on by associations of obstetricians, pediatricians, pediatric neurologists,
WILLEMS et al
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and pediatric surgeons, by 3 associations of parents, and by the Inspectorate
of Health. Both the NVK and the KNMG
decreed a final version (after a further
round of comments) in May 2013.
We will summarize the main findings
and advice of the report, following the
sequence of events as they usually occur in time after the birth of a child
whose prognosis is deemed very poor.
In addition, we will define the areas of
agreement and difference with standards for EoL care in North America.
EOL DECISION-MAKING
Decisions about withdrawing or withholding life-supporting treatments are
usually made by a team of professionals
and the parents of the severely ill
newborn. Within the professional team,
views may differ on the chances of
survival and, more often, on the quality
of life if the child survives.7,8 The decision
that further treatment is becoming futile
is therefore not a 1-step decision: it takes
time and repeated team discussions to
realize that this is the case. In almost all
situations, professional teams will be
able to reach a consensus despite possible differences. However, if a consensus
is unattainable, that should not prevent
a decision from being made; the treating
physician remains primarily responsible,
even within a team.
Whether a child has a chance of survival
is essentially a medical judgment. The
views of parents regarding (dis)continuation of treatment should be taken
into account, but cannot be decisive.
Obviously, parents should be allowed
the time to adapt, as far as that is ever
possible, to a judgment that further
treatment will not be beneficial, but
continuing a futile treatment will be
harmful for the child whose well-being
is the physicians’ primary responsibility.
It is important to realize how difficult it
may be for parents to grasp what they
are told about the hopeless situation of
their child from a medical point of view.
SPECIAL ARTICLE
Their need for time can justify postponing the decision to withdraw or
withhold treatment, but only if this does
not increase or prolong the suffering of
the child.
It is crucial to inform parents carefully
about the possible events after withdrawing or withholding life-supporting
treatment and about the palliative care
that is available to assure as much
comfort as possible for their child.9–11
This often means that the child may be
touched by the parents, and that tubes
and lines will be removed as much as
possible.
If parents and professionals have different opinions about the best way to
care for the child who eventually will
die, clear and repeated exchanges of
mutual views (not only information)
usually leads to a consensus, however
painful. According to the KNMG commission, it is crucial that professionals
are aware of the parents’ views on
death and dying, as these may have
a profound impact on their views and
emotions.
Usually one second opinion or more will
have been obtained before it is accepted
that a consensus cannot be reached. If
so, parents cannot force professionals
to perform treatments that are clearly
medically futile. Conversely, parents
sometimes withhold permission for
treatments that physicians consider
mandatory, such as morphine for pain,
or sedation for intractable suffering.
Physicians may then need to disregard
the parents’ refusal and start treatment
they view as beneficial and necessary.
WITHHOLDING OR WITHDRAWING
LIFE-SUPPORTING TREATMENT AND
PROVISION OF TERMINAL CARE
In severely ill newborns, treatment is
always started in a situation of extreme
uncertainty. The first treatment decision to be taken is whether to start life
support immediately after birth. Even
when the chance of survival appears
poor from the outset, physicians have
no choice but to start life support, to
prevent deterioration and obtain more
certainty about the diagnosis and the
chance of survival of the newborn
(benefit of the doubt). Continuation of
life support, in those cases, is conditional on subsequent developments in
diagnosis and prognosis.
If it becomes clear, therefore, that the
child will not survive, or that survival
will only be possible with a severely
damaged quality of life, then not only the
withdrawal, but also the continuation
of life-supporting treatment demands
justification. The chance of survival, but
also the prospects of independence,
communication, the burden of a mostly
lifelong treatment, and the relations
between these factors must be taken
into account. If the continuation of life
support is no longer in the child’s best
interest, it has no further justification.
Then life support should be withdrawn.
Two types of life-supporting treatment
demand specific attention in this context: artificial nutrition and hydration,
and respiration support.
