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Gaillard-Le Roux B, Cremer R, de Saint Blanquat L, Beaux J, Blanot S, Bonnin F, Bordet F, Deho A, Dupont S, Klusiewicz A, Lafargue A, Lemains M, Merchaoui Z, Quéré R, Samyn M, Saulnier ML, Temper L, Michel F, Dauger S. Organ donation by Maastricht-III pediatric patients: Recommendations of the Groupe Francophone de Réanimation et Urgences Pédiatriques (GFRUP) and Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF) Part I: Ethical considerations and family care. Arch Pediatr 2022; 29:502-508. [DOI: 10.1016/j.arcped.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 05/04/2022] [Accepted: 06/18/2022] [Indexed: 11/27/2022]
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Cremer R, de Saint Blanquat L, Birsan S, Bordet F, Botte A, Brissaud O, Guilbert J, Le Roux B, Le Reun C, Michel F, Millasseau F, Sinet M, Hubert P. Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations. Arch Pediatr 2021; 28:325-337. [PMID: 33875345 DOI: 10.1016/j.arcped.2021.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/15/2021] [Indexed: 11/29/2022]
Abstract
In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.
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Affiliation(s)
- R Cremer
- Réanimation et soins continus pédiatriques, hôpital Jeanne-de-Flandre, ERER des Hauts-de-France, CHU de Lille, 59037 Lille, France.
| | - L de Saint Blanquat
- Réanimation pédiatrique, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France
| | - S Birsan
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - F Bordet
- Réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Lyon-Bron, France
| | - A Botte
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - O Brissaud
- Unité de soins continus et réanimation néonatale et pédiatrique, hôpital des enfants, CHU Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - J Guilbert
- Réanimation néonatale pédiatrique, hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - B Le Roux
- Réanimation pédiatrique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - C Le Reun
- Réanimation pédiatrique, hôpital Clocheville, CHU de Tours, 2, boulevard Tonnelle, 37000 Tours, France
| | - F Michel
- Anesthésie et réanimation pédiatrique, hôpital de la Timone, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France
| | - F Millasseau
- Réanimation pédiatrique, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France
| | - M Sinet
- Réanimation néonatale pédiatrique, hôpital Armand-Trousseau, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France; Réanimation et surveillance continue pédiatriques, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France
| | - P Hubert
- Réanimation pédiatrique, hôpital Necker-Enfants-malades, 149, rue de Sèvres, 75015 Paris, France
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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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de Saint Blanquat L, Viallard ML. Réflexions éthiques et démarche palliative intégrée dans les réanimations pédiatriques françaises en 2017. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
En réanimation pédiatrique, 40 % des décès surviennent à la suite d’une décision de limitation ou d’arrêt de traitement (LAT). Ces situations sont sources de questionnements éthiques complexes au sein de l’équipe soignante. La législation française et les recommandations des sociétés savantes donnent un cadre aux réanimateurs pédiatres pour les prises de décisions de LAT. Les enquêtes de pratiques nous montrent qu’ils se sont approprié certains éléments de la procédure collégiale comme la nécessité de la concertation pluriprofessionnelle, l’information et la communication avec les parents. Néanmoins, certains points tels que la présence du consultant, la réalité de la collégialité avec l’expression de toutes les personnes soignantes présentes sont encore insuffisamment appliqués. La place des parents dans les décisions doit être également réfléchie. La collaboration entre les équipes de réanimation pédiatrique et de médecine palliative est une possibilité pour améliorer sensiblement la qualité des soins et de l’accompagnement proposés. Cette collaboration élargit également les possibilités de la réflexion éthique nécessaire dans les situations de fin de vie complexes. L’intégration dans l’enseignement de la réanimation des principes de la médecine palliative est en cours de réflexion.
