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White Makinde K, Silverstein A, Peckham-Gregory E, Kim E, Casas J. Exploring Pediatric Code Status, Advance Care Planning, and Mode of Death Disparities at End of Life. J Pain Symptom Manage 2024; 68:410-420. [PMID: 39032676 DOI: 10.1016/j.jpainsymman.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 07/08/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024]
Abstract
CONTEXT Children from marginalized groups are at risk for worse medical outcomes, yet little is known about their end of life experiences. OBJECTIVE We examine the characteristics of deceased children with a focus on race, ethnicity, and preferred language. METHODS We conducted a cross-sectional study of patients who died at Texas Children's Hospital from 2018 to 2019. Demographics, date of death, and final code status were extracted. Medical complexity prior to admission and mode of death were obtained from chart review. RESULTS We included 433 patients. Over one-third were Hispanic (39.3%) with 42.3% preferring Spanish. The majority were White (61.4%) or Black (21.0%). Most patients had significant medical complexity (52.0%) or were infants in their birth admission (29.4%). Half (52.4%) received palliative care; patients with increased medical complexity were more likely to have palliative care involved (P<0.001). There were no differences in palliative care, code status, or mode of death by race. Hispanic patients were less likely to have a full code status (OR 0.42, 95% CI: 0.25-0.73). Spanish-speaking patients were more likely to have palliative care involvement (OR 2.05, 95% CI: 1.21-3.46) and less likely full code orders (OR 0.24, 95% CI: 0.1-0.63). CONCLUSION Palliative care services are engaged with most children at end of life and is accessible to marginalized patient groups. Spanish-speaking patients have different code status orders and modes of death at end of life. Further studies are needed to elucidate explanatory factors for differences revealed and multicenter studies are needed to characterize more widespread experiences.
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Affiliation(s)
- Keisha White Makinde
- Department of Pediatrics (K.W.M.), Division of Newborn Medicine,Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.
| | - Allison Silverstein
- Department of Pediatrics (A.S.), Section of Palliative Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erin Peckham-Gregory
- Department of Pediatrics (E.P.G.), Center for Epidemiology and Population Health, Baylor College of Medicine, Houston, Texas, USA
| | - Erin Kim
- McGovern Medical School at UTHealth Houston (E.K.), Houston, Texas, USA
| | - Jessica Casas
- Department of Pediatrics (J.S.), Division of Palliative Care, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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Liesse KM, Malladi L, Dinh TC, Wesp BM, Kam BN, Turturice BA, Pyke-Grimm KA, Char DS, Hollander SA. Trajectories in Intensity of Medical Interventions at the End of Life: Clustering Analysis in a Pediatric, Single-Center Retrospective Cohort, 2013-2021. Pediatr Crit Care Med 2024; 25:899-911. [PMID: 39023327 DOI: 10.1097/pcc.0000000000003579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
OBJECTIVE Pediatric deaths often occur within hospitals and involve balancing aggressive treatment with minimization of suffering. This study first investigated associations between clinical/demographic features and the level of intensity of various therapies these patients undergo at the end of life (EOL). Second, the work used these data to develop a new, broader spectrum for classifying pediatric EOL trajectories. DESIGN Retrospective, single-center study, 2013-2021. SETTING Four hundred sixty-one bed tertiary, stand-alone children's hospital with 112 ICU beds. PATIENTS Patients of age 0-26 years old at the time of death. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1111 included patients, 85.7% died in-hospital. Patients who died outside the hospital were older. Among the 952 in-hospital deaths, most occurred in ICUs (89.5%). Clustering analysis was used to distinguish EOL trajectories based on the presence of intensive therapies and/or an active resuscitation attempt at the EOL. We identified five simplified categories: 1) death during active resuscitation, 2) controlled withdrawal of life-sustaining technology, 3) natural progression to death despite maximal therapy, 4) discontinuation of nonsustaining therapies, and 5) withholding/noninitiation of future therapies. Patients with recent surgical procedures, a history of organ transplantation, or admission to the Cardiovascular ICU had more intense therapies at EOL than those who received palliative care consultations, had known genetic conditions, or were of older age. CONCLUSIONS In this retrospective study of pediatric EOL trajectories based on the intensity of technology and/or resuscitation discontinued at the EOL, we have identified associations between these trajectories and patient characteristics. Further research is needed to investigate the impact of these trajectories on families, patients, and healthcare providers.
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Affiliation(s)
- Kelly M Liesse
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Lakshmee Malladi
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Tu C Dinh
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Brendan M Wesp
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Brittni N Kam
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | | | - Kimberly A Pyke-Grimm
- Division of Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Danton S Char
- Division of Pediatric Anesthesia, Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Seth A Hollander
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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Curkovic M, Rubic F, Jozepovic A, Novak M, Filipovic-Grcic B, Mestrovic J, Lah Tomulic K, Peter B, Spoljar D, Grosek Š, Janković S, Vukovic J, Kujundžić Tiljak M, Štajduhar A, Borovecki A. Navigating the shadows: medical professionals' values and perspectives on end-of-life care within pediatric intensive care units in Croatia. Front Pediatr 2024; 12:1394071. [PMID: 39188642 PMCID: PMC11345198 DOI: 10.3389/fped.2024.1394071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 07/15/2024] [Indexed: 08/28/2024] Open
Abstract
Background and aim This study explores healthcare professionals' perspectives on end-of-life care in pediatric intensive care units (ICUs) in Croatia, aiming to illuminate their experiences with such practices, underlying attitudes, and major decision-making considerations. Amid the high variability, complexity, and emotional intensity of pediatric end-of-life decisions and practices, understanding these perspectives is crucial for improving care and policies. Methods The study utilized a cross-sectional survey intended for physicians and nurses across all pediatric ICUs in Croatia. It included healthcare professionals from six neonatal and four pediatric ICUs in total. As the data from neonatal and pediatric ICUs were examined jointly, the term pediatric ICU was used to denominate both types of ICUs. A statistical analysis was performed using Python and JASP, focusing on professional roles, professional experience, and regional differences. Results The study included a total of 103 participants (with an overall response rate-in relation to the whole target population-of 48% for physicians and 29% for nurses). The survey revealed diverse attitudes toward and experiences with various aspects of end-of-life care, with a significant portion of healthcare professionals indicating infrequent involvement in life-sustaining treatment (LST) limitation discussions and decisions, as well as somewhat ambiguous attitudes regarding such practices. Notably, discrepancies emerged between different professional roles and, in particular, regions, underscoring the high variability of LST limitation-related procedures. Conclusions The findings highlight a pressing need for more straightforward guidelines, legal frameworks, support mechanisms, and communication strategies to navigate the complex terrain of rather burdensome end-of-life pediatric care, which is intrinsically loaded with profound ethical quandaries.
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Affiliation(s)
- Marko Curkovic
- University Psychiatric Hospital Vrapče, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Filip Rubic
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ana Jozepovic
- Department of Anesthesiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Milivoj Novak
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Boris Filipovic-Grcic
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Julije Mestrovic
- Department of Pediatrics, University Hospital Centre Split, Split, Croatia
| | | | - Branimir Peter
- Department of Gynecology and Obstetrics, University Hospital Centre Rijeka, Rijeka, Croatia
| | - Diana Spoljar
- Palliative Care Service, Community Health Center Zagreb, Zagreb, Croatia
| | - Štefan Grosek
- Department of Perinatology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Sunčana Janković
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jurica Vukovic
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Department of Pediatrics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mirjana Kujundžić Tiljak
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Andrija Štajduhar
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ana Borovecki
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
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Adistie F, Neilson S, Shaw KL, Bay B, Efstathiou N. The elements of end-of-life care provision in paediatric intensive care units: a systematic integrative review. BMC Palliat Care 2024; 23:184. [PMID: 39054465 PMCID: PMC11271050 DOI: 10.1186/s12904-024-01512-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 07/11/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Deaths in paediatric intensive care units (PICUs) are not uncommon. End-of-life care in PICUs is generally considered more challenging than other settings since it is framed within a context where care is focused on curative or life-sustaining treatments for children who are seriously ill. This review aimed to identify and synthesise literature related to the essential elements in the provision of end-of-life care in the PICU from the perspectives of both healthcare professionals (HCPs) and families. METHODS A systematic integrative review was conducted by searching EMBASE, CINAHL, MEDLINE, Nursing and Allied Health Database, PsycINFO, Scopus, Web of Science, and Google Scholar databases. Grey literature was searched via Electronic Theses Online Service (EthOS), OpenGrey, Grey literature report. Additionally, hand searches were performed by checking the reference lists of all included papers. Inclusion and exclusion criteria were used to screen retrieved papers by two reviewers independently. The findings were analysed using a constant comparative method. RESULTS Twenty-one studies met the inclusion criteria. Three elements in end-of-life care provision for children in the PICUs were identified: 1) Assessment of entering the end-of-life stage; 2) Discussion with parents and decision making; 3) End of life care processes, including care provided during the dying phase, care provided at the time of death, and care provided after death. CONCLUSION The focus of end-of-life care in PICUs varies depending on HCPs' and families' preferences, at different stages such as during the dying phase, at the time of death, and after the child died. Tailoring end-of-life care to families' beliefs and rituals was acknowledged as important by PICU HCPs. This review also emphasises the importance of HCPs collaborating to provide the optimum end-of-life care in the PICU and involving a palliative care team in end-of-life care.
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Affiliation(s)
- Fanny Adistie
- School of Nursing and Midwifery, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
- Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia.
| | - Susan Neilson
- School of Nursing and Midwifery, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Karen L Shaw
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Betul Bay
- School of Nursing and Midwifery, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Nikolaos Efstathiou
- School of Nursing and Midwifery, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
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5
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Crain N, Miller J. Palliative Care in the Pediatric Intensive Care Unit. AACN Adv Crit Care 2024; 35:134-145. [PMID: 38848559 DOI: 10.4037/aacnacc2024104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
The purposes of this review are to describe differences between palliative care for adult patients and palliative care for pediatric patients, both generally and in the intensive care unit; to highlight ethical considerations for pediatric intensive care unit patients by using illustrative cases; and to examine the impact of these ethical considerations on decision-making for children and their families.