The administration of artificial nutrition
and hydration must be regarded as
a medical form of life support. As a
consequence, a judgment that further treatment has become futile also
applies to nutrition and hydration and
implies their discontinuation.
This is not without emotional difficulties
for those involved. Sometimes the argument is made that giving artificial
nutrition and hydration contributes to
the comfort of the child, because it
prevents feelings of hunger and thirst
(this would render the withdrawal inhumane). This, however, is uncertain;
continuation, on the other hand, may have
complications and may be the cause of
a protracted dying process. Withdrawal
of artificial nutrition and hydration, according to this KNMG commission, will not
be inhumane if state-of-the-art palliative
care is provided.
PEDIATRICS Volume 134, Number 4, October 2014
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Some severely ill newborns do not need
to be fed and hydrated artificially, but
may be breast- or bottle-fed. This is
normal basic care that needs to be
stopped only if it causes discomfort
through choking or dyspnea.
After the withdrawal of treatment, including withdrawal of artificial nutrition
and hydration, the child will certainly die.
Clinical experience indicates that the
duration of the dying process may be
several hours and sometimes as long as
several days; however, literature on the
subject is very scarce.12–14 There is also
not sufficient knowledge about possible suffering as a consequence of
withdrawing nutrition and hydration.
Because it cannot be excluded, physicians need to discuss comfort care,
including sedation, with parents.
The parents must be thoroughly prepared for the withdrawal of respiratory
support because they may interpret any
change in their child as a sign of suffering. It may be necessary to increase
the dosages of analgesics and sedatives
to prevent postwithdrawal suffering.15–17
Parents need to be prepared and know
that the color of their child may change
and that breathing may become very
irregular and may appear to be difficult
(gasping). It is unclear whether gasping
causes suffering in the newborn, but it
cannot be excluded. Sometimes infants
show signs of suffering, such as clutching
their fists or grimacing, making appropriate palliative measures necessary.
Cases have been reported, however, in
which optimal palliative care did not
provide sufficient relief.15,16,18–20
Two questions may then come up about
muscle relaxants: can or should they
be continued after withdrawal of respiratory support, and, secondly, can or
should they be started in children who
did not receive them?
The KNMG commission distinguishes 3
possible scenarios: firstly, continuation
after withdrawal of respiratory support. This may sometimes be justifiable
e1165
in a scenario that was best described
by Truog et al in 2000.21 This involves
patients who are receiving neuromuscular blocking agents as part of the
medical treatment when the decision
to withdraw life support is made, but
neuromuscular function cannot be
restored for several hours, days, or
even weeks. In these circumstances,
insistence on the restoration of neuromuscular function by withdrawing
blocking agents before the withdrawal
of ventilation will delay the termination of life support well beyond the
point at which the patient and family
have determined that the burdens of
such treatments outweigh the probable benefits.
The second scenario would be to administer relaxants de novo, in addition
to high doses of analgesics and sedatives, with the aim of stopping prolonged gasping and potential suffering
in newborns who are weaned from the
respirator. According to the Commission, this could be acceptable, but it
would mean DELN and should, in the
Netherlands, be reported to the commission of experts.
Thirdly, relaxants are sometimes given
to end a protracted dying process,
which only adds to the suffering of the
parents who have been through a lot of
pain already. Even though careful preparation of the parents is often sufficient for them to support this, in
extreme cases the Commission considers this reason acceptable for DELN.
Again, this should be reported.
TREATMENT OF SYMPTOMS AT THE
EOL
Often, severely ill newborns need medication for pain and other symptoms.
Even though a proportionate use of
opioids and other drugs will almost
never shorten the life of the patient,
physicians should always take into
account this possibility and prepare
the parents for it. It is completely
e1166
understandable that sometimes physicians and parents may even hope that
this will happen. However, in the view of
the KNMG commission, this should never
lead to disproportionate dosages as
a means of ending the suffering of the
patient.
die; sometimes this may take a very long
time. For the moment, we feel that these
situations are too difficult to solve, and
that they may become very rare if the
recommendations issued by our Commission are acted on.
