Forgoing life-sustaining treatments: how the decision is made in French pediatric intensive care units

Factors affecting nurses' attitude toward withdrawal of life-sustaining treatment for children

PURPOSE

The purpose of study was to investigate factors affecting nurses' attitudes toward withdrawal of life-sustaining treatment in children.

DESIGN AND METHODS

This descriptive survey study included 167 nurses working at children's hospitals or children's wards. Data were collected through a structured self-administered survey in November 2022. Data were analyzed using descriptive analysis, t-test, ANOVA, the Dunnett's T3 test, Pearson's correlation coefficient, and multiple linear regression.

RESULTS

Attitude toward withdrawal of life-sustaining treatment in children showed a significant positive correlation with knowledge of life-sustaining treatment decision-making (r = 0.38, p < .001) and meaning as a subcategory of moral sensitivity (r = 0.21, p 0.008). The factors affecting attitude toward withdrawal of life-sustaining treatment in children were knowledge of life-sustaining treatment decision-making (β =0.31, p < .001) and meaning (β = 0.18, p = .015). This model showed a 21.0% explanation of attitude toward withdrawal of life-sustaining treatment in children.

CONCLUSIONS

Developing an effective educational program designed to improve nurses' knowledge and attitude toward life-sustaining treatment decision-making is necessary.

PRACTICE IMPLICATIONS

It may have a positive influence on attitudes toward withdrawal of life-sustaining treatment in children by improving child nurses' knowledge about life-sustaining treatment decision-making and moral sensitivity.

Pediatric neuropalliative care

Pediatric palliative care seeks to support quality of life for children and families affected by serious illness. Children with neurological disease are among the most frequent recipients of pediatric palliative care. Several important elements distinguish pediatric palliative care from adult practice, including a longer illness duration, longitudinal relationships over the span of years, diseases characterized by chronic fragility rather than progressive pathology, and the reliance on parents as proxy decision makers. This chapter will provide an overview of pediatric neuropalliative care, with emphasis on the types of disease trajectories, symptom management, and communication principles for supporting shared decision making with families. The role of neurology expertise is highlighted throughout, with special attention toward incorporating palliative care into pediatric neurology practice.

Compassionate de-escalation of life-sustaining treatments in pediatric oncology: An opportunity for palliative care and intensive care collaboration

Context

Approximately 40%-60% of deaths in the pediatric intensive care unit (PICU) are in the context of de-escalation of life-sustaining treatments (LSTs), including compassionate extubation, withdrawal of vasopressors, or other LSTs. Suffering at the end of life (EOL) is often undertreated and underrecognized. Pain and poor quality of life are common concerns amongst parents and providers at a child’s EOL. Integration of palliative care (PC) may decrease suffering and improve symptom management in many clinical situations; however, few studies have described medical management and symptom burden in children with cancer in the pediatric intensive care unit (PICU) undergoing de-escalation of LSTs.

Methods

A retrospective chart review was completed for deceased pediatric oncology patients who experienced compassionate extubation and/or withdrawal of vasopressor support at EOL in the PICU. Demographics, EOL characteristics, and medication use for symptom management were abstracted. Descriptive analyses were applied.

Results

Charts of 43 patients treated over a 10-year period were reviewed. Most patients (69.8%) were white males who had undergone hematopoietic stem cell transplantation and experienced compassionate extubation (67.4%) and/or withdrawal of vasopressor support (44.2%). The majority (88.3%) had a physician order for scope of treatment (POST – DNaR) in place an average of 13.9 days before death. PC was consulted for all but one patient; however, in 18.6% of cases, consultations occurred on the day of death. During EOL, many patients received medications to treat or prevent respiratory distress, pain, and agitation/anxiety. Sedative medications were utilized, specifically propofol (14%), dexmedetomidine (12%), or both (44%), often with opioids and benzodiazepines.

Conclusions

Pediatric oncology patients undergoing de-escalation of LSTs experience symptoms of pain, anxiety, and respiratory distress during EOL. Dexmedetomidine and propofol may help prevent and/or relieve suffering during compassionate de-escalation of LSTs. Further efforts to optimize institutional policies, education, and collaborations between pediatric intensivists and PC teams are needed.

Réflexions éthiques et démarche palliative intégrée dans les réanimations pédiatriques françaises en 2017

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.