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Salins N, Gursahani R, Mathur R, Iyer S, Macaden S, Simha N, Mani RK, Rajagopal MR. Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at the End of Life: The Indian Council of Medical Research Commission Report. Indian J Crit Care Med 2018; 22:249-262. [PMID: 29743764 PMCID: PMC5930529 DOI: 10.4103/ijccm.ijccm_165_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Indian hospitals, in general, lack policies on the limitation of inappropriate life-sustaining interventions at the end of life. To facilitate discussion, preparation of guidelines and framing of laws, terminologies relating to the treatment limitation, and providing palliative care at the end-of-life care (EOLC) need to be defined and brought up to date. METHODOLOGY This consensus document on terminologies and definitions of terminologies was prepared under the aegis of the Indian Council of Medical Research. The consensus statement was created using Nominal Group and Delphi Method. RESULTS Twenty-five definitions related to the limitations of treatment and providing palliative care at the end of life were created by reviewing existing international documents and suitably modifying it to the Indian sociocultural context by achieving national consensus. Twenty-five terminologies defined within the scope of this document are (1) terminal illness, (2) actively dying, (3) life-sustaining treatment, (4) potentially inappropriate treatment, (5) cardiopulmonary resuscitation (CPR), (6) do not attempt CPR, (7) withholding life-sustaining treatment, (8) withdrawing life-sustaining treatment, (9) euthanasia (10) active shortening of the dying process, (11) physician-assisted suicide, (12) palliative care, (13) EOLC, (14) palliative sedation, (15) double effect, (16) death, (17) best interests, (18) health-care decision-making capacity, (19) shared decision-making, (20) advance directives, (21) surrogates, (22) autonomy, (23) beneficence, (24) nonmaleficence, and (25) justice.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, India
| | - Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India
| | - Roli Mathur
- ICMR Bioethics Unit, National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
| | - Stanley Macaden
- Palliative Care Program of the Christian Medical Association of India, India
- Coordinator of the Palliative Care Program of Christian Medical Association of India and Honorary Palliative Medicine Consultant at Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Nagesh Simha
- Medical Director, Karunashraya Hospice, Bengaluru, Karnataka, India
| | - Raj Kumar Mani
- CEO and Chairman, Department of Critical Care, Pulmonology and Sleep Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India
| | - M. R. Rajagopal
- Chairman of Pallium India and Director of Trivandrum Institute of Palliative Sciences, Pallium, India
- Trivandrum Institute of Palliative Sciences, Thiruvananthapuram, Kerala, India
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Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Eraldi JP, Bougerol F, Large A, Andreu P, Rigaud JP. What are the ethical dimensions in the profession of intensive care specialist? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S47. [PMID: 29302603 DOI: 10.21037/atm.2017.09.34] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Two essential components of the profession of a medical doctor are the constant review of the patient's therapeutic project, and collaboration between healthcare professionals. The profession of intensive care unit (ICU) physician goes further in terms of responsibility, vis-à-vis the intensive treatments dispensed to the patients, and the physician's responsibilities towards the patient's family and the caregiving team, also bearing in mind that ICU care is costly in terms of human and financial resources. In this review, we address the profession of ICU physician from the perspective of the ethical questions that arise constantly, focusing on the timeframe of the reflection process. Firstly, admission to the ICU must be anticipated. The concept of advance care planning is a suitable tool for this, and in case of non-admission to the ICU, does not by any means constitute an abandonment of the patient, because palliative care can also be anticipated, with a view to avoiding suffering for the patient and their family. Next, during an ICU stay, while the technical aspects undoubtedly characterise the ICU best at the start of the patient's stay, the process of reflection rapidly becomes preponderant, and involves the analysis of often complex situations with a view to defining the level of therapeutic engagement and optimizing the care dispensed to the patient. Last, a further ethical issue concerns the decision to re-admit (or not) a patient to the ICU. This decision can be made, for example, in the framework of a systematic, formalised, structured, multidisciplinary meeting at the end of an ICU stay, using a similar procedure to that implemented for decisions relating to withholding or withdrawal of life-sustaining therapies. The profession of ICU physician is not simply a question of prolonging or sustaining life, but is also fraught with ethical questions about how best to employ their competences. In this regard, it is essential to foster interdisciplinary collaboration, and emphasise the need for ICU physicians to be involved in the development of therapeutic projects, particularly when the disease in question is likely to be complicated by acute situations that may require admission of the patient to the ICU.
