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Sarpal A, Miller MR, Martin CM, Sibbald RW, Speechley KN. Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers. Front Pediatr 2024; 12:1272648. [PMID: 38304746 PMCID: PMC10830678 DOI: 10.3389/fped.2024.1272648] [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: 08/04/2023] [Accepted: 01/03/2024] [Indexed: 02/03/2024] Open
Abstract
Background Potentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited. Objectives Determine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate. Methods Prospective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0-17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale. Results Of 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty. Conclusions While treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.
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Affiliation(s)
- Amrita Sarpal
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Michael R. Miller
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Claudio M. Martin
- Lawson Health Research Institute, London, ON, Canada
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Robert W. Sibbald
- Department of Ethics, London Health Sciences Centre, London, ON, Canada
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kathy N. Speechley
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Schouela N, Kyeremanteng K, Thompson LH, Neilipovitz D, Shamy M, D'Egidio G. Cost of Futile ICU Care in One Ontario Hospital. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2021; 58:469580211028577. [PMID: 34218711 PMCID: PMC8261843 DOI: 10.1177/00469580211028577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Critical care is a costly and finite resource that provides the ability to manage
patients with life-threatening illnesses in the most advanced forms available.
However, not every condition benefits from critical care. There are
unrecoverable health states in which it should not be used to perpetuate. Such
situations are considered futile. The determination of medical futility remains
controversial. In this study we describe the length of stay (LOS), cost, and
long-term outcomes of 12 cases considered futile and that have been or were
considered for adjudication by Ontario’s Consent and Capacity Board (CBB). A
chart review was undertaken to identify patients admitted to the Intensive Care
Unit (ICU), whose care was deemed futile and cases were considered for, or
brought before the CCB. Costs for each of these admissions were determined using
the case-costing system of The Ottawa Hospital Data Warehouse. All 12 patients
identified had a LOS of greater than 4 months (range: 122-704 days) and a median
age 83.5 years. Seven patients died in hospital, while 5 were transferred to
long term or acute care facilities. All patients ultimately died without
returning to independent living situations. The total cost of care for these 12
patients was $7 897 557.85 (mean: $658 129.82). There is a significant economic
cost of providing resource-intensive critical care to patients in which these
treatments are considered futile. Clinicians should carefully consider the
allocation of finite critical care resources in order to utilize them in a way
that most benefits patients.
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Affiliation(s)
| | | | | | | | - Michel Shamy
- University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Abstract
INTRODUCTION Studies have suggested 5-20% of paediatric ICU patients may receive care felt to be futile. No data exists on the prevalence and impact of futile care in the Paediatric Cardiac ICU. The aim is to determine the prevalence and economic impact of futile care. MATERIALS AND METHOD Retrospective cohort of patients with congenital cardiac disease 0-21 years old, with length of stay >30 days and died (2015-2018). Documentation of futility by the medical team was retrospectively and independently reviewed. RESULTS Of the 127 deaths during the study period, 51 (40%) had hospitalisation >30 days, 13 (25%) had received futile care and 26 (51%) withdrew life-sustaining treatment. Futile care comprised 0.69% of total patient days with no difference in charges from patients not receiving futile care. There was no difference in insurance, single motherhood, education, income, poverty, or unemployment in families continuing futile care or electing withdrawal of life-sustaining treatment. Black families were less likely than White families to elect for withdrawal (p = 0.01), and Hispanic families were more likely to continue futile care than non-Hispanics (p = 0.044). CONCLUSIONS This is the first study to examine the impact of futile care and characteristics in the paediatric cardiac ICU. Black families were less likely to elect for withdrawal, while Hispanic families more likely to continue futile care. Futile care comprised 0.69% of bed days and little burden on resources. Cultural factors should be investigated to better support families through end-of-life decisions.