Effects of Medical Transport on Outcomes in Children Requiring Intensive Care

BACKGROUND AND OBJECTIVES

The need to centralize patients for specialty care in the setting of regionalization may delay access to specialist services and compromise outcomes, particularly in a large geographic area. The aim of this study was to explore the effects of interhospital transferring of children requiring intensive care in a Canadian regionalization model.

METHODS

A retrospective cohort design with a matched pair analysis was adopted to compare the outcomes in children younger than 17 years admitted to a pediatric intensive care unit (PICU) of a Canadian children's hospital by a specialized transport team (pediatric critical care transported [PCCT] group) and those children admitted directly to PICU from its pediatric emergency department (PED group). The outcomes of interest included mortality 72 hours from initial contact with the critical care team (ie, either PICU transport team or intrahospital PICU team).

RESULTS

In total, 680 (27%) transports met our inclusion criteria, whereas 866 (7%) cases of 11 570 total PICU admissions were admitted directly from the emergency department. A total of 493 pairs were formed for the matched analyses. Odds of mortality within 72 hours in the PCCT group were significantly higher than in the PED group (odds ratio [OR]: 2.18, 95% confidence interval [CI]: 1.07-4.45; P = .032). When excluding cases who had at least one episode of cardiac arrest before involvement of the pediatric critical care (PCC) transport team, the OR dropped to 1.66 (95% CI: 0.77-3.46).

CONCLUSIONS

Children transported from nonpediatric hospitals had a higher 72-hour mortality when compared to those children admitted directly to a children's hospital PICU from its own PED in a Canadian regionalized health-care model.

Life-Sustaining Treatment Status at the Time of Death in a Japanese Pediatric Intensive Care Unit

BACKGROUND

Substantial variability exists among countries regarding the modes of death in pediatric intensive care units (PICUs). However, there is limited information on end-of-life care in Japanese PICUs. Thus, this study aimed to elucidate the characteristics of end-of-life care practice for children in a Japanese PICU.

METHODS

We examined life-sustaining treatment (LST) status at the time of death based on medical chart reviews from 2010 to 2014. All deaths were classified into 3 groups: limitation of LST (limitation group, death after withholding or withdrawal of LST or a do not attempt resuscitation order), no limitation of LST (no-limitation group, death following failed resuscitation attempts), or brain death (brain death group).

RESULTS

Of the 62 patients who died, 44 (71%) had limitation of LST, 18 (29%) had no limitation of LST, and none had brain death. In the limitation group, the length of PICU stay was longer than that in the no-limitation group (13.5 vs 2.5 days; P = .01). The median time to death after the decision to limit LST was 2 days (interquartile range: 1-5.5 days), and 94% of the patients were on mechanical ventilation at the time of death in the limitation group.

CONCLUSIONS

Although limiting LST was a common practice in end-of-life care in a Japanese PICU, a severe limitation of LST such as withdrawal from the ventilator was hardly practiced, and a considerable LST was still provided at the time of death.

[Limitation of the therapeutic effort in pediatric intensive care]

Pediatric intensive care is a relatively new medical specialty, which has experienced significant technological advances in recent years. These developments have led to a prolongation of the dying process, with additional suffering for patients and their families, creating complex situations, and often causing a painful life extension. The term, limitation of the therapeutic effort refers to the adequacy and/or proportionality of the treatment, trying to avoid obstinacy and futility. The English literature does not talk about limitation of treatments, but instead the terms, withholding or withdrawal of life-sustaining treatment, are used. The removal or the non-installation of certain life support measures and the absence of CPR are the types of limitation most used. Also, there is evidence of insufficient medical training in bioethics, which is essential, as most doctors in the PICU discuss and make decisions regarding the end of life without the opinion of bioethicists. This article attempts to review the current status of knowledge concerning the limitation of therapeutic efforts to support pediatric clinical work.

End-of-Life Decisions in Pediatric Cancer Patients

BACKGROUND

End-of-life decisions (ELDs) have been investigated in several care settings, but rarely in pediatric oncology.

OBJECTIVE

The aims of this study were to characterize the practice of end-of-life decision making in a Dutch academic medical center and to explore pediatric oncologists' perspectives on decision making.