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Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
| | - Nicolas Meunier-Beillard
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Département de sociologie, Centre Georges Chevrier UMR 7366 CNRS-Université de Bourgogne, Dijon, France
| | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | | | - François Bougerol
- Department of Intensive Care, Dieppe General Hospital, Dieppe, France
| | - Audrey Large
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
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Fin de vie en services pédiatriques hospitaliers spécialisés : étude nationale. Arch Pediatr 2017; 24:231-240. [DOI: 10.1016/j.arcped.2017.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 06/15/2016] [Accepted: 06/15/2016] [Indexed: 11/23/2022]
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Joffre C, Lesage F, Bustarret O, Hubert P, Oualha M. Children with Down syndrome: Clinical course and mortality-associated factors in a French medical paediatric intensive care unit. J Paediatr Child Health 2016; 52:595-9. [PMID: 27333845 DOI: 10.1111/jpc.13214] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2016] [Indexed: 01/20/2023]
Abstract
AIM To investigate clinical course and mortality-associated factors in children with Down syndrome (DS) managed in a medical paediatric intensive care unit. METHODS A single-centre, retrospective study conducted between 2001 and 2010 in DS children aged 1 month to 16 years. RESULTS Sixty-six patients with a median age of 24 months (1-192) and a male/female ratio of 1.5 were analysed. Patients presented with history of congenital heart disease (n = 52, 78.8%), mechanical ventilation (n = 40, 60.6%) and chronic upper airway obstruction (n = 10, 15.1%). The primary reason for admission was respiratory failure (n = 56, 84.8%). Pulmonary arterial hypertension (PAH) (n = 19, 28.8%), acute respiratory distress syndrome (ARDS) (n = 18, 27.2%) and sepsis (n = 14, 21.2%) were observed during their clinical course. Twenty-six patients died (39.4%). Mortality-associated factors included the following: (i) baseline characteristics: history of mechanical ventilation, chronic upper airway obstruction and congenital heart disease; (ii) clinical course during paediatric intensive care unit stay: sepsis, catecholamine support, ARDS, PAH and nosocomial infection. In multivariate logistic analysis, history of mechanical ventilation, ARDS and PAH remained independently associated with death. CONCLUSIONS The mortality rate in critically ill DS children admitted for medical reasons is high and is predominantly associated with respiratory conditions.
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Affiliation(s)
- Christelle Joffre
- Paediatrics, Antoine Béclère Hospital, Assistance Publique - Hôpitaux de Paris, Clamart, France
| | - Fabrice Lesage
- Paediatric Intensive Care Unit, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Olivier Bustarret
- Surgical Paediatric Intensive Care Unit, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Philippe Hubert
- Paediatric Intensive Care Unit, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris Descartes University, Paris, France
| | - Mehdi Oualha
- Paediatric Intensive Care Unit, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris Descartes University, Paris, France
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Hua M, Halpern SD, Gabler NB, Wunsch H. Effect of ICU strain on timing of limitations in life-sustaining therapy and on death. Intensive Care Med 2016; 42:987-94. [PMID: 26862018 PMCID: PMC4846491 DOI: 10.1007/s00134-016-4240-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/21/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE The effect of capacity strain in an ICU on the timing of end-of-life decision-making is unknown. We sought to determine how changes in strain impact timing of new do-not-resuscitate (DNR) orders and of death. METHODS Retrospective cohort study of 9891 patients dying in the hospital following an ICU stay ≥72 h in Project IMPACT, 2001-2008. We examined the effect of ICU capacity strain (measured by standardized census, proportion of new admissions, and average patient acuity) on time to initiation of DNR orders and time to death for all ICU decedents using fixed-effects linear regression. RESULTS Increases in strain were associated with shorter time to DNR for patients with limitations in therapy (predicted time to DNR 6.11 days for highest versus 7.70 days for lowest quintile of acuity, p = 0.02; 6.50 days for highest versus 7.77 days for lowest quintile of admissions, p < 0.001), and shorter time to death (predicted time to death 7.64 days for highest versus 9.05 days for lowest quintile of admissions, p < 0.001; 8.28 days for highest versus 9.06 days for lowest quintile of census, only in closed ICUs, p = 0.006). Time to DNR order significantly mediated relationships between acuity and admissions and time to death, explaining the entire effect of acuity, and 65 % of the effect of admissions. There was no association between strain and time to death for decedents without a limitation in therapy. CONCLUSIONS Strains in ICU capacity are associated with end-of-life decision-making, with shorter times to placement of DNR orders and death for patients admitted during high-strain days.
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Affiliation(s)
- May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street PH5, Room 527D, New York, NY, 10032, USA.