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Masri C, Farrell CA, Lacroix J, Rocker G, Shemie SD. Decision Making and End-of-Life Care in Critically Ill Children. J Palliat Care 2019. [DOI: 10.1177/082585970001601s09] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives 1) To comment on the medical literature on decision making regarding end-of-life therapy, 2) to analyze the data on disagreement about such therapy, including palliative care, and withholding and withdrawal practices for critically ill children in the pediatric intensive care unit (PICU), and 3) to make some general recommendations. Data Sources and Study Selection All papers published in peer-reviewed journals, and all chapters on end-of-life therapy, or on conflict between parents and caregivers about end-of-life decisions in the PICU were retrieved. Results We found three case series, three systematic descriptive studies, two qualitative studies, four surveys, and many legal opinions, editorials, reviews, guidelines, and book chapters. The main determinants of end-of-life decisions are the child's age, premorbid cognitive condition and functional status, pain or discomfort, probability of survival, and quality of life. Risk factors in persistent conflict between parents and caregivers about end-of-life care include a grave underlying condition or an unexpected and severe event. Conclusion Making decisions about end-of-life care is a frequent event in the PICU. Children may need both intensive care and palliative care concurrently at different stages of their illness. Disagreements are more likely to be resolved if the root cause of the conflict is better understood.
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Affiliation(s)
- Christian Masri
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Catherine Ann Farrell
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Jacques Lacroix
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Graeme Rocker
- Department of Medicine, The Queen Elizabeth II Health Center, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Sam D. Shemie
- Pediatric Intensive Care Unit, The Hospital For Sick Children, and Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Carter HE, Winch S, Barnett AG, Parker M, Gallois C, Willmott L, White BP, Patton MA, Burridge L, Salkield G, Close E, Callaway L, Graves N. Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study. BMJ Open 2017; 7:e017661. [PMID: 29038186 PMCID: PMC5652539 DOI: 10.1136/bmjopen-2017-017661] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To estimate the incidence, duration and cost of futile treatment for end-of-life hospital admissions. DESIGN Retrospective multicentre cohort study involving a clinical audit of hospital admissions. SETTING Three Australian public-sector tertiary hospitals. PARTICIPANTS Adult patients who died while admitted to one of the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES Incidences of futile treatment among end-of-life admissions; length of stay in both ward and intensive care settings for the duration that patients received futile treatments; health system costs associated with futile treatments; monetary valuation of bed days associated with futile treatment. RESULTS The incidence rate of futile treatment in end-of-life admissions was 12.1% across the three study hospitals (range 6.0%-19.6%). For admissions involving futile treatment, the mean length of stay following the onset of futile treatment was 15 days, with 5.25 of these days in the intensive care unit. The cost associated with futile bed days was estimated to be $AA12.4 million for the three study hospitals using health system costs, and $A988 000 when using a decision maker's willingness to pay for bed days. This was extrapolated to an annual national health system cost of $A153.1 million and a decision maker's willingness to pay of $A12.3 million. CONCLUSIONS The incidence rate and cost of futile treatment in end-of-life admissions varied between hospitals. The overall impact was substantial in terms of both the bed days and cost incurred. An increased awareness of these economic costs may generate support for interventions designed to reduce futile treatments. We did not include emotional hardship or pain and suffering, which represent additional costs.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Australia
| | - Sarah Winch
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Adrian G Barnett
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Australia
| | - Malcolm Parker
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Cindy Gallois
- School of Psychology, The University of Queensland, Brisbane, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Australia
| | - Mary Anne Patton
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Letitia Burridge
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Gayle Salkield
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Australia
| | - Leonie Callaway
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Australia
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Vose LA, Nelson RM. Ethical Issues Surrounding Limitation and Withdrawal of Support in the Pediatric Intensive Care Unit. J Intensive Care Med 2016. [DOI: 10.1177/088506669901400502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Wilkinson D. Which newborn infants are too expensive to treat? Camosy and rationing in intensive care. JOURNAL OF MEDICAL ETHICS 2013; 39:502-506. [PMID: 23355229 DOI: 10.1136/medethics-2012-100745] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Are there some newborn infants whose short- and long-term care costs are so great that treatment should not be provided and they should be allowed to die? Public discourse and academic debate about the ethics of newborn intensive care has often shied away from this question. There has been enough ink spilt over whether or when for the infant's sake it might be better not to provide life-saving treatment. The further question of not saving infants because of inadequate resources has seemed too difficult, too controversial, or perhaps too outrageous to even consider. However, Roman Catholic ethicist Charles Camosy has recently challenged this, arguing that costs should be a primary consideration in decision-making in neonatal intensive care. In the first part of this paper I will outline and critique Camosy's central argument, which he calls the 'social quality of life (sQOL)' model. Although there are some conceptual problems with the way the argument is presented, even those who do not share Camosy's Catholic background have good reason to accept his key point that resources should be considered in intensive care treatment decisions for all patients. In the second part of the paper, I explore the ways in which we might identify which infants are too expensive to treat. I argue that both traditional personal 'quality of life' and Camosy's 'sQOL' should factor into these decisions, and I outline two practical proposals.
