- Non-Initiation and Discontinuation of Resuscitation
- Family Communication, Comfort Care, and Team Wellbeing
Family Communication, Comfort Care, and Team Wellbeing
Family communication during resuscitation
Families present during or immediately after a neonatal resuscitation need two things: honest information and someone who isn't leaving the room. The team leader or attending neonatologist carries primary responsibility for family communication during and after the event.
Key principles:
- Provide brief, honest updates as the situation evolves: families do not need a detailed clinical commentary, but they should not be left in silence
- Avoid false certainty in either direction: do not offer reassurance that cannot be supported by the clinical picture, and do not communicate hopelessness before the resuscitation has been fully pursued
- Use plain language: clinical terminology during a crisis compounds distress without adding understanding
- Offer presence: where it is clinically safe and the family wishes it, allowing a support person to be present in the room during resuscitation is consistent with family-centred care principles
- After stabilisation, provide a structured debrief to the family that explains what happened, what was done, what the current status is, and what the next steps are
Communication when resuscitation is unsuccessful
When a neonate dies, the conversation with the family cannot wait and cannot be vague. The provider should:
- Sit with the family rather than standing: a posture of presence rather than departure
- Use the words "died" or "death": euphemisms such as "we lost him" or "he didn't make it" are less clear and can cause confusion in a state of acute distress
- Allow silence: resist the impulse to fill pauses with clinical detail
- Offer the family time with their baby: holding, skin-to-skin contact, and naming the infant are important for the grieving process and should be offered without hesitation
- Provide written information about next steps, bereavement support services, and who to contact with questions
Comfort care pathway
Where resuscitation is not initiated or is discontinued, comfort care provides the clinical framework. Comfort care is not the absence of care; it is a specific set of interventions directed at the infant's comfort and the family's experience: warmth, skin-to-skin contact where possible, pain management where signs of distress are present, unrestricted family presence, and facilitation of pastoral, cultural, or religious rites according to the family's wishes.
The comfort care decision and the family's wishes must be clearly documented in the medical record.
Team debriefing and psychological safety
Neonatal resuscitation, particularly an unsuccessful one, carries a significant psychological load for the team involved. A brief hot debrief (meaning an immediate debrief conducted within hours of the event) allows the team to review what happened clinically, identify any departures from expected practice, and acknowledge the emotional weight of the event.
Team leaders carry responsibility for creating the conditions for psychological safety: acknowledging distress, normalising the emotional response, and ensuring access to support resources where needed.
Documentation of ethical decisions
All decisions involving non-initiation, discontinuation, or comfort care must be documented at the time they are made, and documented comprehensively. The record should include: the clinical findings that informed the decision, the individuals present at the discussion, the family's expressed wishes and the information they were given, the time of the decision, and the names of all providers involved. This documentation is both a clinical record and a medicolegal protection for the team.
Medically reviewed by: Kim Murray, RN, MS., Medical Educator