METHODS

Between 2001 and 2010, in a specified period of 2 years, 57 children died of cancer. The attending pediatric oncologists of 48 deceased children were eligible for this study. They were requested to complete a retrospective questionnaire on characteristics of ELDs that may have preceded a child's death. ELDs were defined as decisions concerning administering or forgoing treatment that may unintentionally or intentionally hasten death.

RESULTS

In 31 of 48 cases (65%) one or more ELDs were made. In 20 of 31 cases potentially life-prolonging treatments were discontinued or withheld, and in 22 of 31 cases drugs were administered to alleviate pain or other symptoms in potentially life-shortening dosages. Frequently mentioned considerations for making ELDs were no prospects of improvement (n=21;68%) and unbearable suffering without a curative perspective (n=13;42%). ELDs were discussed with parents in all cases, and with the child in 9 of 31 cases. After the child's death, the pediatric oncologist met the parents in all ELD cases and in 11 of 17 non-ELD cases. Pediatric oncologists were satisfied with care around the child's death in 90% of the ELD cases versus 59% of the non-ELD cases.

CONCLUSIONS

In two-thirds of cases, ELDs preceded the death of a child with cancer. This is the first study providing insights into the characteristics of ELDs from a pediatric oncologist's point of view.

Modes of Death in a Pediatric Cardiac ICU

OBJECTIVE

To determine epidemiology and proximate causes of death in a pediatric cardiac ICU in Southern Europe.

DESIGN

Retrospective chart review.

SETTING

Single-center institution.

PATIENTS

We concurrently identified 57 consecutive patients who died prior to discharge from the cardiac ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Over the study period, there were 57 deaths for a combined mortality rate of 2.4%. Four patients (7%) were declared brain dead, 25 patients (43.8%) died after a failed resuscitation attempt, and 28 patients (49.1%) died after withholding or withdrawal of life-sustaining treatment. Cardiorespiratory failure was the most frequent proximate cause of death (39, 68.4%) followed by brain injury (14, 24.6%) and septic shock (4, 7%). Older age at admission, presence of mechanical ventilation and/or device-dependent nutrition support, patients on a left-ventricular assist device and longer cardiac ICU stay were more likely to have life support withheld or withdrawn.

CONCLUSIONS

Almost half of the deaths in the cardiac ICU are predictable, and they are anticipated by the decision to limit life-sustaining treatments. Brain injuries play a direct role in the death of 25% of patients who die in the cardiac ICU. Patients with left-ventricular assist device are associated with withdrawal of treatment.

The Parents', Hospitalized Child's, and Health Care Providers' Perceptions and Experiences of Family-Centered Care Within a Pediatric Critical Care Setting: A Synthesis of Quantitative Research

Family-centered care (FCC) purports that unlimited presence and involvement of the family in the care of the hospitalized child will optimize the best outcome for the child, family, and institution. A systematic appraisal was conducted of peer-reviewed, English-language, primary quantitative research conducted within a pediatric critical care setting reported from 1998 to 2014. The aim of this review was to explore the parents', hospitalized child's, and health care providers' perception of FCC within pediatric critical care. Fifty-nine articles met the criteria that generated themes of stress, communication, and parents' and children's needs. This review highlighted that communication tailored to meet the parents' and child's needs is the key to facilitating FCC and positive health outcomes. Health care providers need to be available to provide clinical expertise and support throughout the health care journey. Future initiatives, education, and research are needed to evaluate the benefits of parent- and child-led FCC practice.

Mortality patterns among critically ill children in a Pediatric Intensive Care Unit of a developing country

BACKGROUND AND AIM

Advances in biomedical technology have made medical treatment to be continued beyond a point, at which it does not confer an advantage but may increase the suffering of patients. In such cases, continuation of care may not always be useful, and this has given rise to the concept of limitation of life-sustaining treatment. Our aim was to study mortality patterns over a 6-year period in a Pediatric Intensive Care Unit (PICU) in a developing country and to compare the results with published data from other countries.

MATERIALS AND METHODS

Retrospective cohort study was conducted in a PICU of a tertiary care hospital in Pakistan. Data were drawn from the medical records of children aged 1-month - 16 years of age who died in PICU, from January 2007 to December 2012.