Palliative sedation, the intentional and
proportional lowering of consciousness in a patient who has otherwise
intractable symptoms, may be an appropriate way to relieve the suffering
of a dying newborn. It is a solution of
the last resort. The drug of choice is
midazolam, sometimes combined with
propofol or esketamin. Dosages for
very young children are unknown, but
should be increased until the symptoms
subside.
DISCUSSION
The last and most contentious decision
at the EoL in newborns is deliberately
ending it.4 In the Netherlands, each
case of DELN has to be reported for
review to a national commission of
experts that, in view of the general
prosecuting office’s decision to prosecute or not, assesses retrospectively
whether the case followed a set of
conditions deduced from the euthanasia
law. DELN, in our commission’s view, is
acceptable in cases of severe suffering
that cannot be relieved by excellent
palliative care including sedation or,
as mentioned above, in exceptional cases
of a protracted dying process that
becomes unbearable for the parents.
Examples could be asphyxiated newborns
who remain restless under sedation or
newborns who have epidermiolysis
bullosa.
There is a small but particularly difficult
group of newborns who have serious
illnesses who remain stable after life
support has been withdrawn or withheld to let the child die. These children
do not appear to be suffering and are
not dying. DELN would not be justifiable
under Dutch regulations. These children have to wait for a complication
such as a pneumonia to be allowed to
WILLEMS et al
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This report about EoL decision-making
in newborns is largely compatible with
currently accepted practices in North
America and many other countries in
the industrialized world. American
ethics and law recognize the rights of all
patients or surrogates to refuse any
medical treatment, even if life sustaining, if the patient or surrogate
believes that the burdens of treatment
exceed the benefits. This is true for the
2 treatments that were highlighted in
our summary (mechanical ventilation
and medical nutrition/hydration), but is
also true for a variety of other lifesustaining interventions, such as dialysis, transplantation, pacemakers,
and others.11,22,23 In addition, US law
and ethics also support the practice of
palliative sedation for patients of all
ages, meaning that patients whose pain
and suffering cannot be controlled
with standard palliative care treatments may be sedated to the point of
unconsciousness.24,25 The ethical justification for that approach, commonly
used by doctors in the United States, is
the doctrine of double effect, which
permits actions that may hasten death,
so long as the intention of the caregiver
is to relieve the patient’s pain and suffering, not to cause death. This principle
also defines the general legal stance in
North America.
Guidelines in the United States permit
withdrawal of life support in paralyzed
patients, similar to the Dutch report,
in the situation in which a patient
receives muscle relaxation for therapeutic reasons and waiting for this
medication to wear off may take hours
or days.25
SPECIAL ARTICLE
Thefirstareainwhichtheguidelinesfrom
the report differ from North American
practice is the authority of parents and
surrogates in the Netherlands. The views
of parents should be taken into account,
but cannot be decisive. Withdrawing or
withholding life-supporting treatment
is considered a medical decision, fully
with regard to survival and at least
partly with regard to quality of life.
Criteria to value the expected quality of
life have been formulated by multidisciplinary working groups to help
physicians and parents decide.2,3,26
Physicians’ stewardship of the scarce
resources of NICU beds and technology
does not play a role. In contrast, in
North America, physicians’ roles in
determining what constitutes an acceptable quality of life is very limited
and physicians do not have the authority to make these decisions unilaterally.