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Affiliation(s)
- Noreen Crain
- Noreen Crain is Associate Professor of Pediatrics and Anesthesia, Division of Pediatric Critical Care, and Medical Director of Pediatric Palliative Care, University of Virginia Children's Hospital, 1215 Lee St, Charlottesville, VA 22908-0386
| | - Joy Miller
- Joy Miller is Pediatric Nurse Practitioner, Pediatric Palliative Care, University of Virginia Children's Hospital, Charlottesville, Virginia
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Pringle CP, Filipp SL, Morrison WE, Fainberg NA, Aczon MD, Avesar M, Burkiewicz KF, Chandnani HK, Hsu SC, Laksana E, Ledbetter DR, McCrory MC, Morrow KR, Noguchi AE, O'Brien CE, Ojha A, Ross PA, Shah S, Shah JK, Siegel LB, Tripathi S, Wetzel RC, Zhou AX, Winter MC. Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study. Crit Care Med 2024; 52:396-406. [PMID: 37889228 PMCID: PMC10922051 DOI: 10.1097/ccm.0000000000006101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
OBJECTIVE Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not. DESIGN Secondary analysis of multicenter retrospective cohort study. SETTING Ten PICUs in the United States between 2009 and 2021. PATIENTS Nine hundred thirteen patients 0-21 years old who died after WLST. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS 71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality). CONCLUSIONS Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.
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Affiliation(s)
- Charlene P Pringle
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
| | - Stephanie L Filipp
- Department of Pediatrics, Pediatric Research Hub, University of Florida Gainesville, FL
| | - Wynne E Morrison
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
- Department of Pediatrics, Pediatric Research Hub, University of Florida Gainesville, FL
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
- Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia Philadelphia, PA
- Division of Pediatric Critical Care, Children's Hospital of Philadelphia Philadelphia, PA
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
- Division of Critical Care Medicine, Department of Pediatrics, Dallas, TX
- The University of Texas Southwestern Medical Center at Dallas, Children's Health Medical Center Dallas Dallas, TX
- KPMG Lighthouse, Dallas, TX
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Program Coordinator for Organ, Eye, and Tissue Donation Johns Hopkins Hospital, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
- Michigan State University College of Human Medicine, East Lansing, MI
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
- Division of Pediatric Critical Care, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Nina A Fainberg
- Division of Pediatric Critical Care, Children's Hospital of Philadelphia Philadelphia, PA
| | - Melissa D Aczon
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Michael Avesar
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Kimberly F Burkiewicz
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
| | - Harsha K Chandnani
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Stephanie C Hsu
- Division of Critical Care Medicine, Department of Pediatrics, Dallas, TX
- The University of Texas Southwestern Medical Center at Dallas, Children's Health Medical Center Dallas Dallas, TX
| | - Eugene Laksana
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | | | - Michael C McCrory
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC
| | - Katie R Morrow
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anna E Noguchi
- Program Coordinator for Organ, Eye, and Tissue Donation Johns Hopkins Hospital, Baltimore, MD
| | - Caitlin E O'Brien
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Apoorva Ojha
- Michigan State University College of Human Medicine, East Lansing, MI
| | - Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Sareen Shah
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Division of Pediatric Critical Care, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jui K Shah
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Linda B Siegel
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Sandeep Tripathi
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
| | - Randall C Wetzel
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Alice X Zhou
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Meredith C Winter
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Francoeur C, Silva A, Hornby L, Wollny K, Lee LA, Pomeroy A, Cayouette F, Scales N, Weiss MJ, Dhanani S. Pediatric Death After Withdrawal of Life-Sustaining Therapies: A Scoping Review. Pediatr Crit Care Med 2024; 25:e12-e19. [PMID: 37678383 PMCID: PMC10756696 DOI: 10.1097/pcc.0000000000003358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Evaluate literature on the dying process in children after withdrawal of life sustaining measures (WLSM) in the PICU. We focused on the physiology of dying, prediction of time to death, impact of time to death, and uncertainty of the dying process on families, healthcare workers, and organ donation. DATA SOURCES MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, and Web of Science. STUDY SELECTION We included studies that discussed the dying process after WLSM in the PICU, with no date or study type restrictions. We excluded studies focused exclusively on adult or neonatal populations, children outside the PICU, or on organ donation or adult/pediatric studies where pediatric data could not be isolated. DATA EXTRACTION Inductive qualitative content analysis was performed. DATA SYNTHESIS Six thousand two hundred twenty-five studies were screened and 24 included. Results were grouped into four categories: dying process, perspectives of healthcare professionals and family, WLSM and organ donation, and recommendations for future research. Few tools exist to predict time to death after WLSM in children. Most deaths after WLSM occur within 1 hour and during this process, healthcare providers must offer support to families regarding logistics, medications, and expectations. Providers describe the unpredictability of the dying process as emotionally challenging and stressful for family members and staff; however, no reports of families discussing the impact of time to death prediction were found. The unpredictability of death after WLSM makes families less likely to pursue donation. Future research priorities include developing death prediction tools of tools, provider and parental decision-making, and interventions to improve end-of-life care. CONCLUSIONS The dying process in children is poorly understood and understudied. This knowledge gap leaves families in a vulnerable position and the clinical team without the necessary tools to support patients, families, or themselves. Improving time to death prediction after WLSM may improve care provision and enable identification of potential organ donors.
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Affiliation(s)
- Conall Francoeur
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Amina Silva
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Laura Hornby
- Consultant, Canadian Blood Services, Hamilton, ON, Canada
| | - Krista Wollny
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Laurie A Lee
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Consultant, Canadian Blood Services, Hamilton, ON, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada
- School of Nursing, Queen's University, Kingston, ON, Canada
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
- Dynamical Analysis Lab, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Transplant Québec, Montréal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | | | - Florence Cayouette
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
| | - Nathan Scales
- Dynamical Analysis Lab, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Matthew J Weiss
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
- Transplant Québec, Montréal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Sonny Dhanani
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
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8
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Porter AS, Gouda SR, Broden EG, Snaman JM. "Palliative Intensive Care" at the End of a Child's Life. Hosp Pediatr 2023; 13:e395-e398. [PMID: 37920949 DOI: 10.1542/hpeds.2023-007348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Affiliation(s)
- Amy S Porter
- Boston Children's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer M Snaman
- Boston Children's Hospital, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
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9
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Broden EG, Mazzola E, DeCourcey DD, Blume ED, Wolfe J, Snaman JM. The roles of preparation, location, and palliative care involvement in parent-perceived child suffering at the end of life. J Pediatr Nurs 2023; 72:e166-e173. [PMID: 37355461 DOI: 10.1016/j.pedn.2023.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE Parents' perceptions of their child's suffering affect their bereavement experience. Identifying factors that shape parental perceptions of suffering could help build effective supportive interventions for children and parents navigating EOL and grief. We aimed to compare parent-perceived child suffering between diagnostic groups and identify related factors. DESIGN AND METHODS We combined databases from 3 surveys of parents whose children who died following cancer, a complex chronic condition (CCC), or advanced heart disease. We built multivariable logistic regression models to identify relationships between parent-perceived child suffering and parent/child, illness experience, and care-related factors. RESULTS Among 277 parents, 41% rated their child's suffering as moderate or high. Fifty-seven percent of parents whose child died from cancer reported that their child suffered "a lot" or "a great deal" at EOL, compared to 33% whose child died from a CCC, and 17% whose child died from heart disease (P < 0.001). Preparation for EOL symptoms was associated with decreased parent-perceived child suffering in multivariable modeling, with parents who were prepared for EOL 68% less likely to rate their child's suffering as high compared to those who felt unprepared (AOR: 0.32, CI [0.13-0.77], P = 0.013). CONCLUSIONS Preparing families for their child's EOL may help mitigate lingering perceptions of suffering. Operationalizing preparation is crucial to optimizing family support during EOL care. IMPLICATIONS TO PRACTICE Preparation for symptoms, and access to resources, including medical/psychosocial interventions and staff, may help ease parental perception of EOL suffering. Clinicians should prioritize preparing families for what to expect during a child's dying process.
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Affiliation(s)
- Elizabeth G Broden
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Emanuele Mazzola
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Division of Medical Critical Care, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jennifer M Snaman
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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10
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Holton C, Lee BR, Escobar H, Benton T, Bauer P. Admission Pao2 and Mortality Among PICU Patients and Select Diagnostic Subgroups. Pediatr Crit Care Med 2023:00130478-990000000-00177. [PMID: 37092837 DOI: 10.1097/pcc.0000000000003247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Evaluate the relationship between admission Pao2 and mortality in a large multicenter dataset and among diagnostic subgroups. DESIGN Retrospective cohort study. SETTING North American PICUs participating in Virtual Pediatric Systems, LLC (VPS), 2015-2019. PATIENTS Noncardiac patients 18 years or younger admitted to a VPS PICU with admission Pao2. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirteen thousand seventy-one patient encounters were included with an overall mortality of 13.52%. Age categories were equally distributed among survivors and nonsurvivors with the exception of small differences among neonates and adolescents. Importantly, there was a tightly fitting quadratic relationship between admission Pao2 and mortality, with the highest mortality rates seen among hypoxemic and hyperoxemic patients (likelihood-ratio test p < 0.001). This relationship persisted after adjustment for illness severity using modified Pediatric Index of Mortality 3 scores. A similar U-shaped relationship was demonstrated among patients with diagnoses of trauma, head trauma, sepsis, renal failure, hemorrhagic shock, and drowning. However, among the 1,500 patients admitted following cardiac arrest, there was no clear relationship between admission Pao2 and mortality. CONCLUSIONS In a large multicenter pediatric cohort, admission Pao2 demonstrates a tightly fitting quadratic relationship with mortality. The persistence of this relationship among some but not all diagnostic subgroups suggests the pathophysiology of certain disease states may modify the hyperoxemia association.