RESULTS

A total of 248 (from an admitted number of 1919) patients died over a period of 6 years with a mortality rate 12.9%. The median age of children who died was 2.8 years, of which 60.5% (n = 150) were males. The most common source of admission was from the emergency room (57.5%, n = 143). The most common cause of death was limitation of life-sustaining treatment (63.7%, n = 158) followed by failed cardiopulmonary resuscitation (28.2%, n = 70) and brain death (8.1%, n = 20). We also found an increasing trend of limitation of life-sustaining treatment do-not-resuscitate (DNR) over the 6-year reporting period.

CONCLUSION

We found limitation of life support treatment (DNR + Withdrawal of Life support Treatment) to be the most common cause of death, and parents were always involved in the end-of-life care decision-making.

[Epidemiology and evaluation of withdrawing and withholding of treatment procedure in a pediatric intensive care unit]

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.

Short-term and long-term mortality following pediatric intensive care

BACKGROUND

The aim of the present study was to examine short-term and long-term mortality following discharge from the pediatric intensive care unit (PICU).

METHODS

This was a prospective observational study. Data collected consisted of demographics, severity scores, procedures, treatment, need for and duration of mechanical ventilation (MV), length of PICU and hospital stay, and mortality at PICU and hospital discharge, at 3 and 6 months and at 1 and 2 years.

RESULTS

A total of 300 patients (196 boys and 104 girls), aged 54.26 ± 49.93 months, were included in the study. Median (interquartile range) Pediatric Risk of Mortality (PRISM III-24) score was 7 (3-11) and predicted mortality rate was 11.16%. MV rate was 67.3% (58.3% at admission) for 6.54 ± 14.15 days, and length of PICU and hospital stay was 8.85 ± 23.28 days and 20.69 ± 28.64 days, respectively. Mortality rate at discharge was 9.7% and cumulative mortality rate thereafter was 12.7%, 15.0%, 16.7%, 19.0%, and 19.0% at hospital discharge, 3 months, 6 months, 1 year and 2 years, respectively. Significant risk factors of PICU mortality were inotrope use, PRISM III-24 score >8, MV, arterial and central venous catheterization, nosocomial infection, complications, and cancer. Independent predictors of mortality at discharge were inotrope use and PRISM III-24 score, whereas predictors of mortality at 2 years were comorbidity and cancer.

CONCLUSIONS

A 2 year follow-up period seems sufficient for a comprehensive mortality analysis of PICU patients. Severity of critical illness is the key factor of short-term mortality, whereas comorbidity is the major determinant of long-term mortality.

Prevalence of questioning regarding life-sustaining treatment and time utilisation by forgoing treatment in francophone PICUs

PURPOSE

Our goal is to assess the prevalence of questioning about the appropriateness of initiating or maintaining life-sustaining treatments (LST) in French-speaking paediatric intensive care units (PICUs) and to evaluate time utilisation related to decision-making processes (DMP).

METHODS

18-month, multicentre, prospective, descriptive, observational study in 15 French-speaking PICUs.

RESULTS

Among the 5,602 children admitted, 410 died (7.3%), including 175 after forgoing LST (42.7% of deaths). LST was questioned in 308 children (5.5%) with a prevalence of 13.3 per 100 patient-days. More than 30% of children survived despite the appropriateness of LST being questioned (23% despite a decision to forgo treatment). Median caregiver time spent on making and presenting the decisions was 11 h per child.

CONCLUSIONS

In this study, on any given day in each 10-bed PICU, there was more than one child for whom a DMP was underway. Of children, 23% survived despite a decision to forgo LST being made, which underlines the need to elaborate a care plan for these children. Also, DMP represented a large amount of staff time that is undervalued but necessary to ensure optimal palliative practice in PICU.

The acceptability among lay persons and health professionals of actively ending the lives of damaged newborns

BACKGROUND

Euthanasia is performed on occasion, even on newborns, but is highly controversial, and it is prohibited by law and condemned by medical ethics in most countries.

AIM

To characterise and compare the judgments of lay persons, nurses, and physicians of the acceptability of actively ending the life of a damaged newborn.

METHODS

Convenience samples of 237 lay persons, 214 nurses, and 76 physicians in the south of France rated the acceptability on a scale of 0-10 of giving a lethal injection in 54 scenarios composed of all combinations of 4 within-subject factors: gestational age of 6, 7, or 9 months; 3 levels of severity of either perinatal asphyxia or of genetic disease; attitude of the parents about prolonging care unknown, favourable, or unfavourable; and decision made individually by the physician or collectively by the medical team. Overall ratings were subjected to cluster analysis and each cluster to analysis of variance and graphic representation.