| | - Scott D Halpern
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Nicole B Gabler
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Canada
- Department of Anesthesia and Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA
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Cremer R, Lervat C, Laffargue A, Le Cunff J, Joriot S, Minnaert C, Cuisset JM, Mention K, Thomas D, Guimber D, Matthews A, Fayoux P, Storme L, Vandoolaeghe S. Comment organiser la délibération collégiale pour limiter ou arrêter les traitements en pédiatrie ? Arch Pediatr 2015; 22:1119-28. [DOI: 10.1016/j.arcped.2015.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 05/15/2015] [Accepted: 08/13/2015] [Indexed: 11/29/2022]
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Paoletti M, Litnhouvongs MN, Tandonnet J. [Development, implementation, and analysis of a "collaborative decision-making for reasonable care" document in pediatric palliative care]. Arch Pediatr 2015; 22:498-504. [PMID: 25840464 DOI: 10.1016/j.arcped.2015.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 12/10/2014] [Accepted: 02/10/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In France, a legal framework and guidelines state that decisions to limit treatments (DLT) require a collaborative decision meeting and a transcription of decisions in the patient's file. The do-not-attempt-resuscitation order involves the same decision-making process for children in palliative care. To fulfill the law's requirements and encourage communication within the teams, the Resource Team in Pediatric Palliative Care in Aquitaine created a document shared by all children's hospital units, tracing the decision-making process. This study analyzed the decision-making process, quality of information transmission, and most particularly the relevance of this new "collaborative decision-making for reasonable care" card. MATERIAL AND METHODS Retrospective study evaluating the implementation of a traceable document relating the DLT process. All the data sheets collected between January and December 2013 were analyzed. RESULTS A total of 58 data sheets were completed between January and December 2013. We chose to collect the most relevant data to evaluate the relevance of the items to be completed and the transmission of the document, to draw up the patients' profile, and the contents of discussions with families. Of the 58 children for whom DLT was discussed, 41 data sheets were drawn up in the pediatric intensive care unit, seven in the oncology and hematology unit, five in the neonatology unit, four in the neurology unit, and one in the pneumology unit. For 30 children, one sheet was created, for 11 children, two sheets and for two children, three sheets were filled out. Thirty-nine decisions were made for withholding lifesaving treatment, 11 withdrawing treatment, and for five children, no limitation was set. Nine children survived after DLT. Of the 58 data sheets, only 31 discussions with families were related to the content of the data sheet. Of the 14 children transferred out of the unit with a completed data sheet, it was transmitted to the new unit for 11 children (79%). DISCUSSION The number of data sheets collected in 1 year shows the value of this document. The participation of several pediatric specialities' referents in its creation, then its progressive presentation in the children's hospital units, were essential steps in introducing and establishing its use. Items describing the situation, management proposals, and adaptation of the children's supportive care were completed in the majority of cases. They correspond to a clinical description, the object of the discussion, and the daily caregiver's practices, respectively. On the other hand, discussions with families were related to the card's contents in only 53% of the cases. This can be explained by the time required to complete the DLT process. It is difficult for referring doctors to systematically, faithfully, and objectively transcribe discussions with parents. Although this process has been used for a long time in intensive care units, this document made possible an indispensable formalisation in the decision-making process. In other pediatric specialities, the sheet allowed introducing the palliative approach and was a starter and a tool for reflection on the do-not-attempt-resuscitation order, thus suggesting the need for anticipation in these situations. CONCLUSION With the implementation of this new document, the DLT, data transmission, and continuity of care conditions were improved in the children's hospital units. Sharing this sheet with all professionals in charge of these children would support homogeneity and quality of management and care for children and their parents.
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Affiliation(s)
- M Paoletti
- Équipe ressource régionale de soins palliatifs pédiatriques aquitaine, groupe hospitalier Pellegrin, hôpital des enfants, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France.
| | - M-N Litnhouvongs
- Équipe ressource régionale de soins palliatifs pédiatriques aquitaine, groupe hospitalier Pellegrin, hôpital des enfants, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - J Tandonnet
- Équipe ressource régionale de soins palliatifs pédiatriques aquitaine, groupe hospitalier Pellegrin, hôpital des enfants, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
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de Vos MA, Bos AP, Plötz FB, van Heerde M, de Graaff BM, Tates K, Truog RD, Willems DL. Talking with parents about end-of-life decisions for their children. Pediatrics 2015; 135:e465-76. [PMID: 25560442 DOI: 10.1542/peds.2014-1903] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) from their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision-making process. METHODS We conducted a prospective exploratory study in 2 Dutch University Medical Centers. RESULTS Overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audio recorded, ranging from 1 to 8 meetings per patient. By means of a coding instrument we quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in 2 cases were parents asked to share in the decision-making. Despite their intense emotions, most parents made great effort to actively participate in the conversation. They did this by asking for clarifications, offering their preferences, and reacting to the decision being proposed (mostly by expressing their assent). In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision. CONCLUSIONS We conclude that parents are able to handle a more active role than they are currently being given. Parents' greatest concern is that their child might suffer.