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Affiliation(s)
- Caroline Holton
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Brian R Lee
- Division of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO
| | - Hugo Escobar
- Division of Pulmonology, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Tara Benton
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Paul Bauer
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
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11
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Karakaya Z, Boyraz M, Atis SK, Yuce S, Duyu M. Descriptive and Clinical Characteristics of Nonsurvivors in a Tertiary Pediatric Intensive Care Unit in Turkey: 6 Years of Experience. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0043-1764330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
AbstractThe objective of this study was to identify the characteristics of nonsurvivors in a pediatric intensive care unit (PICU) in Turkey. This is a retrospective analysis of patients who died in a tertiary PICU over a 6-year period from 2016 to 2021. Data were drawn from electronic medical records and resuscitation notes. Mode of death was categorized as failed cardiopulmonary resuscitation (F-CPR) or brain death. Among the 161 deaths, 136 nonsurvivors were included and 30.1% were younger than 1 year. Severe pneumonia, respiratory failure, and acute respiratory distress syndrome (ARDS) (31.6%) were the most common primary diagnoses. The most common mode of death was F-CPR (86.8%). More than half of the subjects had been admitted from pediatric emergency departments (58.1%), and more than half (53.7%) had died within 7 days in the PICU. Patients admitted from pediatric emergency departments had the lowest frequency of comorbidities (p < 0.001). Severe pneumonia, respiratory failure, and ARDS diagnoses were significantly more frequent in those who died after 7 days (p < 0.001), whereas septicemia, shock, and multiple organ dysfunction were more common among those who died within the first day of PICU admission (p < 0.001). It may be important to note that patients referred from wards are highly likely to have comorbidities, while those referred from pediatric emergency departments may be relatively younger. Additionally, patients with septicemia, shock, or multiple organ dysfunction were more likely to die earlier (within 7 days), especially compared with those with severe pneumonia, respiratory failure, or ARDS.
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Affiliation(s)
- Zeynep Karakaya
- Department of Pediatrics, Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Merve Boyraz
- Department of Pediatrics, Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Seyma Koksal Atis
- Department of Pediatrics, Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Servet Yuce
- Department of Public Health, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Muhterem Duyu
- Pediatric Intensive Care Unit, Goztepe Prof. Dr. Suleyman Yalcin City Hospital, Istanbul Medeniyet University, Istanbul, Turkey
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12
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Nickerson TE, Lovett ME, O'Brien NF. Organ Dysfunction Among Children Meeting Brain Death Criteria: Implications for Organ Donation. Pediatr Crit Care Med 2023; 24:e156-e161. [PMID: 36472423 DOI: 10.1097/pcc.0000000000003124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Over 70% of pediatric organ donors are declared deceased by brain death (BD) criteria. Patients with these devastating neurologic injuries often have accompanying multiple organ dysfunction. This study was performed to characterize organ dysfunction in children who met BD criteria and were able to donate their organs compared with those deemed medically ineligible. DESIGN Retrospective cohort study. SETTING PICU at a quaternary care children's hospital. PATIENTS Patients with International Classification of Diseases , 9th Edition codes corresponding to BD between 2012 and 2018 were included. MEASUREMENTS AND MAIN RESULTS Demographics, comorbidities, Pediatric Risk of Mortality (PRISM)-III, and injury mechanisms were derived from the medical record. Organ dysfunction was quantified by evaluating peak daily organ-specific variables. Fifty-eight patients, from newborn to 22 years old, were included with a median PRISM-III of 34 (interquartile range [IQR], 26-36), and all met criteria for multiple organ dysfunction syndrome (MODS). Thirty-four of 58 BD children (59%) donated at least one organ. Of the donors (not mutually exclusive proportions), 10 of 34 donated lungs, with a peak oxygenation index of 11 (IQR, 8-23); 24 of 34 donated their heart (with peak Vasoactive Inotrope Score 23 [IQR, 18-33]); 31 of 34 donated kidneys, of whom 16 of 31 (52%) had evidence of acute kidney injury; and 28 of 34 patients donated their liver, with peak alanine transferase (ALT) of 104 U/L (IQR, 44-268 U/L) and aspartate aminotransferase (AST) of 165 U/L (IQR, 94-434 U/L). Organ dysfunction was similar between heart and lung donors and respective medically ineligible nondonors. Those deemed medically ineligible to donate their liver had higher peak ALT 1,518 U/L (IQR, 986-1,748 U/L) ( p = 0.01) and AST 2,200 U/L (IQR, 1,453-2,405 U/L) ( p = 0.01) compared with liver donors. CONCLUSIONS In our single-center experience, all children with BD had MODS, yet more than one-half were still able to donate organs. Future research should further evaluate transplant outcomes of dysfunctional organs prior to standardizing donation eligibility criteria.
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Affiliation(s)
- Taylor E Nickerson
- Division of Critical Care Medicine, Department of Pediatrics, Cohen Children's Medical Center at Northwell, Zucker School of Medicine at Hofstra, New Hyde Park, NY
| | - Marlina E Lovett
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Nicole F O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
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13
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Miñambres E, Estébanez B, Ballesteros MÁ, Coll E, Flores-Cabeza EM, Mosteiro F, Lara R, Domínguez-Gil B. Normothermic Regional Perfusion in Pediatric Controlled Donation After Circulatory Death Can Lead to Optimal Organ Utilization and Posttransplant Outcomes. Transplantation 2023; 107:703-708. [PMID: 36226852 DOI: 10.1097/tp.0000000000004326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The benefits of normothermic regional perfusion (NRP) in posttransplant outcomes after controlled donation after the determination of death by circulatory criteria (cDCD) has been shown in different international adult experiences. However, there is no information on the use of NRP in pediatric cDCD donors. METHODS This is a multicenter, retrospective, observational cohort study describing the pediatric (<18 y) cDCD procedures performed in Spain, using either abdominal NRP or thoracoabdominal NRP and the outcomes of recipients of the obtained organs. RESULTS Thirteen pediatric cDCD donors (age range, 2-17 y) subject to abdominal NRP or thoracoabdominal NRP were included. A total of 46 grafts (24 kidneys, 11 livers, 8 lungs, 2 hearts, and 1 pancreas) were finally transplanted (3.5 grafts per donor). The mean functional warm ischemic time was 15 min (SD 6 min)' and the median duration of NRP was 87 min (interquartile range, 69-101 min). One-year noncensored for death kidney graft survival was 91.3%. The incidence of delayed graft function was 13%. One-year' noncensored-for-death liver graft survival was 90.9%. All lung and pancreas recipients had an excellent evolution. One heart recipient died due to a septic shock. CONCLUSIONS This is the largest experience of pediatric cDCD using NRP as graft preservation method. Although our study has several limitations, such as its retrospective nature and the small sample size, its reveals that NRP may increase the utilization of cDCD pediatric organs and offer optimal recipients' outcomes.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- School of Medicine, Universidad de Cantabria, Santander, Spain
| | - Belen Estébanez
- Transplant Coordination Unit & Service of Intensive Care, University Hospital La Paz, Madrid, Spain
| | - Maria Ángeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Fernando Mosteiro
- Transplant Coordination Unit & Service of Intensive Care, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Ramón Lara
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Virgen De Las Nieves, Granada, Spain
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14
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Serrano-Pejenaute I, Carmona-Nunez A, Zorrilla-Sarriegui A, Martin-Irazabal G, Lopez-Bayon J, Sanchez-Echaniz J, Astigarraga I. How do hospitalised children die? The context of death and end-of-life decision-making. J Paediatr Child Health 2023; 59:625-630. [PMID: 36752181 DOI: 10.1111/jpc.16354] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/11/2023] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
AIM The decrease in childhood mortality, the growing clinical complexity and the greater technification of intensive care units have changed the circumstances of death of paediatric patients. The aim of this study is to describe the context of death and end-of-life decision-making. METHODS Single-centre, retrospective, observational study of deaths in inpatients or home hospitalised children under 18 years old between 2011 and 2021. Demographic data, pathological history and circumstances of death were obtained from the medical record. The whole study period was divided into two halves for the analysis of the temporal trends. RESULTS A total of 358 patients died, 63.2% under the age of 1 year old; 86.9% had underlying life-limiting illnesses and 73.2% died in the intensive care unit, with no differences between the two time periods. Death at home was significantly higher in the second study period (3.8% vs. 9%). A total of 20.1% died during advanced cardiopulmonary resuscitation. Life-sustaining treatment was withheld or withdrawn in 53.6%, with no differences between the time courses. Life-sustaining treatment was withheld mainly in patients with neurological, metabolic and oncological conditions, and less frequently in patients with cardiovascular or respiratory diseases or who were previously healthy. Most patients coded as palliative care (PC) or followed up by PC teams had an advance care plan (ACP) recorded, while in the others it was infrequent. PC coding, following by PC teams and ACP recording increased in the last years of the study. CONCLUSIONS Death of children in our setting usually occurs in relation to complex underlying pathology and after the decision of withdrawing or withholding life-sustaining treatment. In this context, PC and ACP acquire greater importance. In our study, PC involvement resulted in better documentation of ACP and PC coding.
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Affiliation(s)
- Idoya Serrano-Pejenaute
- Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain.,Doctoral Programme in Medicine and Surgery, University of the Basque Country, Leioa, Bizkaia, Spain
| | | | | | | | - Julio Lopez-Bayon
- Pediatric Palliative Care and Home Hospitalisation, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Jesus Sanchez-Echaniz
- Pediatric Palliative Care and Home Hospitalisation, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Itziar Astigarraga
- Department of Pediatrics, Faculty of Medicine, University of the Basque Country, Leioa, Bizkaia, Spain.,Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain.,Pediatric Hematology and Oncology, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
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15
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Francoeur C, Hornby L, Silva A, Scales NB, Weiss M, Dhanani S. Paediatric death after withdrawal of life-sustaining therapies: a scoping review protocol. BMJ Open 2022; 12:e064918. [PMID: 36123110 PMCID: PMC9486282 DOI: 10.1136/bmjopen-2022-064918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The physiology of dying after withdrawal of life-sustaining measures (WLSM) is not well described in children. This lack of knowledge makes predicting the duration of the dying process difficult. For families, not knowing this process's duration interferes with planning of rituals related to dying, travel for distant relatives and emotional strain during the wait for death. Time-to-death also impacts end-of-life care and determines whether a child will be eligible for donation after circulatory determination of death. This scoping review will summarise the current literature about what is known about the dying process in children after WLSM in paediatric intensive care units (PICUs). METHODS AND ANALYSIS This review will use Joanna Briggs Institute methodology for scoping reviews. Databases searched will include Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials via EBM Reviews Ovid, Ovid PsycINFO, CINAHL and Web of Science. Literature reporting on the physiology of dying process after WLSM, or tools that predict time of death in children after WLSM among children aged 0-18 years in PICUs worldwide will be considered. Literature describing the impact of prediction or timing of death after WLSM on families, healthcare workers and the organ donation process will also be included. Quantitative and qualitative studies will be evaluated. Two independent reviewers will screen references by title and abstract, and then by full text, and complete data extraction and analysis. ETHICS AND DISSEMINATION The review uses published data and does not require ethics review. Review results will be published in a peer-reviewed scientific journal.