Court interventions are sometimes
sought in these matters and parents
are given wide latitude in deciding
what quality of life is acceptable for
their child.27
The second way that the Dutch developments differ from the North American
EoL practices is that they permit the
use of interventions even when the
intention is clearly to cause the death
of the patient, not just to relieve pain
and suffering. The Dutch endorse the
use of muscle relaxants de novo with
the aim of stopping prolonged gasping
during ventilator withdrawal and to
treat parental suffering by putting an
end to a prolonged dying process. This
situation may occur occasionally, when
even state-of-the-art palliative sedation is insufficient to relieve pain and
suffering. Such situations may justify,
if the parents request it, active ending
of the life of the dying newborn by
administering muscle relaxants in
addition to the analgesics and sedatives that are already being administered. All cases must be reported
for review, to maintain full transparency and accountability. The North
American view is that muscle relaxants should never be administered
de novo to a terminally ill patient,
The significance of this document is
twofold. First, the document has considerable legal standing because NVK
and the KNMG have endorsed it, which
means that this document expresses
the opinion of the medical profession. In
the absence of formal legislation, judicial decisions will be primarily based
on the medical profession’s opinion.
Second, the retrospective legal assessment imposes the risk that doctors are being accused of murder or
manslaughter if they provide DELN,
which may drive them to under-report.
This may be a less serious impediment
to the reporting if the conditions that
justify DELN are described in great detail and publicly acknowledged by the
medical profession.
6. Verhagen AA. The Groningen Protocol for
newborn euthanasia; which way did the
slippery slope tilt? J Med Ethics. 2013;39(5):
293–295
7. de Vos MA, van der Heide A, Maurice-Stam
H, et al. The process of end-of-life decisionmaking in pediatrics: a national survey in
the Netherlands. Pediatrics. 2011;127(4).
Available at: www.pediatrics.org/cgi/content/
full/127/4/e1004
8. Verhagen AA, de Vos M, Dorscheidt JH,
Engels B, Hubben JH, Sauer PJ. Conflicts
about end-of-life decisions in NICUs in the
Netherlands. Pediatrics. 2009;124(1). Available at: www.pediatrics.org/cgi/content/full/
124/1/e112
9. Batton DG, Barrington KJ, Wallman C;
American Academy of Pediatrics Committee
on Fetus and Newborn; American Academy
of Pediatrics Section on Surgery; Canadian
Paediatric Society Fetus and Newborn
Committee. Prevention and management of
pain in the neonate: an update. Pediatrics.
2006;118(5):2231–2241
10. De Lisle-Porter M, Podruchny AM. The dying
neonate: family-centered end-of-life care.
Neonatal Netw. 2009;28(2):75–83
11. Bell EF; American Academy of Pediatrics Committee on Fetus and Newborn. Noninitiation
or withdrawal of intensive care for high-risk
newborns. Pediatrics. 2007;119(2):401–403
12. Hellmann J, Williams C, Ives-Baine L, Shah
PS. Withdrawal of artificial nutrition and
hydration in the neonatal intensive care
unit: parental perspectives. Arch Dis Child
Fetal Neonatal Ed. 2013;98(1):F21–F25
13. Miraie ED. Withholding nutrition from seriously
ill newborn infants: a parent’s perspective.
J Pediatr. 1988;113(2):262–265
14. Diekema DS, Botkin JR; Committee on
Bioethics. Clinical report—Forgoing medically provided nutrition and hydration in
children. Pediatrics. 2009;124(2):813–822
15. Burns JP, Mitchell C, Outwater KM, et al.
End-of-life care in the pediatric intensive care unit after the forgoing of lifesustaining treatment. Crit Care Med.
2000;28(8):3060–3066
because they do not have any sedative
or analgesic properties and it is impossible for the clinician to be intending
to relieve pain and suffering if that is
not a pharmacological property of the
drug.25
CONCLUSIONS
REFERENCES
1. Royal Dutch Medical Association (KNMG).
Medische beslissingen rond het levenseinde
bij pasgeborenen met zeer ernstige
afwijkingen [Medical End-of-Life Decisions In
Newborns With Severe Handicaps]. Utrecht,
Netherlands: KNMG; 2013
2. Nederlandse Vereniging voor Kindergeneeskunde.
Doen of laten. Grenzen van het medisch
handelen in de neonatologie [To Treat or Not
to Treat? Limits for Life-Sustaining Treatment
in Neonatology]. Utrecht, Netherlands: Den
Daas; 1992
3. Overleggroep toetsing zorgvuldig medisch
handelen rond het levenseinde bij pasgeborenen.