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Affiliation(s)
- Dominic Wilkinson
- Robinson Institute, Discipline of Obstetrics and Gynecology, University of Adelaide, North Adelaide, South Australia, Australia.
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Abstract
Rationing is the allocation of scarce resources, which in health care necessarily entails withholding potentially beneficial treatments from some individuals. Rationing is unavoidable because need is limitless and resources are not. How rationing occurs is important because it not only affects individual lives but also expresses society's most important values. This article discusses the following topics: (1) the inevitability of rationing of social goods, including medical care; (2) types of rationing; (3) ethical principles and procedures for fair allocation; and (4) whether rationing ICU care to those near the end of life would result in substantial cost savings.
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Affiliation(s)
- Leslie P Scheunemann
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina Hospitals, Chapel Hill, NC; Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Douglas B White
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina Hospitals, Chapel Hill, NC; Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, PA.
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10
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[Prolonged stay in pediatric intensive care units: mortality and healthcare resource consumption]. Med Intensiva 2011; 35:417-23. [PMID: 21620524 DOI: 10.1016/j.medin.2011.04.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 04/04/2011] [Accepted: 04/06/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To analyze mortality and resource consumption in patients with long stays in pediatric intensive care units (PICUs). DESIGN A retrospective, descriptive case series study. SCOPE Medical-surgical PICU in a third level hospital. PATIENTS Data were collected from patients with a stay of 28 days or more in PICU between 2006 and 2010. Of the 2118 patients assisted in this period, 83 (3.9%) required prolonged stay. STUDY VARIABLES Morbidity-mortality and resource consumption among patients with prolonged stay in the PICU. RESULTS Mortality was higher in patients with a long stay (22.9%) than in the rest of patients (2%) (p<0.001). In 52.6% of these patients, death occurred after withdrawal of treatment or after not starting resuscitation measures. Patients with prolonged stay showed a high incidence of nosocomial infection (96.3%) and an important consumption of healthcare resources (97.6% required conventional mechanical ventilation, 90.2% required transfusion of blood products, 86.7% required intravenous vasoactive drugs and 22.9% required extracorporeal membrane oxygenation [ECMO]). CONCLUSIONS Critical children with prolonged stay in the PICU show important morbidity and mortality, and an important consumption of healthcare resources. The adoption of specific measures permitting early identification of patients at risk of prolonged stay is needed in order to adapt therapeutic measures and available resources, and to improve treatment efficiency.
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Truog RD, Meyer EC, Burns JP. Toward interventions to improve end-of-life care in the pediatric intensive care unit. Crit Care Med 2007; 34:S373-9. [PMID: 17057601 DOI: 10.1097/01.ccm.0000237043.70264.87] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although children account for only about 3% of all deaths that occur in the United States each year, these patients and their families have needs that are uniquely different from those of adult patients. To date, however, no research on interventions to improve end-of-life care in the pediatric intensive care unit (PICU) has been performed. This review seeks to facilitate and inform future interventional studies by summarizing existing descriptive data about end-of-life care in this setting. These data are organized around six domains that have been identified as critical to high-quality, family-centered care: 1) support of the family unit; 2) communication with the child and family about treatment goals and plans; 3) ethics and shared decision making; 4) relief of pain and other symptoms; 5) continuity of care; and 6) grief and bereavement support. These data are integrated and used to develop evidence-based suggestions for a variety of interventions that could be implemented and then evaluated for their potential contribution to improving the care of children dying in the PICU.
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Affiliation(s)
- Robert D Truog
- Medical Ethics, Harvard Medical School, Boston, Massachusetts, USA
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Fortune PM. Limiting and rationing treatment in paediatric and neonatal intensive care. Best Pract Res Clin Anaesthesiol 2007; 20:577-88. [PMID: 17219942 DOI: 10.1016/j.bpa.2006.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In this chapter I consider the ethical decisions surrounding the provision and limitation of treatment offered to children requiring intensive care. I focus on the processes surrounding end of life decision making and consider how the concepts of futility, burden and uncertainty should impact upon these decisions. I also examine resource allocation to children's critical care services. The discussion does not provide a structure that will solve any given situation. It does take a practical approach to the issues faced by considering why we should engage in life limiting discussions; When they should occur; Who should be involved; How they should be carried out; and where and by what means withholding or withdrawal should occur. I have drawn the discussions closer to clinical practice with the intention of making them more useful, for those engaged in direct patient care, than those focused around philosophical principles.