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Affiliation(s)
- Conall Francoeur
- Department of Pediatrics, Centre de recherche du CHU de Quebec-Universite Laval, Quebec, Quebec, Canada
| | - Laura Hornby
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Amina Silva
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | | | - Matthew Weiss
- Department of Pediatrics, Centre de recherche du CHU de Quebec-Universite Laval, Quebec, Quebec, Canada
- Transplant Québec, Quebec, Québec, Canada
- Canadian Donation and Transplantation Research Program, Ottawa, Ontario, Canada
| | - Sonny Dhanani
- Canadian Donation and Transplantation Research Program, Ottawa, Ontario, Canada
- Critical Care, CHEO, Ottawa, Ontario, Canada
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16
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Predicting Time to Death After Withdrawal of Life-Sustaining Treatment in Children. Crit Care Explor 2022; 4:e0764. [PMID: 36101830 PMCID: PMC9462532 DOI: 10.1097/cce.0000000000000764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Accurately predicting time to death after withdrawal of life-sustaining treatment is valuable for family counseling and for identifying candidates for organ donation after cardiac death. This topic has been well studied in adults, but literature is scant in pediatrics. The purpose of this report is to assess the performance and clinical utility of the available tools for predicting time to death after treatment withdrawal in children.
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17
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Broden EG, Werner-Lin A, Curley MAQ, Hinds PS. Shifting and intersecting needs: Parents' experiences during and following the withdrawal of life sustaining treatments in the paediatric intensive care unit. Intensive Crit Care Nurs 2022; 70:103216. [PMID: 35219558 PMCID: PMC9128001 DOI: 10.1016/j.iccn.2022.103216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To examine parents' perceptions of nursing care needs; including specific concerns, preferences and supportive actions for themselves and their dying child during and following the withdrawal of life support in the paediatric intensive care unit. RESEARCH DESIGN Qualitative description with content analysis. SETTING Interviews with eight parents of eight children who died in the paediatric intensive care unit 7-11 years prior. MAIN OUTCOME MEASURES Descriptive categories of parents' perceptions of end-of-life needs. FINDINGS Parents identified four shifting and intersecting categories of needs: To be together, To make sense of the child's evolving clinical care, To manage institutional, situational, and structural factors, and To navigate an array of emotions in a sterile context. Being closely connected with the child was highly important, but often intersected with other domains, requiring nurses' support. Parents' memories demonstrated persistent uncertainty about their child's end-of-life care that influenced their long-term grief. CONCLUSIONS Intersections between parent-identified care needs suggest potential mechanisms to strengthen nurses' care for dying children. Equipped with the knowledge that the parent-child bond often shapes parents' priorities; nurses should aim to facilitate connections amidst paediatric intensive care unit processes. Ongoing uncertainty in parents' adaptation to loss suggests that attention to instances when needs intersect can have a lasting impact on parents' grief.
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Affiliation(s)
- Elizabeth G Broden
- Psychosocial Oncology & Palliative Care, Dana-Farber Cancer Institute, 375 Longwood Ave, Boston, MA 02215, United States; University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States.
| | - Allison Werner-Lin
- University of Pennsylvania School of Social Policy and Practice, 3701 Locust Walk, Philadelphia, PA 19104, United States; National Cancer Institute, National Institutes of Health, 31 Center Drive, Bethesda, MD 20814, United States
| | - Martha A Q Curley
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States; Anesthesia and Critical Care Medicine University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Pamela S Hinds
- Children's National Hospital, 111 Michigan Ave NW, Washington, DC 20010, United States; George Washington University, 2121 I St NW, Washington, DC 20052, United States
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18
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Linebarger JS, Johnson V, Boss RD, Linebarger JS, Collura CA, Humphrey LM, Miller EG, Williams CSP, Rholl E, Ajayi T, Lord B, McCarty CL. Guidance for Pediatric End-of-Life Care. Pediatrics 2022; 149:186860. [PMID: 35490287 DOI: 10.1542/peds.2022-057011] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The final hours, days, and weeks in the life of a child or adolescent with serious illness are stressful for families, pediatricians, and other pediatric caregivers. This clinical report reviews essential elements of pediatric care for these patients and their families, establishing end-of-life care goals, anticipatory counseling about the dying process (expected signs or symptoms, code status, desired location of death), and engagement with palliative and hospice resources. This report also outlines postmortem tasks for the pediatric team, including staff debriefing and bereavement.
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Affiliation(s)
- Jennifer S Linebarger
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri, Kansas City, School of Medicine, Kansas City, Missouri
| | - Victoria Johnson
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Renee D Boss
- Department of Pediatrics, Johns Hopkins University School of Medicine, Berman Institute of Bioethics, Baltimore, Maryland
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19
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Broden EG, Hinds PS, Werner-Lin A, Quinn R, Asaro LA, Curley MAQ. Nursing Care at End of Life in Pediatric Intensive Care Unit Patients Requiring Mechanical Ventilation. Am J Crit Care 2022; 31:230-239. [PMID: 35466341 PMCID: PMC11289849 DOI: 10.4037/ajcc2022294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Parents' perceptions of critical care during the final days of their child's life shape their grief for decades. Little is known about nursing care needs of children actively dying in the pediatric intensive care unit (PICU). OBJECTIVES To examine associations between patient characteristics, circumstances of death, and nursing care requirements for children who died in the PICU. METHODS A secondary analysis of the data set from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial was conducted. RESULTS This analysis included 104 children; 67 died after withdrawal of life-sustaining treatments; 21, after failed resuscitation; and 16, after brain death. Patients had a median age of 7.5 years, were cognitively appropriate, and were intubated for acute respiratory failure. Daily pain and sedation scores indicated patients' comfort was well managed (mean pain scores: modal, 0; peak, 2; mean sedation scores: modal, -2; peak, -1). Patients with longer PICU stays more often experienced pain and agitation on the day of death. Illness trajectory (acute, complex chronic condition, or cancer) was associated with pain scores (P = .04). Specifically, children with cancer had higher pain scores than children with acute illness trajectories (P = .01). Many patients (62%) had no change in critical care devices in their last days of life (median, 5 devices). Patterns of pain, sedation, comfort medications, and nursing care requirements did not differ by circumstances of death. CONCLUSION Children with cancer and longer PICU stays may need comprehensive comfort management. Invasive devices left in place during withdrawal of life support may have inhibited parents' ability to connect with their child. Future research should incorporate parents' perspectives.
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Affiliation(s)
- Elizabeth G Broden
- Elizabeth G. Broden is a postdoctoral research fellow in psychosocial oncology and palliative care at Dana-Farber Cancer Institute, Boston, Massachusetts, and a pediatric ICU/CICU nurse at Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Pamela S Hinds
- Pamela S. Hinds is the William and Joanne Conway Chair in Nursing Research and executive director of Nursing Science, Professional Practice, and Quality Outcomes, Children's National Hospital, Washington, DC, and a pediatrics professor, George Washington University, Washington, DC
| | - Allison Werner-Lin
- Allison Werner-Lin is an associate professor, University of Pennsylvania School of Social Policy and Practice, Philadelphia, Pennsylvania, and a senior advisor, National Cancer Institute, Bethesda, Maryland
| | - Ryan Quinn
- Ryan Quinn is a biostatistician, Biostatistics Evaluation Collaboration Consultation and Analysis Lab, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Lisa A Asaro
- Lisa A. Asaro is a biostatistician, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Martha A Q Curley
- Martha A. Q. Curley is the Ruth M. Colket Endowed Chair in Pediatric Nursing, Research Institute, Children's Hospital of Philadelphia, Pennsylvania; a professor, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; and a professor, Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Trujillo Rivera EA, Chamberlain JM, Patel AK, Morizono H, Heneghan JA, Pollack MM. Dynamic Mortality Risk Predictions for Children in ICUs: Development and Validation of Machine Learning Models. Pediatr Crit Care Med 2022; 23:344-352. [PMID: 35190501 PMCID: PMC9117400 DOI: 10.1097/pcc.0000000000002910] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Assess a machine learning method of serially updated mortality risk. DESIGN Retrospective analysis of a national database (Health Facts; Cerner Corporation, Kansas City, MO). SETTING Hospitals caring for children in ICUs. PATIENTS A total of 27,354 admissions cared for in ICUs from 2009 to 2018. INTERVENTIONS None. MAIN OUTCOME Hospital mortality risk estimates determined at 6-hour time periods during care in the ICU. Models were truncated at 180 hours due to decreased sample size secondary to discharges and deaths. MEASUREMENTS AND MAIN RESULTS The Criticality Index, based on physiology, therapy, and care intensity, was computed for each admission for each time period and calibrated to hospital mortality risk (Criticality Index-Mortality [CI-M]) at each of 29 time periods (initial assessment: 6 hr; last assessment: 180 hr). Performance metrics and clinical validity were determined from the held-out test sample (n = 3,453, 13%). Discrimination assessed with the area under the receiver operating characteristic curve was 0.852 (95% CI, 0.843-0.861) overall and greater than or equal to 0.80 for all individual time periods. Calibration assessed by the Hosmer-Lemeshow goodness-of-fit test showed good fit overall (p = 0.196) and was statistically not significant for 28 of the 29 time periods. Calibration plots for all models revealed the intercept ranged from--0.002 to 0.009, the slope ranged from 0.867 to 1.415, and the R2 ranged from 0.862 to 0.989. Clinical validity assessed using population trajectories and changes in the risk status of admissions (clinical volatility) revealed clinical trajectories consistent with clinical expectations and greater clinical volatility in deaths than survivors (p < 0.001). CONCLUSIONS Machine learning models incorporating physiology, therapy, and care intensity can track changes in hospital mortality risk during intensive care. The CI-M's framework and modeling method are potentially applicable to monitoring clinical improvement and deterioration in real time.
