Ethical Considerations of a Neonatal Intensive Care Unit Pharmacist

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The neonatal intensive care unit (NICU) is an environment saturated with unique challenges and ethical dilemmas that affect all of us involved in the care of these patients.1,2 These ethical dilemmas range from delivering a fetus on the threshold of viability to continuing the care of a critically ill infant with a devastatingly poor prognosis, as well as challenge neonatal staff in different ways depending on their role on the care team. For the neonatal pharmacist, ethical dilemmas result for a variety of reasons. Data are frequently lacking in the neonatal population for medications, often leaving the clinician with little assurance of the efficacy and safety of a therapy. In fact, neonatal patients have been described as “therapeutic orphans” due to the lack of pharmacotherapeutic research in this population.3,4 Contributing to this, multiple challenges and obstacles exist surrounding the research of this patient population.3,5,6
The role of a neonatal pharmacist centers on being the pharmacotherapy expert. Responsibilities include determining effective and safe medication dosing regimens, the appropriate preparation, storage, and administration of medications, as well as the necessary monitoring parameters to ensure efficacy and prevent toxicities. In addition, neonatal pharmacists are experts on the appropriate indication and patient selection for pharmacotherapeutic interventions. Staying current with the primary literature is essential to contribute this knowledge during clinical decision-making as a member of the care team. However, with data lacking in the neonatal realm, dilemmas may arise where the right thing to do is not clear and a risk versus benefit analysis may be difficult to perform.
The history of neonatal medicine is plagued by practices that were not supported by efficacy or safety data but became the standard of care.3,7 Examples of these practices include synthetic vitamin K prophylaxis, sulfisoxazole prophylaxis, chloramphenicol prophylaxis, hexachlorophene to decrease Staphylococcus aureus infections, flushing lines with normal saline containing benzyl alcohol, intravenous vitamin E–containing polysorbate for prevention of retrolental fibroplasia (now known as retinopathy of prematurity), and high-dose dexamethasone for bronchopulmonary dysplasia.7 Avoidance of futile care, defined as not improving quality of life, prolonging suffering, or lacking a beneficial outcome, is paramount to providing ethical care to our neonates.4 It is imperative to critically evaluate pharmacotherapies for outcome measures in a controlled manner before introducing them into neonatal practice. Without such data, neonatal pharmacists may find themselves in ethical dilemmas that are difficult to navigate.

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