practical attitudes of the staff during two periods: from 1 January 1992 to 31 December 1995 and, one decade later, from 1 January 2002 to 31 December 2005. The charts of the newborns who died in a level III NICU at Sa˜o Joa˜o Hospital were retrospectively reviewed. This NICU provides care to all premature neonates and newborns affected by respira- tory, cardiac, neurological, metabolic, renal, and gastro- intestinal, diseases as well as newborns recovering from surgery. It is a reference center for neonatal cardiology and surgery in northern Portugal. Our goal was to analyze the documented end-of-life care of neonates and their families, with a focus on five areas: 1) therapeutic activities, 2) pain and distress relief, 3) family support, 4) decision-making, and 5) parental presence during death. A simple data collection methodology was developed and piloted by the researchers, and its reliability was tested. The categories registered in the chart review included the following: the infant’s birth weight and gestational age, resuscitation in the delivery room, the cause of death, any prenatal diagnosis, the hospitalization period, any medical interventions in the final 24 hours of life, any decisions to withdraw or withhold medical interventions, any documen- ted orders to limit medical interventions or to initiate palliative care, the use of a neonatal pain scale, opioid and sedative administration, referrals to chaplains or other spiritual advisors, psychosocial support, permission for siblings and other relatives to visit the infant, interdisciplin- ary meetings between parents and neonatologists, advice from an ethics committee or judicial support during decision- making, and parental presence during the death of the infant. Each chart was reviewed by two researchers. To identify the mode of death, the researchers used the classifications of Garros, Rosychuk and Cox13 to gather the data and allocate the neonatal deaths into three groups: cardiopulmonary resuscitation failure (CPR failure), withholding and/or with- drawal of therapy (W/W), and do-not-resuscitate (DNR). A total of 313 deaths occurred from 1 January 1992 to 31 December 1995 and from 1 January 2002 to 31 Decem- ber 2005; of these, 256 (81.8%) charts were examined. Incomplete charts were excluded. The data were analyzed using Statistical Package for Social Sciences (SPSS) (version 14.0). We used descriptive statistics and a Chi square test to identify any differences between the cohorts; p,0.05 was required to achieve statistical significance. RESULTS In both cohorts, approximately 50% of the neonates were born after 37 weeks of gestation and weighed more than 2,500 g at birth. Death occurred within the first six days of life in 59.5% of the 1992-1995 cohort and 62.5% of the 2002- 2005 cohort. Therapeutic activities In the final four years (2002-2005), W/W was found in 51.6% of the charts, CPR failure was found in 44.1% and DNR was found in 4.3% (Table 1). In the final 24 hours of life, in both cohorts, 93.8% of the infants died with ventilatory support, 75.8% died with antibiotics, 48.8% died with inotropic support, 1.2% died with peritoneal dialysis, 25.4% died with parenteral nutrition, and 16.4% died with enteral nutrition (Table 2). DNR orders were documented in CLINICS 2011;66(9):1569-1572 Table 1 - Modes of death in the NICU in the two cohorts. 1992-1995 2002-2005 Modes of death n (%) n (%) Total p-value* Failed CPR 94 (57.7) Withholding and/or withdrawal of therapy 54 (33.1) Do-not-resuscitate 15 (9.2) Total 163 (100) 41 (44.1) 135 (52.7) 0.036 48 (51.6) 102 (39.8) 4 (4.3) 19 (7.4) 93 (100) 256 (100) 0.044 0.147 *Chi-squared test. only one chart, in 1994. In the eight (7.8%) charts in which the mode of death was W/W, the following was written: ‘‘comfort care only’’, ‘‘decided to reduce ventilatory measures’’, and ‘‘decided to withdraw vital support’’. In the 2002-2005 cohort, there were seven orders to limit therapeutic activities. In 92.6% of the charts, the charts from both cohorts, no specific order was found. Pain and distress relief In the 1992-1995 cohort, the charts of 151 (9.6%) infants mentioned the use of a neonatal pain scale; 123 (75.5%) and 71 (43.6%) infants received opioids and sedatives, respec- tively. In the 2002-2005 cohort, the charts of 89 (95.7%) infants mentioned the use of a neonatal pain scale; 71 (76.3%) and 54 (58.1%) infants received opioids and sedatives, respectively (Table 3). Family support In the later cohort, 28 (30.1%) charts mentioned a chaplain visiting the NICU. Permission for siblings and other family members to freely visit the infant was documented in 30 (32.3%) charts. There was no referral to psychosocial family support or support groups (Table 4). The reviewed charts focused on the neonate’s physical condition and therapeutic procedures; the emotional support provided by the care- givers (physicians and especially nurses) to the neonate, parents, and others family members during the grieving process was not recorded. Decision-making There were no data regarding parental participation during decision-making. However, 56 (60.2%) charts in the 2002-2005 cohort mentioned that the parents had meetings with their neonatologists to discuss the clinical situation of their infants. In the first cohort, 62 (38%) parents commu- nicated with their neonatologists (p,0.001). Regarding the involvement of other entities in the decision-making Table 2 - Therapeutic activities in the final 24 hours in the two cohorts. 1570 Therapeutic activities in the final 24 hours Ventilation Antibiotics Inotropics Peritoneal dialysis Parenteral nutrition Enteral nutrition *Chi-squared test. 1992-1995 2002-2005 n (%) n (%) Total p-value* 151 (92.6) 89 (95.7%) 240 (93.8%) 0.331 123 (75.5) 71 (76.3%) 194 (75.8%) 0.563 71 (43.6) 54 (58.1) 125 (48.8) 0.056 1 (0.6) 2 (2.2) 3 (1.2) 0.311 37 (22.7) 28 (30.1) 65 (25.4) 0.256 26 (16) 16 (17.2) 42 (16.4) 0.549