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Affiliation(s)
| | - James M Chamberlain
- Department of Pediatrics, Division of Emergency Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Anita K Patel
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Hiroki Morizono
- Children's National Research Institute, Associate Research Professor of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Julia A Heneghan
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Murray M Pollack
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
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21
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End-of-Life Decision-Making in Pediatric and Neonatal Intensive Care Units in Croatia—A Focus Group Study among Nurses and Physicians. Medicina (B Aires) 2022; 58:medicina58020250. [PMID: 35208575 PMCID: PMC8879945 DOI: 10.3390/medicina58020250] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives: Working in pediatric and neonatal intensive care units (ICUs) can be challenging and differs from work in adult ICUs. This study investigated for the first time the perceptions, experiences and challenges that healthcare professionals face when dealing with end-of-life decisions in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) in Croatia. Materials and Methods: This qualitative study with focus groups was conducted among physicians and nurses working in NICUs and PICUs in five healthcare institutions (three pediatric intensive care units (PICUs) and five neonatal intensive care units (NICUs)) at the tertiary level of healthcare in the Republic of Croatia, in Zagreb, Rijeka and Split. A total of 20 physicians and 21 nurses participated in eight focus groups. The questions concerned everyday practices in end-of-life decision-making and their connection with interpersonal relationships between physicians, nurses, patients and their families. The constant comparative analysis method was used in the analysis of the data. Results: The analysis revealed two main themes that were the same among the professional groups as well as in both NICU and PICU units. The theme “critical illness” consisted of the following subthemes: the child, the family, myself and other professionals. The theme “end-of-life procedures” consisted of the following subthemes: breaking point, decision-making, end-of-life procedures, “spill-over” and the four walls of the ICU. The perceptions and experiences of end-of-life issues among nurses and physicians working in NICUs and PICUs share multiple common characteristics. The high variability in end-of-life procedures applied and various difficulties experienced during shared decision-making processes were observed. Conclusions: There is a need for further research in order to develop clinical and professional guidelines that will inform end-of-life decision-making, including the specific perspectives of everyone involved, and the need to influence policymakers.
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22
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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23
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Buang SNH, Loh SW, Mok YH, Lee JH, Chan YH. Palliative and Critical Care: Their Convergence in the Pediatric Intensive Care Unit. Front Pediatr 2022; 10:907268. [PMID: 35757116 PMCID: PMC9226486 DOI: 10.3389/fped.2022.907268] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
Palliative care (PC) is an integral component of optimal critical care (CC) practice for pediatric patients facing life-threatening illness. PC acts as an additional resource for patients and families as they navigate through critical illness. Although PC encompasses end of life care, it is most effective when integrated early alongside disease-directed and curative therapies. PC primarily focuses on improving quality of life for patients and families by anticipating, preventing and treating suffering throughout the continuum of illness. This includes addressing symptom distress and facilitating communication. Effective communication is vital to elicit value-based goals of care, and to guide parents through patient-focused and potentially difficult decision-making process which includes advanced care planning. A multidisciplinary approach is most favorable when providing support to both patient and family, whether it is from the psychosocial, practical, emotional, spiritual or cultural aspects. PC also ensures coordination and continuity of care across different care settings. Support for family carries on after death with grief and bereavement support. This narrative review aims to appraise the current evidence of integration of PC into pediatric CC and its impact on patient- and family-centered outcomes. We will also summarize the impact of integration of good PC into pediatric CC, including effective communication with families, advanced care planning, withholding or withdrawal of life sustaining measures and bereavement support. Finally, we will provide a framework on how best to integrate PC in PICU. These findings will provide insights on how PC can improve the quality of care of a critically ill child.
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Affiliation(s)
- Siti Nur Hanim Buang
- Pediatric Palliative Care Service, Department of Pediatric Subspecialities, KK Women's and Children's Hospital, Singapore, Singapore
| | - Sin Wee Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Hui Mok
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, Singapore, Singapore
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24
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Patel AK, Trujillo-Rivera E, Morizono H, Pollack MM. The criticality Index-mortality: A dynamic machine learning prediction algorithm for mortality prediction in children cared for in an ICU. Front Pediatr 2022; 10:1023539. [PMID: 36533242 PMCID: PMC9752098 DOI: 10.3389/fped.2022.1023539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/26/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The Criticality Index-Mortality uses physiology, therapy, and intensity of care to compute mortality risk for pediatric ICU patients. If the frequency of mortality risk computations were increased to every 3 h with model performance that could improve the assessment of severity of illness, it could be utilized to monitor patients for significant mortality risk change. OBJECTIVES To assess the performance of a dynamic method of updating mortality risk every 3 h using the Criticality Index-Mortality methodology and identify variables that are significant contributors to mortality risk predictions. POPULATION There were 8,399 pediatric ICU admissions with 312 (3.7%) deaths from January 1, 2018 to February 29, 2020. We randomly selected 75% of patients for training, 13% for validation, and 12% for testing. MODEL A neural network was trained to predict hospital survival or death during or following an ICU admission. Variables included age, gender, laboratory tests, vital signs, medications categories, and mechanical ventilation variables. The neural network was calibrated to mortality risk using nonparametric logistic regression. RESULTS Discrimination assessed across all time periods found an AUROC of 0.851 (0.841-0.862) and an AUPRC was 0.443 (0.417-0.467). When assessed for performance every 3 h, the AUROCs had a minimum value of 0.778 (0.689-0.867) and a maximum value of 0.885 (0.841,0.862); the AUPRCs had a minimum value 0.148 (0.058-0.328) and a maximum value of 0.499 (0.229-0.769). The calibration plot had an intercept of 0.011, a slope of 0.956, and the R2 was 0.814. Comparison of observed vs. expected proportion of deaths revealed that 95.8% of the 543 risk intervals were not statistically significantly different. Construct validity assessed by death and survivor risk trajectories analyzed by mortality risk quartiles and 7 high and low risk diseases confirmed a priori clinical expectations about the trajectories of death and survivors. CONCLUSIONS The Criticality Index-Mortality computing mortality risk every 3 h for pediatric ICU patients has model performance that could enhance the clinical assessment of severity of illness. The overall Criticality Index-Mortality framework was effectively applied to develop an institutionally specific, and clinically relevant model for dynamic risk assessment of pediatric ICU patients.
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Affiliation(s)
- Anita K Patel
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Eduardo Trujillo-Rivera
- Department of Bio-Informatics, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Hiroki Morizono
- Department of Pediatrics, Children's National Research Institute, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Murray M Pollack
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
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25
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Nicoll J, Dryden-Palmer K, Frndova H, Gottesman R, Gray M, Hunt EA, Hutchison JS, Joffe AR, Lacroix J, Middaugh K, Nadkarni V, Szadkowski L, Tomlinson GA, Wensley D, Parshuram CS, Farrell C. Death and Dying in Hospitalized Pediatric Patients: A Prospective Multicenter, Multinational Study. J Palliat Med 2021; 25:227-233. [PMID: 34847737 DOI: 10.1089/jpm.2021.0205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: For hospitalized children admitted outside of a critical care unit, the location, mode of death, "do-not-resuscitate" order (DNR) use, and involvement of palliative care teams have not been described across high-income countries. Objective: To describe location of death, patient and terminal care plan characteristics of pediatric inpatient deaths inside and outside the pediatric intensive care unit (PICU). Design: Secondary analysis of inpatient deaths in the Evaluating Processes of Care and Outcomes of Children in Hospital (EPOCH) randomized controlled trial. Setting/Subjects: Twenty-one centers from Canada, Belgium, the United Kingdom, Ireland, Italy, the Netherlands, and New Zealand. Measurement: Descriptive statistics were used to compare patient and terminal care plan characteristics. A multivariable generalized estimating equation examined if palliative care consult during hospital admission was associated with location of death. Results: A total of 365 of 144,539 patients enrolled in EPOCH died; 219 (60%) died in PICU and 143 (40%) died on another inpatient unit. Compared with other inpatient wards, patients who died in PICU were less likely to be expected to die, have a DNR or palliative care consult. Hospital palliative care consultation was more common in older children and independently associated with a lower adjusted odds (95% confidence interval) of dying in PICU [0.59 (0.52-0.68)]. Conclusion: Most pediatric inpatient deaths occur in PICU where patients were less likely to have a DNR or palliative care consult. Palliative care consultation could be better integrated into end-of-life care for younger children and those dying in PICU.
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Affiliation(s)
- Jessica Nicoll
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Janeway Children's Health and Rehabilitation Centre, Discipline of Pediatrics, Memorial University, St. John's Newfoundland and Labrador, Canada.,Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Karen Dryden-Palmer
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Helena Frndova
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronald Gottesman
- Department of Critical Care, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Martin Gray
- Pediatric Intensive Care, St. George's Hospital, Tooting, London, United Kingdom
| | - Elizabeth A Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - James S Hutchison
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jacques Lacroix
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada
| | - Kristen Middaugh
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leah Szadkowski
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
| | - George A Tomlinson
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David Wensley
- Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Chris S Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Farrell
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada
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26
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End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study. J Pediatr (Rio J) 2021; 97:525-530. [PMID: 33358967 PMCID: PMC9431998 DOI: 10.1016/j.jped.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the prevalence of life support limitation (LSL) in patients who died after at least 24h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered. METHODS Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24h of admission. RESULTS 53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a do-not-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support. CONCLUSIONS LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.
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Unassisted Return of Spontaneous Circulation Following Withdrawal of Life-Sustaining Therapy During Donation After Circulatory Determination of Death in a Child. Crit Care Med 2021; 50:e183-e188. [PMID: 34369429 DOI: 10.1097/ccm.0000000000005273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the unassisted return of spontaneous circulation following withdrawal of life-sustaining treatment in a child. DESIGN Case report based on clinical observation and medical record review. SETTING Community Children's Hospital. PATIENT Two-year old child. INTERVENTIONS Following hypoxic-ischemic brain injury, the child was taken to the operating room for withdrawal of life-sustaining treatment during controlled donation after circulatory determination of death. MEASUREMENTS AND MAIN RESULTS In addition to direct observation by experienced pediatric critical care providers, the child was monitored with electrocardiography, pulse oximetry, and invasive blood pressure via femoral arterial catheter in addition to direct observation by experienced pediatric critical care providers. Unassisted return of spontaneous circulation occurred greater than 2 minutes following circulatory arrest and was accompanied by return of respiration. CONCLUSIONS We provide the first report of unassisted return of spontaneous circulation following withdrawal of life-sustaining treatment in a child. In our case, return of spontaneous circulation occurred in the setting of controlled donation after circulatory determination of death and was accompanied by return of respiration. Return of spontaneous circulation greater than 2 minutes following circulatory arrest in our patient indicates that 2 minutes of observation is insufficient to ensure that cessation of circulation is permanent after withdrawal of life-sustaining treatment in a child.
