Neonatal palliative care and end-of-life decision-making — viva

Stem

Examiner-led viva on a disputed neonatal end-of-life scenario. [10]

Examiner: The team agrees intensive care can no longer help this baby. On what principle do you frame the recommendation? [10]

Strong answer: I frame it on the best-interests standard, which for a newborn who cannot decide for themselves weighs the benefits of continued life-sustaining treatment against its burdens from the baby's point of view. I weigh the chance of meaningful recovery against the cumulative suffering, loss of dignity and prolonged dying the baby is now bearing, and I bring a second neonatologist and the wider team to consensus before I bring a recommendation to the parents. [10]

Examiner: The parents say stopping the ventilator is worse than never starting it. How do you respond? [11]

Strong answer: I explain that withholding and withdrawing life-sustaining treatment are morally equivalent — the consensus position is that there is no ethical difference between never starting a non-beneficial treatment and stopping one already begun. Treating them differently biases practice toward overtreatment. Stopping is not abandonment; it is an active comfort procedure with symptom relief and the family present, and comfort care is intensified, never withdrawn. [11] [1]

Examiner: They insist on full escalation and a miracle. Is this futility? [10]

Strong answer: I distinguish physiological futility, a factual claim that a treatment cannot achieve its goal, from a value dispute about whether the resulting quality of life is worth living. Here the team and parents may broadly agree the prognosis is dire but disagree about the worth of the outcome — that is a value dispute, not pure physiological futility, so I do not declare futility unilaterally. I resolve it through shared deliberation, a second opinion and ethics input. [10]

Examiner: You cannot reach agreement. What now? [10]

Strong answer: I escalate through an ethics consultation and mediation, and I consider a time-limited trial if any meaningful uncertainty remains. If consensus still cannot be reached, I seek a court declaration rather than overriding the family unilaterally or capitulating to indefinite non-beneficial treatment. Comfort and symptom care continue throughout. [10]

Examiner: What comfort medications would you have ready if ventilation were withdrawn? [4]

Strong answer: I anticipate the predictable symptoms of dying — pain, agitation, dyspnoea, secretions and seizures — and have comfort agents ready, titrated to the baby's comfort. Morphine covers pain, dyspnoea and dysphoria; midazolam treats agitation once pain is addressed; glycopyrrolate dries secretions; and phenobarbital treats seizures. The goal is symptom relief, not life-shortening, and I give medication for symptom relief before and during extubation so the baby does not experience a distressed death. [4]

Examiner: One key pitfall to avoid? [11]

Strong answer: Treating an isolated 'not for resuscitation' entry as a complete neonatal end-of-life plan. A defensible plan documents what will and will not be offered across escalation, ventilation, symptom care and feeding, and links the resuscitation decision to the broader comfort plan rather than leaving it as a single order. [11]