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Affiliation(s)
- Peter-Marc Fortune
- Royal Manchester Children's Hospital, Pendlebury, Manchester M20 3FJ, UK.
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Abstract
Patients and families in NICU and PICU settings can be well served by fundamental palliative care approaches during curative and end-of-life care.A wide variety of patients are suitable for these services. Although barriers exist to implementing these teams within the ICU, the concepts remain sound,and models for successful integration of practices in these settings exist.
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Affiliation(s)
- Brian S Carter
- Pediatric Advance Comfort Team, Department of Pediatrics, Vanderbilt Children's Hospital (Neonatology), 11111 Doctor's Office Tower, Nashville, TN 37232-9544, USA
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Abstract
BACKGROUND Over recent years, there have been increasing concerns regarding an increase in the number of futile and inappropriate admissions to pediatric intensive care units (PICUs) in the United Kingdom (UK). METHODS A prospective cross-sectional survey was carried out using a data collection form distributed by mail to the directors of all PICUs in the UK. Respondents were asked to give details of all patients on their unit on a specific day including age, reason for admission and any preexisting medical conditions. An assessment was made by respondents of whether the care being provided in each case was, in their opinion, appropriate, futile or inappropriate according to standard definitions. RESULTS We received responses from 21 units (68%) who reported the details of 111 patients. Care was felt to be appropriate in 88 of these cases (79%), futile in nine cases (8%) and inappropriate in 14 cases (13%). Futile cases were most commonly admitted with respiratory failure and all had preexisting medical conditions, most commonly developmental delay. Where care was felt to be inappropriate, respiratory failure was again the most common reason for admission and all had a preexisting medical condition, most commonly cardiovascular disease. CONCLUSIONS The care being provided in 21% of the PICU cases, described in this study, was felt to be either futile or inappropriate by the directors of those units. There is an urgent need to, accurately, establish the resource consumption associated with these patients and to establish a standard approach to futility and inappropriate care in PICU in the UK.
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Affiliation(s)
- Gopi Vemuri
- Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK
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Abstract
All surgeons must take risks when providing medical care. No guarantees of protection from a lawsuit exist in any guise. Concerning postoperative futile care, the stakes are high when withdrawal of support seems to be indicated but the surrogate believes in sanctity-of-life and demands continued aggressive care. Open-ended questions posed to the family may initiate a dialog that help the surgeon understand their values and negotiate a resolution. Other preventive measures can also reduce the chance of conflict and potential liability. "Do what's right" is a proverbial motto in surgical training and clinical practice. To some surgeons, it may be to honor the wishes of the family surrogate. To others, the right thing may be to withdraw care in the best interest of the patient. If so, "do what's right" is not just to "stop the train." It also consists of a range of clinical activities, including effective communication, emotional care, and pursuing a fair and open negotiation process established by the institution. Properly conducted, "stopping the train" should incur no greater risk for professional liability than any other challenging procedure that surgeons perform. Withdrawal of futile care should be considered as a procedure, and as such, the skills to deliver it should be mastered like any other.
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Affiliation(s)
- K Francis Lee
- Department of Surgery, Baystate Medical Center Tufts University School of Medicine, Springfield, MA 01199, USA.
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Torreão LDA, Pereira CR, Troster E. Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit. ACTA ACUST UNITED AC 2004; 59:3-9. [PMID: 15029279 DOI: 10.1590/s0041-87812004000100002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify the prevalence of management plans and decision-making processes for terminal care patients in pediatric intensive care units. METHODOLOGY Evidence-based medicine was done by a systematic review using an electronic data base (LILACS, 1982 through 2000) and (MEDLINE, 1966 through 2000). The key words used are listed and age limits (0 to 18 years) were used. RESULTS One hundred and eighty two articles were found and after selection according to the exclusion/inclusion criteria and objectives 17 relevant papers were identified. The most common decisions found were do-not-resuscitation orders and withdrawal or withholding life support care. The justifications for these were "imminent death" and "unsatisfatory quality of life". CONCLUSION Care management was based on ethical principles aiming at improving benefits, avoiding harm, and when possible, respecting the autonomy of the terminally ill patient.