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Gouda S, Hoehn KS. What Taiwan Teaches Us: Palliative Care Should Be As Integral to the PICU As the Code Cart. Pediatr Crit Care Med 2021; 22:764-765. [PMID: 34397994 DOI: 10.1097/pcc.0000000000002737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Suzanne Gouda
- All authors: Section of Pediatric Critical Care Medicine, University of Chicago, Comer Children's Hospital, Chicago, IL
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29
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Wu ET, Wang CC, Huang SC, Chen CH, Jou ST, Chen YC, Wu MH, Lu FL. End-of-Life Care in Taiwan: Single-Center Retrospective Study of Modes of Death. Pediatr Crit Care Med 2021; 22:733-742. [PMID: 33767073 DOI: 10.1097/pcc.0000000000002715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Medical advances and the National Health Insurance coverage in Taiwan mean that mortality in the PICU is low. This study describes change in modes of death and end-of-life care in a single center, 2011-2017. SETTING Multidisciplinary PICU in a tertiary referral Children's Hospital in Taiwan. PATIENTS There were 316 deaths in PICU patients. INTERVENTIONS Palliative care consultation in the PICU service occurred after the 2013 "Hospice Palliative Care Act" revision. MEASUREMENTS AND MAIN RESULTS In the whole cohort, 22 of 316 patients (7%) were determined as "death by neurologic criteria". There were 94 of 316 patients (30%) who had an event needing cardiopulmonary resuscitation within 24 hours of death: 17 of these patients (17/94; 18%) died after failed cardiopulmonary resuscitation without a do-not-resuscitate order, and the other 77 of 94 patients (82%) had a do-not-resuscitate order after cardiopulmonary resuscitation. Overall, there were 200 of 316 patients (63%) who had a do-not-resuscitate order and were entered into the palliative program: 169 of 200 (85%) died after life-sustaining treatment was limited, and the other 31 of 200 (15%) died after life-sustaining treatment was withdrawn. From 2011 to 2017, the time-trend in end-of-life care showed the following associations: 1) a decrease in PICU mortality utilization rate, from 22% to 7% (p < 0.001); 2) a decrease in use of catecholamine infusions after do-not-resuscitate consent, from 87% to 47% (p = 0.001), in patients having limitation in life-sustaining treatment; and 3) an increase in withdrawal of life-sustaining treatment, from 4% to 31% (p < 0.001). CONCLUSIONS In our practice in a single PICU-center in Taiwan, we have seen that the integration of a palliative care consultation service, developed after the revision of a national "Palliative Care Act," was associated with increased willingness to accept withdrawal of life-sustaining treatment and a lowered PICU care intensity at the end-of-life.
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Affiliation(s)
- En-Ting Wu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Ching-Chia Wang
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chieh-Ho Chen
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Yih-Charng Chen
- Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Frank Leigh Lu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
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30
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Ghavam A, Thompson NE, Lee J. Comparison of pediatric brain-dead donors to donation after circulatory death donors in the United States. Pediatr Transplant 2021; 25:e13926. [PMID: 33326666 DOI: 10.1111/petr.13926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/13/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022]
Abstract
In pediatrics, an increasing need for transplantable organs exists. This study aimed to describe the epidemiology of pediatric deceased donors in the United States. This retrospective observational study utilized data from the Organ Procurement and Transplantation Network (OPTN) from 2000 to 2015. Patients were stratified based on method of organ donation. Demographic variables and mechanism of death were then compared. A total of 14,481 deceased pediatric organ donors, donation after brain death (DBD) and donation after circulatory death (DCD), were included in the study, of which 8% were DCD donors. A significant difference (p<0.001) existed between the two donor groups with respect to ethnicity and mechanism of death. The annual trend of DCD and DBD donors showed an inverse relationship. During the 15-year study period the number of DBD donors decreased from 985 to 785 per year while DCD donors increased from 15 to 146 per year. As well, overall organs transplanted per year decreased from 3,475 to 3,117 over the 15-year study period. Significant differences exist between pediatric DBD donors and DCD donors, specifically with respect to ethnicity and mechanism of death. The number of pediatric DBD donors is decreasing while the number of pediatric DCD is slowly rising, making it increasingly important to be able to characterize these donors to better identify eligible DCD donors to optimize organ utilization.
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Affiliation(s)
- Ahmeneh Ghavam
- Division of Critical Medicine, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Nathan E Thompson
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Jane Lee
- Division of Special Needs, Department of Pediatrics, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
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Winter MC, Day TE, Ledbetter DR, Aczon MD, Newth CJL, Wetzel RC, Ross PA. Machine Learning to Predict Cardiac Death Within 1 Hour After Terminal Extubation. Pediatr Crit Care Med 2021; 22:161-171. [PMID: 33156210 DOI: 10.1097/pcc.0000000000002612] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Accurate prediction of time to death after withdrawal of life-sustaining therapies may improve counseling for families and help identify candidates for organ donation after cardiac death. The study objectives were to: 1) train a long short-term memory model to predict cardiac death within 1 hour after terminal extubation, 2) calculate the positive predictive value of the model and the number needed to alert among potential organ donors, and 3) examine associations between time to cardiac death and the patient's characteristics and physiologic variables using Cox regression. DESIGN Retrospective cohort study. SETTING PICU and cardiothoracic ICU in a tertiary-care academic children's hospital. PATIENTS Patients 0-21 years old who died after terminal extubation from 2011 to 2018 (n = 237). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The median time to death for the cohort was 0.3 hours after terminal extubation (interquartile range, 0.16-1.6 hr); 70% of patients died within 1 hour. The long short-term memory model had an area under the receiver operating characteristic curve of 0.85 and a positive predictive value of 0.81 at a sensitivity of 94% when predicting death within 1 hour of terminal extubation. About 39% of patients who died within 1 hour met organ procurement and transplantation network criteria for liver and kidney donors. The long short-term memory identified 93% of potential organ donors with a number needed to alert of 1.08, meaning that 13 of 14 prepared operating rooms would have yielded a viable organ. A Cox proportional hazard model identified independent predictors of shorter time to death including low Glasgow Coma Score, high Pao2-to-Fio2 ratio, low-pulse oximetry, and low serum bicarbonate. CONCLUSIONS Our long short-term memory model accurately predicted whether a child will die within 1 hour of terminal extubation and may improve counseling for families. Our model can identify potential candidates for donation after cardiac death while minimizing unnecessarily prepared operating rooms.
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Affiliation(s)
- Meredith C Winter
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Travis E Day
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Department of Computer Science, University of Southern California Viterbi School of Engineering, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - David R Ledbetter
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Melissa D Aczon
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Randall C Wetzel
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Patrick A Ross
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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32
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Rivera EAT, Patel AK, Zeng-Treitler Q, Chamberlain JM, Bost JE, Heneghan JA, Morizono H, Pollack MM. Severity Trajectories of Pediatric Inpatients Using the Criticality Index. Pediatr Crit Care Med 2021; 22:e19-e32. [PMID: 32932405 PMCID: PMC7790848 DOI: 10.1097/pcc.0000000000002561] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To assess severity of illness trajectories described by the Criticality Index for survivors and deaths in five patient groups defined by the sequence of patient care in ICU and routine patient care locations. DESIGN The Criticality Index developed using a calibrated, deep neural network, measures severity of illness using physiology, therapies, and therapeutic intensity. Criticality Index values in sequential 6-hour time periods described severity trajectories. SETTING Hospitals with pediatric inpatient and ICU care. PATIENTS Pediatric patients never cared for in an ICU (n = 20,091), patients only cared for in the ICU (n = 2,096) and patients cared for in both ICU and non-ICU care locations (n = 17,023) from 2009 to 2016 Health Facts database (Cerner Corporation, Kansas City, MO). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Criticality Index values were consistent with clinical experience. The median (25-75th percentile) ICU Criticality Index values (0.878 [0.696-0.966]) were more than 80-fold higher than the non-ICU values (0.010 [0.002-0.099]). Non-ICU Criticality Index values for patients transferred to the ICU were 40-fold higher than those never transferred to the ICU (0.164 vs 0.004). The median for ICU deaths was higher than ICU survivors (0.983 vs 0.875) (p < 0.001). The severity trajectories for the five groups met expectations based on clinical experience. Survivors had increasing Criticality Index values in non-ICU locations prior to ICU admission, decreasing Criticality Index values in the ICU, and decreasing Criticality Index values until hospital discharge. Deaths had higher Criticality Index values than survivors, steeper increases prior to the ICU, and worsening values in the ICU. Deaths had a variable course, especially those who died in non-ICU care locations, consistent with deaths associated with both active therapies and withdrawals/limitations of care. CONCLUSIONS Severity trajectories measured by the Criticality Index showed strong validity, reflecting the expected clinical course for five diverse patient groups.
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Affiliation(s)
| | - Anita K Patel
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Qing Zeng-Treitler
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James M Chamberlain
- Department of Pediatrics, Division of Emergency Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - James E Bost
- Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Julia A Heneghan
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Hiroki Morizono
- Children's National Research Institute, Associate Research Professor of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Murray M Pollack
- Department of Pediatrics, Division of Critical Care Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC
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Zhu Y, Zhu X, Xu L, Deng M. Clinical Factors Influencing End-of-Life Care in a Chinese Pediatric Intensive Care Unit: A Retrospective, post-hoc Study. Front Pediatr 2021; 9:601782. [PMID: 33898354 PMCID: PMC8058173 DOI: 10.3389/fped.2021.601782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: End-of-life(EOL) care decision-making for infants and children is a painful experience. The study aimed to explore the clinical factors influencing the EOL care to withhold/withdraw life-sustaining treatment (WLST) in Chinese pediatric intensive care unit (PICU). Methods: A 14-year retrospective study (2006-2019) for pediatric patients who died in PICU was conducted. Based on the mode of death, patients were classified into WLST group (death after WLST) and fCPR group (death after full intervention, including cardiopulmonary resuscitation). Intergroup differences in the epidemiological and clinical factors were determined. Results: There were 715 patients enrolled in this study. Of these patients, 442 (61.8%) died after WLST and 273 (38.2%) died after fCPR. Patients with previous hospitalizations or those who had been transferred from other hospitals more frequently chose WLST than fCPR (both P < 0.01), and the mean PICU stay duration was significantly longer in the WLST group (P < 0.05). WLST patients were more frequently complicated with chronic underlying disease, especially tumor (P < 0.01). Sepsis, diarrhea, and cardiac attack (all P < 0.05) were more frequent causes of death in the fCPR group, whereas tumor as a direct cause of death was more frequently seen in the WLST group. Logistic regression analysis demonstrated that previous hospitalization and underlying diseases diagnosed before admission were strongly associated with EOL care with WLST decision (OR: 1.6; P < 0.05 and OR: 1.6; P < 0.01, respectively). Conclusions: Pediatric patients with previous hospitalization and underlying diseases diagnosed before admission were associated with the EOL care to WLST.