RESULTS

Lay persons (mean acceptability rating 4.29) were significantly more favourable to euthanasia than nurses (2.84), p < .005, or physicians (2.12), p < .005. Five clusters were found with different judgment rules, i.e., how the information was integrated. More physicians (30 per cent) than nurses (14 per cent), p < .01, or lay persons (11 per cent), p < .01, rated euthanasia as never, under any condition, acceptable. Most, however, asserted that it was increasingly acceptable as the factors combined to favour it, especially when the parents desired to stop treatment. More physicians (45 per cent) and nurses (46 per cent) than lay persons (21 per cent), p < .01, used a complex conjunctive rule (level of parent's attitude x level of severity of damage x consultation with team or not) rather than a simple additive rule.

CONCLUSIONS

Unlike law and medical ethics, most of the lay persons, nurses, and physicians judged the acceptability of euthanasia as a function of the circumstances. Most health professionals combined the factors in a conjunctive (multiplicative), rather than additive, fashion in accordance with legislation for adults in The Netherlands and elsewhere that requires a set of criteria to be fulfilled before it is legitimate to end a patient's life.

Intercontinental differences in end-of-life attitudes in the pediatric intensive care unit: results of a worldwide survey

OBJECTIVE

To examine intercontinental differences in end-of-life practices in pediatric intensive care units.

DESIGN

An international survey. The on-line questionnaire consisted of two case scenarios with five questions each. The scenarios described the management of children in pediatric intensive care units and the questions dealt with the decision-making process and the modalities of forgoing life support.

SETTING

The participants at the 5th World Congress on Pediatric Critical Care Medicine organized by the World Federation of Pediatric Intensive and Critical Care Societies (June 2007, Geneva, Switzerland) were invited to participate.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Six hundred sixty seven complete questionnaires were received from 71 countries, which were grouped into six continents: Europe (52.7%), North America (17.9%) and South America (9.5%), Asia (7.6%), Australia (6%), and Middle East (4.3%). In both scenarios, physicians played the major role in decision making in all of the continents. However, parents from North America, Australia, the Middle East, and Asia seem to be more involved in the decision-making process, compared with those from Europe and South America. In cases of septic shock, caregivers from Europe and South America are more prone to forego life support despite parents' wishes. In North America and Australia, parents' presence during cardiopulmonary resuscitation is usually accepted (89.7% and 92.3%, respectively), whereas their presence is less accepted in Asia (54%) and Europe (54.8%), or much less accepted in South America (25.8%) and the Middle East (7.1%). In both scenarios, the option to withhold rather than withdraw life supports was more commonly chosen among all continents, except South America, where the withdrawal of life support was more often proposed (51.6% vs. 45.2%).

CONCLUSIONS

This study confirms that important intercontinental differences exist toward end-of-life issues in pediatric intensive care. Although the legal and ethical situation is rapidly evolving, a certain degree of paternalism seems to persist among European and South-American caregivers. This study suggests that ethical principles depend on the cultural roots of countries or continents, emphasizing the need to foster dialogue on end-of-life issues around the world to learn from each other and improve end-of-life care in pediatric intensive care units.

A five-step protocol for withholding and withdrawing of life support in an emergency department: an observational study

OBJECTIVE

The objective of the study was to describe a five-step protocol for withholding and withdrawing of life support (WH/WDLS) in an emergency department (ED) for terminally ill patients.

DESIGN AND SETTING

An observational study was conducted in ED of a general hospital.

PATIENTS

A total of 98 patients were admitted over a 1-year period.

INTERVENTIONS

The healthcare team chose a pattern of treatment limitation on the basis of a five-step protocol for every patient, which comprised five groups: group 1: there was no limitation of care, group 2: do not resuscitate order was followed, group 3: administration of therapies without treating an acute organ failure, group 4: active withdrawal of all therapies except mechanical ventilation and group 5: active withdrawal of mechanical ventilation. All the patients received comfort care. The opinions of the patients and their families were collected.