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Affiliation(s)
- Mirjam A de Vos
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands;
| | - Albert P Bos
- Department of Paediatric Intensive Care, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Frans B Plötz
- Department of Paediatrics, Tergooiziekenhuizen, Hilversum, Netherlands
| | - Marc van Heerde
- Department of Paediatric Intensive Care, VU University Medical Centre, Amsterdam, Netherlands
| | - Bert M de Graaff
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, Netherlands
| | - Kiek Tates
- Department of Communication and Information Studies, Tilburg University, Tilburg, Netherlands; and
| | - Robert D Truog
- Division of Critical Care Medicine, Boston Children's Hospital; Division of Medical Ethics, Harvard Medical School, Boston, Massachusetts
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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Opinions des soignants des réanimations pédiatriques françaises sur l’application de la loi Léonetti. Arch Pediatr 2014; 21:34-43. [DOI: 10.1016/j.arcped.2013.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 10/18/2013] [Accepted: 10/23/2013] [Indexed: 11/16/2022]
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Cremer R, Binoche A, le Reun C, Hubert P. Devenir des enfants quittant la réanimation après une décision de limitation ou d’arrêt des traitements. État des connaissances en France. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13546-013-0734-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bordet F, Bouvier-Jambon G, Didier C, Javouhey E. [Epidemiology and evaluation of withdrawing and withholding of treatment procedure in a pediatric intensive care unit]. ACTA ACUST UNITED AC 2012. [PMID: 23182182 DOI: 10.1016/j.annfar.2012.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Leonetti Law of 2005 concerns procedures for questioning about the appropriateness of initiating or maintaining life-sustaining treatments. Decision of withdrawing and withholding treatment has long been practiced by neonatologists, adult and pediatricians intensivists. In this regard, the recommendations of societies encourage medical teams to assess their practices to improve them. Our evaluation is based on the document of the Ethics Committee of SRLF edited in 2010. TYPE OF STUDY We achieved a retrospective evaluation of professional practices of the transcription of our decisions of withdrawing and withholding treatment. PATIENTS AND METHODS This study included all children (95 patients) who have had a questioning about life-sustaining treatment of ICU between March 2008 and August 2011 in the pediatric intensive care unit of Children's Hospital of Lyon. Our evaluation is based on the document of the Ethics Committee of French Society of intensive care (SRLF) edited in 2010. We collected epidemiological data on children concerned by questioning about the appropriateness of initiating or maintaining LST and an evaluation of the transcription of our procedures for LST in our folders. Evaluation included 40 cases: 20 folders randomly selected prior an information meeting (January 2011) which were compared with 20 cases occurred consecutively after this information. This meeting was intended to remind recommendations of good practice and principal points of the law. The main assessment measure was the improvement of the practices respecting criteria of the document of the Ethics Committee of SRLF modified for pediatric care. MAIN RESULTS Epidemiological data on procedures are comparable to literature data. Concerning the evaluation of our practices before/after a briefing and highlighted a tendency to the improvement without statistically significance. The transcription of reflection and the arguments of decision of withdrawing and withholding treatment and evaluation of pain was the points who need improvement. Finally, despite the positive developments in the therapeutic use of analgesics and sedatives, pain continues to be undervalued. CONCLUSION The evaluation of professional practices is recommended to improve the procedures of questioning about life-sustaining treatments have become an area of expertise in intensive care.
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Affiliation(s)
- F Bordet
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, 59 boulevard Pinel, Lyon-Bron, France.
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Cremer R, Fayoux P, Guimber D, Joriot S, Laffargue A, Lervat C, Matthews A, Mention K, Sfeir R, Storme L, Thomas D, Thumerelle C, Vandoolaeghe S. Le médecin consultant pour les limitations et les arrêts de traitement en pédiatrie. Arch Pediatr 2012; 19:856-62. [DOI: 10.1016/j.arcped.2012.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 03/19/2012] [Accepted: 05/16/2012] [Indexed: 10/26/2022]
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17
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Devenir des malades qui survivent après une décision de limitation ou d'arrêt de traitements en réanimation. Arch Pediatr 2012. [DOI: 10.1016/s0929-693x(12)71179-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cremer R. Le médecin consultant, une chance pour l’interdisciplinarité. Arch Pediatr 2012. [DOI: 10.1016/s0929-693x(12)71180-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, De Backer D, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2011: I. Nephrology, epidemiology, nutrition and therapeutics, neurology, ethical and legal issues, experimentals. Intensive Care Med 2012; 38:192-209. [PMID: 22215044 PMCID: PMC3291847 DOI: 10.1007/s00134-011-2447-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 12/29/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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