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Affiliation(s)
- Lara de Araújo Torreão
- São Rafael Hospital and Pediatric Wards, Hospital das Clínicas, Federal University of Bahia, Salvador, BA, Brazil
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Abstract
AIMS To determine the extent of futile care provided to critically ill children admitted to a paediatric intensive care setting. METHODS Prospective evaluation of consecutive admissions to a 20 bedded multidisciplinary paediatric intensive care unit of a North London teaching hospital over a nine month period. Three previously defined criteria for futility were used: (1) imminent demise futility (those with a mortality risk greater than 90% using the Paediatric Risk of Mortality (PRISM II) score); (2) lethal condition futility (those with conditions incompatible with long term survival); and (3) qualitative futility (those with unacceptable quality of life and high morbidity). RESULTS A total of 662 children accounting for 3409 patient bed days were studied. Thirty four patients fulfilled at least one of the criteria for futility, and used a total of 104 bed days (3%). Only 33 (0.9%) bed days were used by patients with mortality risk greater than 90%, 60 (1.8%) by patients with poor long term prognosis, and 16 (0.5%) by those with poor quality of life. Nineteen of 34 patients died; withdrawal of treatment was the mode of death in 15 (79%). CONCLUSIONS Cost containment initiatives focusing on futility in the paediatric intensive care unit setting are unlikely to be successful as only relatively small amounts of resources were used in providing futile care. Paediatricians are recognising futility early and may have taken ethically appropriate measures to limit care that is futile.
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Affiliation(s)
- A Y Goh
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London WC1N 3JH, UK.
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Hallahan AR, Shaw PJ, Rowell G, O'Connell A, Schell D, Gillis J. Improved outcomes of children with malignancy admitted to a pediatric intensive care unit. Crit Care Med 2000; 28:3718-21. [PMID: 11098979 DOI: 10.1097/00003246-200011000-00030] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the acute and long-term outcomes of children admitted to the intensive care unit with cancer or complications after bone marrow transplantation. DESIGN Retrospective analysis of databases from a prospective pediatric intensive care unit (PICU) database supplemented by case notes review. SETTING A PICU in a tertiary pediatric hospital. PATIENTS All children with malignancy admitted to the PICU between May 1, 1987, and April 30, 1996. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 206 admissions to the PICU during a 9-yr study period of 150 children with malignancies or complications after bone marrow transplantation. Forty patents died in the PICU (27% mortality rate). The most frequent indications for PICU admission were shock and respiratory disease. Of 56 children admitted with shock, there were 16 deaths (29% mortality rate). In 24 episodes of sepsis, inotropic and ventilatory support were required and 13 patients (54%) survived. Analysis of long-term survival gave estimates of 50% survival for all oncology patients admitted to the PICU and 42% for those admitted for shock. CONCLUSIONS A high proportion of oncology patients admitted to the PICU requiring intensive intervention survive and go on to be cured of their malignancy. Our study suggests the PICU outcome for these patients has improved.