MEASUREMENTS AND RESULTS

Ninety-eight patients were included in the study (1.5% of admissions). Mean age was 82+/-13 years. An acute organ failure was observed at admission in 80 patients. Severe chronic disease was noted in 93 patients. Among the 98 patients, there were 14 patients in group 2, 65 in group 3, six in group 4 and 13 in group 5. The time interval between admission and WH/WDLS decision was 117+/-77 min and ED stay was 239+/-136 min. The outcome was death in ED (n=21), admission to a medical ward (n=71) or an intensive care unit (n=six). On day 30, 16 patients were still alive.

CONCLUSION

This five-step protocol could improve collaboration in the WH/WDLS decision-making process, while facilitating dialogue and transmission of information between staff and families.

Discussing withholding and withdrawing of life-sustaining medical treatment in paediatric inpatients: audit of current practice

AIM

To understand the circumstances of inpatient deaths at a tertiary paediatric hospital and current practices regarding the timing and documentation of discussions concerning the withholding and withdrawing of life-sustaining medical treatment (WWLSMT).

METHODS

Retrospective review of the medical records of 50 consecutive inpatient deaths.

RESULTS

In total, 84% of inpatient deaths occurred in an intensive care setting. In all, 74% of patients had an underlying life-limiting or life-threatening condition and death was documented as having been expected in the short term in 88% of patients. Life-sustaining treatment was either withdrawn or limited prior to death in 84% of cases. There was documented family involvement in the decision-making process in 98% of cases. A total of 83% of discussions first took place on the day of death itself or in the week leading up to the child's death. Although medical staff frequently documented the outcome of these discussions, the content, clarity and accessibility of documentation varied widely.

CONCLUSIONS

The majority of inpatient deaths at The Royal Children's Hospital occur in acute circumstances and involve patients with chronic conditions. In most cases, death follows WWLSMT. Discussions with families are documented as first occurring relatively late in the course of the final admission although opportunities for earlier discussions may exist. Further research is needed to understand more about how and when discussions actually take place, what the barriers to communication are and to what extent opportunities exist for discussions to be initiated earlier in the illness course.

Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature

OBJECTIVES

To examine withdrawal and limitation of life-sustaining treatment (WLST) in an Australian paediatric intensive care unit (PICU) and to compare this experience with published data from other countries.

DESIGN

Retrospective chart review and literature review.

SOURCE OF DATA

Review of 12 months of patient records from a tertiary Australian children's teaching hospital. Medline search using relevant key words focusing on death and PICU.

RESULTS

Twenty of 27 deaths (74%) followed either WLST (n = 16) or Do Not Resuscitate (DNR) orders (n = 4); five children failed cardiopulmonary resuscitation (CPR); and two children were brain-dead. Meetings between the medical team and family were documented for 15 of 16 children (93.8%) before treatment was withdrawn. The average time between withdrawal of life support and death was 13 min. A review of the English-language literature revealed that 18-65% occurring in PICUs worldwide follow WLST and/or institution of DNR orders. Rates were higher (30-65%) in North America and Europe than elsewhere. Most PICU deaths occurred within 3 days of admission. North American and British parents appear to be involved in decisions regarding withdrawal and limitation of treatment more often than parents in other countries.

CONCLUSIONS

Withdrawal and limitation of life-sustaining treatment was more common in an Australian children's hospital ICU than has been reported from other countries. Details of discussion with parents, including the basis for any decision to WLST, were almost always documented in the patient's medical record.

Forgoing life-sustaining or death-prolonging therapy in the pediatric ICU

Most deaths in the pediatric intensive care unit occur after a decision to withhold or withdraw life-sustaining treatments. The management of children at the end of life can be divided into three steps. The first concerns the decision-making process. The second concerns the actions taken once a decision has been made to forego life-sustaining treatments. The third regards the evaluation of the decision and its implementation. The mission of pediatric intensive care has expanded to provide the best possible care to dying children and their families. Improving the quality of care received by dying children remains an ongoing challenge for every pediatric intensive care unit team member.

Do not attempt resuscitation orders in pediatrics

Do-not-attempt resuscitation orders are becoming more common in pediatrics, particularly as programs for hospice and palliative care in children develop. Concomitantly, there arises the need to decide when it is appropriate to use these technologies. It is at this point that the skills of relationship building, listening, and empathic concern become indispensable.