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Affiliation(s)
- Yueniu Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lili Xu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mengyan Deng
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Palliative Care Knowledge and Characteristics in Caregivers of Chronically Ill Children. J Hosp Palliat Nurs 2020; 22:456-464. [DOI: 10.1097/njh.0000000000000685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
OBJECTIVES To describe how children currently die in Spanish PICUs, their epidemiologic characteristics and clinical diagnoses. DESIGN Prospective multicenter observational study. SETTING Eighteen PICUs participating in the MOdos de Morir en UCI Pediátrica-2 (MOMUCI-2) study in Spain. PATIENTS Children 1 to 16 years old who died in PICU during 2017 and 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the 2-year study period, 250 deaths were recorded. Seventy-three children (29.3%) were younger than 1 year, 131 (52.6%) were between 1 and 12 years old, and 45 (18.1%) were older than 12. One-hundred eighty patients (72%) suffered from an underlying chronic disease, 54 (21.6%) had been admitted to PICU in the past 6 months, and 71 (28.4%) were severely disabled upon admission. Deaths occurred more frequently on the afternoon-night shift (62%) after a median PICU length of stay of 3 days (1-12 d). Nearly half of the patients died (48.8%) after life-sustaining treatment limitation, 71 died (28.4%) despite receiving life-sustaining therapies and cardiopulmonary resuscitation, and 57 (22.8%) were declared brain dead. The most frequent type of life-sustaining treatment limitation was the withdrawal of mechanical ventilation (20.8%), followed by noninitiation of cardiopulmonary resuscitation (18%) and withdrawal of vasoactive drugs (13.7%). Life-sustaining treatment limitation was significantly more frequent in patients with an underlying neurologic-neuromuscular disease, respiratory disease as the cause of admission, a previous admission to PICU in the past 6 months, and severe disability. Multivariate analyses indicated that life-sustaining treatment limitation, chronicity, and poor Pediatric Cerebral Performance Category score were closely related. CONCLUSIONS Currently, nearly half of the deaths in Spanish PICUs occur after the withdrawal of life-sustaining treatments. These children are more likely to have had previous admissions to the PICU, be severely disabled or to suffer from chronic diseases. Healthcare professionals who treat critically ill children ought to be aware of this situation and should therefore be prepared and trained to provide the best end-of-life care possible.
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Parents' Wishes for What They Had or Had Not Done and Their Coping After Their Infant's or Child's Neonatal Intensive Care Unit/Pediatric Intensive Care Unit/Emergency Department Death. J Hosp Palliat Nurs 2020; 21:333-343. [PMID: 30933014 DOI: 10.1097/njh.0000000000000559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This qualitative study asked 70 mothers and 26 fathers 3 open-ended questions on what they wish they had and had not done and on coping 2, 4, 6, and 13 months after their infant's/child's neonatal intensive care unit/pediatric intensive care unit/emergency department death. Mothers wished they spent more time with the child, chosen different treatments, advocated for care changes, and allowed the child his or her wishes. Fathers wished they had spent more time with the child and gotten care earlier. Mothers wished they had not agreed to child's surgery/treatment, taken her own actions (self-blame), and left the hospital before the death. Fathers wished they had not been so hard on the child, agreed with doctors/treatment, and taken own actions (self-blame). Religious activities, caring for herself, and talking about/with the deceased child were the most frequent mothers' coping strategies; those of the fathers were caring for self and religious activities. Both mothers and fathers wished they had spent more time with their child and had not agreed to surgery/treatments. The most frequent coping was caring for themselves, likely to care for the family and retain employment. Nurses must be sensitive to parents' need for time with their infant/child before and after death and to receive information on child's treatments at levels and in languages they understand.
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Audigé M, Gillam L, Stark Z. Treatment limitation and advance planning: Hospital-wide audit of paediatric death. J Paediatr Child Health 2020; 56:893-899. [PMID: 31898378 DOI: 10.1111/jpc.14771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/14/2019] [Accepted: 12/19/2019] [Indexed: 11/30/2022]
Abstract
AIM To examine paediatric deaths following withdrawal or withholding of medical treatment (WWMT) from a hospital-wide perspective and identify changes over a 10 year period. METHODS A retrospective review of medical records was conducted for all paediatric inpatient deaths at the Royal Children's Hospital, Melbourne from April 2015 to April 2016, and results were compared to 2007 data from our centre. χ2 tests were used for comparisons. RESULTS A total of 101 deaths occurred in the inpatient setting in 2015-2016. Most deaths followed WWMT (88/101, 87%) and occurred in children with pre-existing chronic conditions (85/101, 85%). There was a shift to earlier discussions with parents regarding WWMT compared to 10 years prior. Cases where discussions began prior to the last admission increased from 4 to 19% (P = 0.004). There was increased paediatric palliative care (PPC) involvement (10 vs. 37%, P < 0.001), and a slightly greater proportion of children died outside of intensive care (16 vs. 22%, P = 0.25). In 2015-2016, subgroup analysis showed that children who died as inpatients but outside of intensive care were 76% more likely to have PPC involved than those who died in intensive care (P < 0.001). Their families were 51% more likely to have discussed WWMT with medical staff before the last admission (P < 0.001). CONCLUSIONS The last decade has seen an increase in PPC involvement and advance discussions around WWMT at our centre. Both of these are associated with death outside of intensive care.
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Affiliation(s)
- Manon Audigé
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The Royal Children's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Zornitza Stark
- Department of Paediatrics, The Royal Children's Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Comparison of End-of-Life Care Practices Between Children With Complex Chronic Conditions and Neonates Dying in an ICU Versus Non-ICUs: A Substudy of the Pediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) Project. Pediatr Crit Care Med 2020; 21:e236-e246. [PMID: 32091504 DOI: 10.1097/pcc.0000000000002259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe and compare characteristics of care provided at the end of life for children with chronic complex conditions and neonates who died in an ICU with those who died outside an ICU. DESIGN Substudy of a nation-wide retrospective chart review. SETTING Thirteen hospitals, including 14 pediatric and neonatal ICUs, two long-term institutions, and 10 community-based organizations in the three language regions of Switzerland. PATIENTS One hundred forty-nine children (0-18 yr) who died in the years 2011 or 2012. Causes of death were related to cardiac, neurologic, oncological, or neonatal conditions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and clinical characteristics, therapeutic procedures, circumstances of death, and patterns of decisional processes were extracted from the medical charts. Ninety-three (62%) neonates (median age, 4 d) and children (median age, 23 mo) died in ICU, and 56 (38%) with a median age of 63 months outside ICU. Generally, ICU patients had more therapeutic and invasive procedures, compared with non-ICU patients. Changes in treatment plan in the last 4 weeks of life, such as do-not-resuscitate orders occurred in 40% of ICU patients and 25% of non-ICU patients (p < 0.001). In the ICU, when decision to withdraw life-sustaining treatment was made, time to death in children and newborns was 4:25 and 3:00, respectively. In institutions where it was available, involvement of specialized pediatric palliative care services was recorded in 15 ICU patients (43%) and in 18 non-ICU patients (78%) (p = 0.008). CONCLUSIONS This nation-wide study demonstrated that patients with a complex chronic condition who die in ICU, compared with those who die outside ICU, are characterized by fast changing care situations, including when to withdraw life-sustaining treatment. This highlights the importance of early effective communication and shared decision making among clinicians and families.
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Is It Time to Move Beyond Observational Studies of the Epidemiology and Mode of PICU Deaths? Pediatr Crit Care Med 2020; 21:505-506. [PMID: 32358336 DOI: 10.1097/pcc.0000000000002262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhang Z, Huang X, Wang Y, Li Y, Miao H, Zhang C, Pan G, Zhang Y, Zhu X, Chen W, Li J, Su D, Bi Y, Chen Z, Jin B, Miao H, Kong X, Cheng Y, Chen Y, Yan G, Yan W, Lu G. Performance of Three Mortality Prediction Scores and Evaluation of Important Determinants in Eight Pediatric Intensive Care Units in China. Front Pediatr 2020; 8:522. [PMID: 33014927 PMCID: PMC7505927 DOI: 10.3389/fped.2020.00522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/23/2020] [Indexed: 12/12/2022] Open
Abstract
Background: The mortality prediction scores were widely used in pediatric intensive care units. However, their performances were unclear in Chinese patients and there were also no reports based on large sample sizes in China. This study aims to evaluate the performances of three existing severity assessment scores in predicting PICU mortality and to identify important determinants. Methods: This prospective observational cohort study was carried out in eight multidisciplinary, tertiary-care PICUs of teaching hospitals in China. All eligible patients admitted to the PICUs between Aug 1, 2016, and Jul 31, 2017, were consecutively enrolled, among whom 3,957 were included for analysis. We calculated PCIS, PRISM IV, and PELOD-2 scores based on patient data collected in the first 24 h after PICU admission. The in-hospital mortality was defined as all-cause death within 3 months after admission. The discrimination of mortality was assessed using the area under the receiver-operating characteristics curve (AUC) and calibrated using the Hosmer-Lemeshow goodness-of-fit test. Results: A total of 4,770 eligible patients were recruited (median age 18.2 months, overall mortality rate 4.7%, median length of PICU stay 6 days), and 3,957 participants were included in the analysis. The AUC (95% confidence intervals, CI) were 0.74 (0.71-0.78), 0.76 (0.73-0.80), and 0.80 (0.77-0.83) for PCIS, PRISM IV, and PELOD-2, respectively. The Hosmer-Lemeshow test gave a chi-square of 3.16 for PCIS, 2.16 for PRISM IV and 4.81 for PELOD-2 (p ≥ 0.19). Cox regression identified five predictors from the items of scores better associated with higher death risk, with a C-index of 0.83 (95%CI 0.79-0.86), including higher platelet (HR = 1.85, 95% CI 1.59-2.16), invasive ventilation (HR = 1.40, 1.26-1.55), pupillary light reflex (HR = 1.31, 95% CI 1.22-1.42) scores, lower pH (HR 0.89, 0.84-0.94), and extreme PaO2 (HR 2.60, 95% CI 1.61-4.19 for the 1st quantile vs. 4th quantile) scores. Conclusions: Performances of the three scores in predicting PICU mortality are comparable, and five predictors were identified with better prediction to PICU mortality in Chinese patients.