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Affiliation(s)
- A R Hallahan
- Pediatric Intensive Care Unit, The Royal Alexandra Hospital for Children, The New Children's Hospital, Sydney, Australia
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Vose LA, Nelson RM. Ethical Issues Surrounding Limitation and Withdrawal of Support in the Pediatric Intensive Care Unit. J Intensive Care Med 1999. [DOI: 10.1046/j.1525-1489.1999.00220.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
OBJECTIVES To compare pediatric intensive care unit (ICU) mortality risk using models from two distinct time periods; and to discuss the implications of changing mortality risk for severity systems and quality-of-care assessment. DATA SOURCES AND SETTING Consecutive admissions (n = 10,833) from 16 pediatric ICUs across the United States that participate in the Pediatric Critical Care Study Group were recorded prospectively. Data collection occurred during a 12-mo period beginning in January 1993. METHODS Data collection for the development and validation of the original Pediatric Risk of Mortality (PRISM) score occurred from 1980 to 1985. The original PRISM coefficients were used to calculate mortality probabilities in the current data set. Updated estimates of mortality probabilities were calculated, using coefficients from a logistic regression analysis using the original PRISM variable set. Quality-of-care tests were performed using standardized mortality ratios. RESULTS Risk of mortality from pediatric ICU admission improved considerably between the two periods. Overall, the reduction in mortality risk averaged 15% (p < .001). Analysis of mortality risk by age indicated a large improvement for younger infants. The mortality risk for infants <1 mo improved by 39% (p < .001). Mortality risk improved by 28% (p < .001) for infants between 1 and 12 mos. Analysis of mortality risk by principal diagnosis indicated substantial improvement in respiratory diseases, including respiratory diseases developing in the perinatal period. The mortality risk for respiratory diseases improved by 45% (p < .001). The improvement in mortality risk substantially deteriorated the calibration of the original PRISM severity system (p < .001). As a result of changing mortality risk, the standardized mortality ratios across the 16 pediatric ICUs demonstrated substantial disparities, depending on the choice of models. CONCLUSIONS This study documents differences in pediatric ICU risk of mortality over time that are consistent with a general improvement in the quality of pediatric intensive care. Despite continued widespread use of the original PRISM, recent improvements in pediatric ICU quality of care have negated its usefulness for many intended applications, including quality-of-care assessment.
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Affiliation(s)
- J M Tilford
- Department of Pediatrics, University of Arkansas for Medical Sciences, and Arkansas Children's Hospital, Little Rock 72202-3591, USA.
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Cooper TR, Berseth CL, Adams JM, Weisman LE. Actuarial survival in the premature infant less than 30 weeks' gestation. Pediatrics 1998; 101:975-8. [PMID: 9606222 DOI: 10.1542/peds.101.6.975] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Because survival from admission to discharge does not provide parents and physicians information about future life expectancy in the premature neonate, we characterized the actuarial survival, defined as the future life expectancy from a given postnatal age, in a large inborn population of premature infants < 30 weeks' gestation. STUDY DESIGN We determined daily actuarial survival of 1925 inborn infants (23 to 29 weeks' gestation) admitted to the Baylor Affiliated Nurseries from July 1986 through December 1994, stratified by 100-g birth weight and by 1-week gestational-age intervals. RESULTS In the 501- to 600-g birth weight stratum, actuarial survival improved from 31% at birth, to 61% on day of life 7, and then to 75% on day of life 28; in the 901- to 1000-g birth weight stratum, actuarial survival improved from 88%, to 94%, and then to 98% throughout the same times, respectively. Similar trends were obtained when data were stratified by gestational age. CONCLUSIONS Survival in the smallest infants improves dramatically during the first few days of life, but there is a significant risk for late death in the smallest of these infants.
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Affiliation(s)
- T R Cooper
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030, USA
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Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997; 25:887-91. [PMID: 9187612 DOI: 10.1097/00003246-199705000-00028] [Citation(s) in RCA: 178] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Society must always face the reality of limited medical resources and must find mechanisms for distributing these resources fairly and efficiently. One recent approach for distributing limited medical resources has been the development of policies that limit the availability of futile treatments. The objectives of this consensus statement are as follows: a) to define futility and thereby enable a clear discussion of the issues; and b) to identify principles and procedures for resolving cases in which life-sustaining treatment may be futile or inadvisable. DATA SOURCES A literature review, synthesis, and committee discussion. CONCLUSIONS Treatments should be defined as futile only when they will not accomplish their intended goal. Treatments that are extremely unlikely to be beneficial, are extremely costly, or are of uncertain benefit may be considered inappropriate and hence inadvisable, but should not be labeled futile. Futile treatments constitute a small fraction of medical care. Thus, employing the concept of futile care in decision-making will not primarily contribute to a reduction in resource use. Nonetheless, communities have a legitimate interest in allocating medical resources by limiting inadvisable treatments. Communities should seek to do so using a rationale that is explicit, equitable, and democratic; that does not disadvantage the disabled, poor, or uninsured; and that recognizes the diversity of individual values and goals. Policies to limit inadvisable treatment should have the following characteristics: a) be disclosed in the public record; b) reflect moral values acceptable to the community; c) not be based exclusively on prognostic scoring systems; d) articulate appellate mechanisms; and e) be recognized by the courts. Healthcare organizations that control payment have a profound influence on treatment decisions and should formally address criteria for determining when treatments are inadvisable and should share accountability for those decisions.
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