Parental involvement in treatment decisions regarding their critically ill child: a comparative study of France and Quebec

OBJECTIVE

To examine whether physicians or parents assume responsibility for treatment decisions for critically ill children and how this relates to subsequent parental experience. A significant controversy has emerged regarding the role of parents, relative to physicians, in relation to treatment decisions for critically ill children. Anglo-American settings have adopted decision-making models where parents are regarded as responsible for such life-support decisions, while in France physicians are commonly considered the decision makers.

DESIGN

Grounded theory qualitative methodology.

SETTING

Four pediatric intensive care units (two in France and two in Quebec, Canada).

PATIENTS

Thirty-one parents of critically ill children; nine physicians and 13 nurses who cared for their children.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Semistructured interviews were conducted. In France, physicians were predominantly the decision makers for treatment decisions. In Quebec, decisional authority practices were more varied; parents were the most common decision maker, but sometimes it was physicians, while for some decisional responsibility depended on the type of decision to be made. French parents appeared more satisfied with their communication and relationship experiences than Quebec parents. French parents referred primarily to the importance of the quality of communication rather than decisional authority. There was no relationship between parents' actual responsibility for decisions and their subsequent guilt experience.

CONCLUSIONS

It was remarkable that a certain degree of medical paternalism was unavoidable, regardless of the legal and ethical norms that were in place. This may not necessarily harm parents' moral experiences. Further research is required to examine parental decisional experience in other pediatric settings.

Legal basis for ethical withholding and withdrawing life-sustaining medical treatment from infants and children

Withholding and withdrawing life-sustaining medical treatment is common in hospitals, particularly in intensive care unit environments. Usually, decisions regarding limitation of therapy are based on ethical considerations and derived by discussion and mutual agreement between parents and clinicians. However, disputes sometimes arise. When such disputes are settled in court, the judgements constitute common law and may serve as the basis for ethical decisions. All cases have been decided in the 'best interests' of the unfortunate child. Although each case has its own circumstances, a composite view reveals three legal criteria for withholding or withdrawing treatment. These are based on the present and future 'quality of life', 'futility' of present treatment and a comparison of 'burdens versus benefits' of present and future treatment and its discontinuance. These legal principles may facilitate difficult ethical decisions. This article identifies a number of common law cases which establishes these principles.

Death in the pediatric ICU: caring for children and families at the end of life

The need to improve care for children and families at the end of life is acknowledged widely. This article reviews current research concerning end-of-life care in the pediatric ICU. How children die, how decisions are made, management of the dying process, and parent and caregiver experiences are major themes. Gaps in current knowledge are identified, and suggestions are made for future research.

Key Factors Affecting Dying Children and Their Families

The death of a child alters the life and health of others immediately and for the rest of their lives. How a child dies influences parents' abilities to continue their role functions as well as siblings' abilities to make and maintain friendships, and may be the basis for health care providers' decisions to exit direct care roles. Thus, facilitating a "good death"-an obvious care priority for all involved with the dying child-ought also to be a priority for the health of bereaved families and affected health care providers. Making this a care priority is complicated by a serious lack of data, as details of the last hours or weeks of a dying child or adolescent's life are largely unknown. The purpose of this paper is to identify key factors that affect the course of dying children and adolescents and that of their bereaved survivors, and to link those key factors to needed research that could produce clinically relevant findings to improve the care of these patients. Key factors described here include suffering (physical, psychological, and spiritual), communication, decision making, prognostic ambiguities, ability of the seriously ill child to give assent to research participation, and educational preparation of health care providers to give competent end-of-life care.

Discretionary death: conditions, dilemmas, and normative regulation

The author examines a major shift in the conceptualization and practices relating to death and dying in Western and other societies with advanced medicine. This shift is the result of socio-technical and cultural developments characterized by but not limited to the routine widespread application of life support technologies in the hospital together with notions of increased patient rights. It has resulted in a class of end-of-life situations, which the author defines as "discretionary death." The concept of discretionary death underscores the role of contextual and discretionary factors in end-of-life decision-making. The author identifies and discusses the necessary and complex process of norm formation that informs and regulates end-of-life medical practice and establishes societal consensus across society with respect to legitimizing "discretionary death."

