Ethical issues in the pediatric intensive care unit

Circumstances surrounding end of life in a pediatric intensive care unit

OBJECTIVE

Approximately 60% of deaths in pediatric intensive care units follow limitation or withdrawal of life-sustaining treatment (LST). We aimed to describe the circumstances surrounding decision making and end-of-life care in this setting.

METHODS

We conducted a prospective, descriptive study based on a survey with the intensivist after every consecutive death during an 8-month period in a single multidisciplinary pediatric intensive care unit. Summary statistics are presented as percentage, mean +/- standard deviation, or median and range; data are compared using the Mantel-Haenszel test and shown as survival curves.

RESULTS

Of the 99 observed deaths, 27 involved failed cardiopulmonary resuscitation; of the remaining 72, 39 followed withdrawal/limitation (W/LT) of LST, 20 were do not resuscitate (DNR), and 13 were brain deaths (BDs). Families initiated discussions about forgoing LST in 24% (17 of 72) of cases. Consensus between caregivers and staff about forgoing LST as the best approach was reached after the first meeting with 51% (35 of 68) of families; 46% (31 of 68) required >or=2 meetings (4 not reported). In the DNR group, the median time to death after consensus was 24 hours and for W/LT was 3 hours. LST was later withdrawn in 11 of 20 DNR cases. The family was present in 76% (45 of 59) of cases when LST was forgone. The dying patient was held by the family in 78% (35 of 45) of these occasions.

CONCLUSIONS

More than 1 formal meeting was required to reach consensus with families about forgoing LST in almost half of the patients. Families often held their child at the time of death. The majority of children died quickly after the end-of-life decision was made.

The death of a child in the emergency department

The death of a child in the emergency department (ED) is often overwhelming to the child's community, including the health care providers involved in that child's care. Sudden death, especially of a child, induces a strong emotional response in health care providers and in the families involved. Advanced preparation by emergency staff is vital to appropriately care for the patient, the grieving family, and the ED staff. The American College of Emergency Physicians and the American Academy of Pediatrics have jointly adopted a policy statement entitled "Death of a Child in the Emergency Department Joint Statement by the American Academy of Pediatrics and the American College of Emergency Physicians." The purpose of this article is to provide the emergency physician with information related to the management of children and their families who die in the ED. The following important issues will be discussed: a family and team-centered approach when a child dies, support for families and communities, communication within the child's medical home, identification of resources for use when a child dies, and critical incident stress management.

Withdrawing life-sustaining medical treatment--a physician's personal reflection

The decision to withhold or withdraw artificially provided hydration and nutrition is one which evolves over time and must be made jointly by the medical team and the patient's family. Although withholding nutrition can be argued to be ethical and appropriate for certain clinical scenarios, it is still a decision which can be difficult to make and, because of different social and legal issues, can be difficult to carry out. This is the story of one physician's journey as he worked with the mother and father of a young child who suffered a severe neurological injury and was left in a persistent vegetative state.

Training pediatric house staff in evidence-based ethics: an exploratory controlled trial

OBJECTIVE

To evaluate an educational intervention in evidence-based ethics (emphasizing clinical knowledge, epidemiologic skills, and recognition of ethical issues) administered to house staff before rotating through our neonatal intensive care unit.

STUDY DESIGN

A controlled trial of 64 pediatric house staff assigned to alternating control and intervention rotations. Questionnaires were administered at the end of the rotation.

RESULTS

Some benefits of the intervention were observed. However, a large percentage of intervention and control house staff substantially overestimated (>1.25 correct value) predischarge mortality (23% vs. 55% of house staff; p<0.02), mortality or major morbidity (74% vs. 46% of house staff; p=0.04), and cerebral palsy rates (70% vs. 87%; p=0.12). Neither group cited many methodological criteria for evaluating follow-up studies (3.3 vs. 2.4 criteria; p=0.05) or ethical issues considered in treatment recommendations for extremely premature infants (3.1 vs. 2.8 issues; p=0.35).

CONCLUSION

Improved house staff training in evidence-based ethics is needed.

Termination of extracorporeal membrane oxygenation for cardiac support

The determination of when to stop extracorporeal membrane oxygenation (ECMO) rests upon demonstration of the return of adequate cardiac function to support vital organs and permit subsequent recovery. In general, patients with myocardial stun will recover function within several days. Factors that limit recovery include elevated end diastolic pressures leading to marginal myocardial perfusion, ongoing organ damage, massive anasarca, or progressive deterioration in lung function. Following a trial of slow weaning of ECMO support to condition the heart to take over the entire system flow requirements, decannulation can be accomplished in a standard fashion. When weaning is not successful and additional time does not lead to adequate recovery of cardiac function, physicians and nurses must be prepare to realistically advise families regarding such options as cardiac transplantation or withdrawal of support. It is critically important to provide an open and nonjudgmental environment for families to make these difficult decisions. The greatest difficulties involve ethical and emotional decisions that need to be made in a timely fashion to prevent undo burden on the patient when further ECMO support is futile.

Ethically based medical decision making in the intensive care unit: residency teaching strategies

It is important that educators in the intensive care unit (ICU) provide physicians in training with the guidance and experience requisite in developing foundational skills in value-based medical practice. This article discusses the underlying philosophy of ethically based medical decision making and describes the components of an educational program in medical humanities for the ICU. In particular, the authors focus on the central role of a relationship between the patient and the caregiver.