CLINICS 2011;66(9):1569-1572 process, some of the reviewed charts mentioned interdisci- plinary meetings to discuss better intervention plans or the solicitation of an ethics committee. An appeal to the Minor Court was found in one chart in the 1992-1995 cohort. Parental presence during infant death In 20 (25.1%) of the reviewed charts in the 2002-2005 cohort, one or both parents were with their infant when death occurred, as compared to 3.7% in the first period (p,0.001). Fifty-four (58.1%) parents in the 2002-2005 cohort did not want to be present during the infant’s death. In 19 (20.4%) charts, there were no data regarding parental communication concerning the death of their infant. DISCUSSION In this study, we found that more than half of the newborns died within the first six days of life and that neonatal palliative care was rarely offered in the NICU. However, there appears to be a strong tendency to not hasten the dying process of a child facing imminent death by withholding and withdrawing medical interventions, which causes more harm than benefits to the neonate and family. This tendency is consistent with published European studies, in our opinion.3-9 Additionally, in 92.6% of the charts, no clear written orders to discontinue life support or withhold resuscitation were found, which has also been previously reported.13,14 Nevertheless, even as caregivers have more regularly given life-limiting therapeutic orders in the 2002-2005 cohort, it remains crucial to have explicit records and written institutional policies permitting the forgoing of life-supporting treatment of neonates in terminal situations. In this context, the American Academy of Pediatrics15 has stated that when a life-sustaining medical treatment is to be forgone, the attending physician should write an order in the medical record, and the chart notes must include the following information: the diagnosis, the prognosis, or other decisions, the contents of any meetings with the involved parties, any disagreements or unresolved issues, and the recommendations of the treatment team and any consultants. Despite recent advances in neurobiology indicating that fetuses and newborns are able to experience acute, persistent or chronic pain and express abnormal biochemistry as well as physical and behavioral changes during pain, neonates in the NICU remain vulnerable to many invasive therapeutic procedures without adequate pain relief.16 Although we observed the development of a neonatal pain scale assess- ment tool and a significant increase in the administration of pain and discomfort medication one decade later, 25.8% of the infants under life-limiting conditions did not receive any sedatives or opioids during their dying processes (Table 3). Today, sedation and analgesia are widely used in neonatal procedures and in situations that require comfort or palliative care.26 Additionally, 95.7% of the infants remained connected to a ventilator until death, 76.3% received antibiotics, and 58.1% received inotropics. These procedures involve repetitive secretion aspiration, tracheal intubation or frequent and potentially painful intravenous punctures. These results show that our NICU urgently needs to develop neonatal palliative care, adopt guidelines and maintain regular staff education to improve the end-of-life care of newborns. Wolfe et al.11 and McCallum et al.10 reported the introduction and persistence of submitting children to Table 3 - Pain and distress management. 1992-1995 2002-2005 n (%) n (%) Total p-value* Neonatal pain scale 151 (9.6) Administration of opioids 123 (75.5) Administration of sedatives 71 (43.6) 89 (95.7) 240 (93.8) ,0.001 71 (76.3) 194 (75.8) ,0.001 54 (58.1) 125 (48.8) 0.007 *Chi-squared test. aggressive procedures until death. A new attitude toward the concept of total pain as a life-limiting condition in the NICU is needed. Appropriate environmental, behavioral, and pharmacological approaches to prevent, reduce, or eliminate the pain and discomfort of neonates at the end of life should be provided. Educational programs should be promoted to improve caregivers’ pain and symptom assess- ment and management skills. Institutional policies and NICU guidelines for the management of neonatal pain under life- limiting conditions should also be implemented. Providing compassionate and family-centered end-of-life care to infants and their families in the NICU should be a mandatory component of optimal neonatal palliative care.12 Honest and complete information, adequate com- munication, careful coordination, emotional expression and support by the staff, preservation of the integrity of the parent-child relationship and support of religious faith are important priorities that have been identified by grieving parents.17 When a child dies, the family needs intense and long-term psychosocial support as well as cultural and spiritual comfort. Nevertheless, no charts documented any emotional and social support given to families or referrals to grief counseling groups.14 A neonatal death in the NICU results in a great deal of spiritual distress and can initiate a serious crisis of meaning and connection, which highlights the need for religious and spiritual support to families and caregivers.18 Our data support the findings of Robinson et al.19, who stated that parents draw on and rely on their spirituality to guide them during end-of-life decision- making, to find meaning in their loss, and to sustain them emotionally. One decade later, we observed a major increase in the number of chaplain interventions in response to families’ spiritual needs, which suggests more acceptance and integration of spiritual issues during end-of-life care in the NICU and emphasizes the significance of having access to a clergyperson as an important part of good care. Facilitating sibling visits or asking parents for other relatives to join them in the NICU is an opportunity to evaluate family dynamics, integrate the family into the dying process. In the final four years of the study, we observed a Table 4 - Family support. 1571 Chaplain/spiritual counselor Psychosocial support Visitation by siblings or other family members *Chi-squared test. 1992- 1995 2002-2005 n (%) 16 (9.8) 0 (0.0) n (%) Total p-value* 28 (30.1) 0 (0.0) 44 (17.2) 0.0 (0.0) ,0.001 19 (11.7) 30 (32.3) 49 (19.1) ,0.001