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Affiliation(s)
- Zhengzheng Zhang
- Pediatric Emergency and Critical Care Center, Children's Hospital of Fudan University, Shanghai, China
| | - Xiangyuan Huang
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Wang
- Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ying Li
- Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, China
| | - Hongjun Miao
- Department of Emergency, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Chenmei Zhang
- Pediatric Intensive Care Unit, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Guoquan Pan
- Pediatric Intensive Care Unit, The Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Weiming Chen
- Pediatric Emergency and Critical Care Center, Children's Hospital of Fudan University, Shanghai, China
| | - Juanzhen Li
- Pediatric Intensive Care Unit, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dongni Su
- Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, China
| | - Yanlong Bi
- Department of Emergency, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhenjie Chen
- Pediatric Intensive Care Unit, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bingxin Jin
- Pediatric Intensive Care Unit, The Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Huijie Miao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiangmei Kong
- Department of Pediatric Critical Care Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ye Cheng
- Pediatric Emergency and Critical Care Center, Children's Hospital of Fudan University, Shanghai, China
| | - Yang Chen
- Pediatric Emergency and Critical Care Center, Children's Hospital of Fudan University, Shanghai, China
| | - Gangfeng Yan
- Pediatric Emergency and Critical Care Center, Children's Hospital of Fudan University, Shanghai, China
| | - Weili Yan
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, China
| | - Guoping Lu
- Pediatric Emergency and Critical Care Center, Children's Hospital of Fudan University, Shanghai, China
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Affiliation(s)
- Rafael González
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria, Pediatric Intensive Care Unit, Madrid, Spain; Maternal and Child Health and Development Network, RETICS funded by the PN I+D+I 2013-2016 (Spain), ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), Madrid, Spain
| | - Jesús López-Herce
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria, Pediatric Intensive Care Unit, Madrid, Spain; Maternal and Child Health and Development Network, RETICS funded by the PN I+D+I 2013-2016 (Spain), ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), Madrid, Spain; Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Salud Pública y Maternoinfantil, Madrid, Spain.
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Mortality of patients with chronic disease: an increasing problem. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2019. [DOI: 10.1016/j.jpedp.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Modos de fallecimiento de los niños en Cuidados Intensivos en España. Estudio MOMUCIP (modos de muerte en UCIP). An Pediatr (Barc) 2019; 91:228-236. [DOI: 10.1016/j.anpedi.2019.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 11/21/2022] Open
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Modes of dying of children in Intensive Care Units in Spain: MOMUCIP study. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
OBJECTIVES Investigations of acute respiratory distress syndrome in adults suggest hypoxemia is an uncommon cause of death. However, the epidemiology of death in pediatric acute respiratory distress syndrome is not well characterized. We aimed to describe the cause, mode, and timing of death in pediatric acute respiratory distress syndrome nonsurvivors. We hypothesized that most deaths would be due to nonpulmonary factors, rather than hypoxemia. DESIGN Retrospective, decedent-only analysis. SETTING Two large, academic PICUs. PATIENTS Nonsurvivors with pediatric acute respiratory distress syndrome. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 798 subjects with pediatric acute respiratory distress syndrome, there were 153 nonsurvivors (19% mortality). Median time to death was 6 days (interquartile range, 3-13 d) after pediatric acute respiratory distress syndrome onset. Patients dying less than 7 days after pediatric acute respiratory distress syndrome onset had greater illness severity and worse oxygenation. Patients dying less than 7 days were more likely to die of a neurologic cause, including brain death. Patients dying greater than or equal to 7 days after pediatric acute respiratory distress syndrome onset were more commonly immunocompromised. Multisystem organ failure predominated in deaths greater than or equal to 7 days. Withdrawal of therapy was the most common mode of death at all timepoints, accounting for 66% of all deaths. Organ dysfunction was common at time of death, irrespective of cause of death. Refractory hypoxemia accounted for only a minority of pediatric acute respiratory distress syndrome deaths (20%). CONCLUSIONS In pediatric acute respiratory distress syndrome, early deaths were due primarily to neurologic failure, whereas later deaths were more commonly due to multisystem organ failure. Deaths from neurologic causes accounted for a substantial portion of nonsurvivors. Refractory hypoxemia accounted for only a minority of deaths. Our study highlights limitations associated with using death as an endpoint in therapeutic pediatric acute respiratory distress syndrome trials.
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Religious and cultural challenges in paediatrics palliative care: A review of literature. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2019. [DOI: 10.1016/j.phoj.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Seino Y, Kurosawa H, Shiima Y, Niitsu T. End-of-life care in the pediatric intensive care unit: Survey in Japan. Pediatr Int 2019; 61:859-864. [PMID: 31247125 DOI: 10.1111/ped.13924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 05/03/2019] [Accepted: 06/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND End-of-life (EOL) care is an important topic in critical care medicine, but EOL discussions with families can be difficult and stressful for intensivists. The aim of this study was to clarify the current practices and barriers facing pediatric intensive care unit (PICU) EOL care and to identify the requisites for excellent PICU EOL care in Japan. METHODS A survey was conducted in 29 facilities across Japan in 2016. The questionnaire consisted of 19 multiple-choice questions and one open-ended question. RESULTS Twenty-seven facilities responded to the survey. Only 19% had educational programs on EOL care for fellows or residents. Although 21 hospitals (78%) had a multidisciplinary palliative care team, only eight of these teams were involved in EOL care in PICUs. Mental health care for health-care providers provided by a psychiatrist was rare (4%). The free comments were categorized as individual, team, environment, legal/ethics, or culture. Commonly raised individual issues included "lack of experience and knowledge about EOL care", "fear of making the decision to end care", and "reluctance to be involved in EOL care because of its complex process". Team issues included "insufficient frequency of conferences" and "non-multidisciplinary approach". Legal and ethics issues were "lack of legal support" and "fear of lawsuits". CONCLUSIONS This study is the first to investigate the current conditions and barriers in PICU EOL care in Japan. Most of the facilities involved were not satisfied with current practices. A need was identified for relevant educational programs, as well as the importance of multidisciplinary and legal support.
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Affiliation(s)
- Yusuke Seino
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Yuko Shiima
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Takehiro Niitsu
- Depertment of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
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Moynihan KM, Snaman JM, Kaye EC, Morrison WE, DeWitt AG, Sacks LD, Thompson JL, Hwang JM, Bailey V, Lafond DA, Wolfe J, Blume ED. Integration of Pediatric Palliative Care Into Cardiac Intensive Care: A Champion-Based Model. Pediatrics 2019; 144:peds.2019-0160. [PMID: 31366685 PMCID: PMC6855829 DOI: 10.1542/peds.2019-0160] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 01/04/2023] Open
Abstract
Integration of pediatric palliative care (PPC) into management of children with serious illness and their families is endorsed as the standard of care. Despite this, timely referral to and integration of PPC into the traditionally cure-oriented cardiac ICU (CICU) remains variable. Despite dramatic declines in mortality in pediatric cardiac disease, key challenges confront the CICU community. Given increasing comorbidities, technological dependence, lengthy recurrent hospitalizations, and interventions risking significant morbidity, many patients in the CICU would benefit from PPC involvement across the illness trajectory. Current PPC delivery models have inherent disadvantages, insufficiently address the unique aspects of the CICU setting, place significant burden on subspecialty PPC teams, and fail to use CICU clinician skill sets. We therefore propose a novel conceptual framework for PPC-CICU integration based on literature review and expert interdisciplinary, multi-institutional consensus-building. This model uses interdisciplinary CICU-based champions who receive additional PPC training through courses and subspecialty rotations. PPC champions strengthen CICU PPC provision by (1) leading PPC-specific educational training of CICU staff; (2) liaising between CICU and PPC, improving use of support staff and encouraging earlier subspecialty PPC involvement in complex patients' management; and (3) developing and implementing quality improvement initiatives and CICU-specific PPC protocols. Our PPC-CICU integration model is designed for adaptability within institutional, cultural, financial, and logistic constraints, with potential applications in other pediatric settings, including ICUs. Although the PPC champion framework offers several unique advantages, barriers to implementation are anticipated and additional research is needed to investigate the model's feasibility, acceptability, and efficacy.
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Affiliation(s)
- Katie M. Moynihan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
| | - Jennifer M. Snaman
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Erica C. Kaye
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Wynne E. Morrison
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Aaron G. DeWitt
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Loren D. Sacks
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Jess L. Thompson
- Department of Cardiothoracic Surgery, Children’s Heart Center, University of Oklahoma, Oklahoma City, Oklahoma; and
| | - Jennifer M. Hwang
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Pediatrics, Perelman School of Medicine, The University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Valerie Bailey
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts
| | - Deborah A. Lafond
- PANDA Palliative Care Team, Children’s National and School of Medicine, The George Washington University, Washington, District of Columbia
| | - Joanne Wolfe
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth D. Blume
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
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Moynihan KM, Alexander PMA, Schlapbach LJ, Millar J, Jacobe S, Ravindranathan H, Croston EJ, Staffa SJ, Burns JP, Gelbart B. Epidemiology of childhood death in Australian and New Zealand intensive care units. Intensive Care Med 2019; 45:1262-1271. [DOI: 10.1007/s00134-019-05675-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/19/2019] [Indexed: 11/30/2022]
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50
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Needle JS, Liaschenko J, Peden-McAlpine C, Boss R. Stopping the Momentum of Clinical Cascades in the PICU: Intentional Responses to the Limits of Medicine. J Palliat Care 2019; 36:12-16. [PMID: 31142203 DOI: 10.1177/0825859719851487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jennifer S Needle
- Department of Pediatrics, Center for Bioethics, 5635University of Minnesota, Minneapolis, MN, USA
| | - Joan Liaschenko
- Department of Pediatrics, Center for Bioethics, 5635University of Minnesota, Minneapolis, MN, USA
| | - Cynthia Peden-McAlpine
- Department of Pediatrics, Center for Bioethics, 5635University of Minnesota, Minneapolis, MN, USA
| | - Renee Boss
- 1466Johns Hopkins University, Baltimore, MD, USA
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