Toetsing als spiegel van de medische praktijk
[Assessment as mirror of medical practice]. Rijswijk, Netherlands: Ministerie van
Volksgezondheid Welzijn en Sport; 1997
4. Verhagen E, Sauer PJ. The Groningen
protocol—euthanasia in severely ill newborns.
N Engl J Med. 2005;352(10):959–962
5. Sheldon T. Dutch doctors adopt guidelines
on mercy killing of newborns. BMJ. 2005;
331(7509):126
PEDIATRICS Volume 134, Number 4, October 2014
Downloaded from by guest on June 17, 2017
e1167
16. Munson D. Withdrawal of mechanical ventilation in pediatric and neonatal intensive
care units. Pediatr Clin North Am. 2007;54
(5):773–785, xii [xii.]
17. Abe N, Catlin A, Mihara D. End of life in the
NICU. A study of ventilator withdrawal.
MCN Am J Matern Child Nurs. 2001;26(3):
141–146
18. Moratti S. Ethical and legal acceptability of
the use of neuromuscular blockers (NMBs)
in connection with abstention decisions in
Dutch NICUs: interviews with neonatologists.
J Med Ethics. 2011;37(1):29–33
19. Perkin RM, Resnik DB. The agony of agonal
respiration: is the last gasp necessary?
J Med Ethics. 2002;28(3):164–169
20. Kon AA. Palliative sedation: it’s not a panacea.
Am J Bioeth. 2011;11(6):41–42
e1168
21. Truog RD, Burns JP, Mitchell C, Johnson J,
Robinson W. Pharmacologic paralysis and
withdrawal of mechanical ventilation at the
end of life. N Engl J Med. 2000;342(7):508–511
22. Tripp J, McGregor D. Withholding and
withdrawing of life sustaining treatment in
the newborn. Arch Dis Child Fetal Neonatal
Ed. 2006;91(1):F67–F71
23. Staatssecretaris van Volksgezondheid Welzijn
en Sport en de minister van Justitie. Brief
van July 29, 2005 aan de Tweede Kamer.
Kamerstukken. Vergaderjaar 2005–2006.
30300XVI. Nr 90. Den Haag: Ministerie van
Volksgezondheid, Welzijn en Sport en de
minister van Justitie
24. Quill TE, Byock IR. Responding to Intractable
Terminal Suffering. Ann Intern Med. 2000;
133(7):561–562
WILLEMS et al
Downloaded from by guest on June 17, 2017
25. Truog RD, Campbell ML, Curtis JR, et al;
American Academy of Critical Care Medicine. Recommendations for end-of-life care
in the intensive care unit: a consensus
statement by the American College [corrected] of Critical Care Medicine. Crit Care
Med. 2008;36(3):953–963
26. KNMG Commissie Aanvaardbaarheid
Levensbeeindigend handelen. Medisch
handelen rond het levenseinde bij
wilsonbekwame patiënten. Houten: Bohn
Stafleu Van Loghem; 1997
27. American Academy of Pediatrics Committee on Bioethics. American Academy
of Pediatrics Committee on Bioethics:
Guidelines on foregoing life-sustaining
medical treatment. Pediatrics. 1994;93(3):
532–536
Infants' Best Interests in End-of-life Care for Newborns
Dick L. Willems, A.A. Eduard Verhagen and Eric van Wijlick
Pediatrics; originally published online September 22, 2014;
DOI: 10.1542/peds.2014-0780
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on June 17, 2017
Infants' Best Interests in End-of-life Care for Newborns
Dick L. Willems, A.A. Eduard Verhagen and Eric van Wijlick
Pediatrics; originally published online September 22, 2014;
DOI: 10.1542/peds.2014-0780
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/early/2014/09/17/peds.2014-0780
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on June 17, 2017