[Withholding or withdrawing life saving treatment in pediatric intensive care unit: GFRUP guidelines]

Several recent French studies have revealed that 40% of death in pediatric intensive care units are associated with withdrawal or limitation of life saving treatments. Because such decisions are common, the Groupe francophone de réanimation et urgences pédiatriques (GFRUP) has decided to publish recommendations in order to help paediatricians dealing with those difficult issues and to improve their decisions. In a first part of the document the ethical principles that imply those guidelines are recalled, followed by definitions of the terms currently employed. The second part contains guidelines regarding decision making process, the way it is applied and organisation of relatives as well as paramedical and medical staff support when the death of a child occurs.

El pediatra ante la muerte del niño: integración de los cuidados paliativos en la unidad de cuidados intensivos pediátricos

Palliative care is essential in the pediatric intensive care unit (PICU). Because of the mortality rates and the presence of life-threatening conditions in children admitted to the PICU, pediatricians must be prepared to provide palliative care independently of cure-directed therapies. The present article reviews certain issues, including the decision-making process in the PICU, psychosocial needs and susceptibility to burnout among PICU staff, and the emotions and attitudes of the staff when a child dies. We provide some guidelines on how to act when a child dies, how to meet with parents after the child's death and how to follow-up parental bereavement. Strategies that can help PICU pediatricians to cope with the numerous loses they experience are suggested.

Under what conditions is euthanasia acceptable to lay people and health professionals?

Euthanasia is legal only in the Netherlands and Belgium, but it is on occasion performed by physicians elsewhere. We recruited in France two convenience samples of 221 lay people and of 189 professionals (36 physicians, 92 nurses, 48 nurse's aides, and 13 psychologists) and asked them how acceptable it would be for a patient's physician to perform euthanasia in each of 72 scenarios. The scenarios were all combinations of three levels of the patient's life expectancy (3 days, 10 days, or 1 month), four levels of the patient's request for euthanasia (no request, unable to formulate a request because in a coma, some form of request, repeated formal requests), three of the family's attitude (do not uselessly prolong care, no opinion, try to keep the patient alive to the very end), and two of the patient's willingness to undergo organ donation (willing or not willing). We found that most lay people and health care professionals structure the factors in the patient scenarios in the same way: they assign most importance to the extent of requests for euthanasia by the patient and least importance (the lay people) or none (the health professionals) to the patient's willingness to donate organs. They also integrate the information from the different factors in the same way: the factors of patient request, patient life expectancy, and (for the lay people) organ donation are combined additively, and the family's attitude toward prolonging care interacts with patient request (playing a larger role when the patient can make no request). Thus we demonstrate a common cognitive foundation for future discussions, at the levels of both clinical care and public policy, of the conditions under which physician-performed euthanasia might be acceptable.

Forgoing life-sustaining treatments in children: a comparison between Northern and Southern European pediatric intensive care units

OBJECTIVES

This study was conducted to determine how the decision-making process to forgo life support differs between southern and northern European pediatric intensive care units.

DESIGN

Multiple-center, prospective study.

SETTING

Thirty-nine pediatric intensive care units: 12 from northern Europe and 27 from southern Europe.

PATIENTS

All consecutive deaths were recorded over a 4-month period. Group 1 and group 2 included patients who died in northern and southern pediatric intensive care units, respectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Three hundred fifty children were enrolled, 68 in group 1 and 282 in group 2. The decision to forgo life-sustaining treatment was made in 116 children (group 1, n = 32; group 2, n = 84). In both groups, the decision was discussed by caregivers during a formal meeting. The decision to forgo life-sustaining treatment was more often made in northern countries than in southern ones (47% vs. 30%, p =.02). Parents were informed of this decision in 95% of cases in group 1 vs. 68% in group 2 (p =.01). In both groups, the final decision was made by the medical staff. Parents' contributions to the decision-making process did not differ between the two groups according to the practitioners' opinion. The decision was documented in the medical charts in 100% of the cases in group 1 and in 51% of the cases in group 2 (p =.0001).

CONCLUSIONS

The decision-making process appears to be similar between northern and southern European countries. The respective contributions of the parents and the medical staff in the final decision itself seem to be identical between northern and southern countries. However, in northern European countries, the level of parents' information about the decision-making process appears higher and the decision is more often documented in the medical chart.

A descriptive study of children dying in the pediatric intensive care unit after withdrawal of life-sustaining treatment

OBJECTIVE

To examine physiologic and therapeutic changes following withdrawal of life-sustaining treatment in children.

DESIGN

Retrospective chart review.

SETTING

University-affiliated tertiary care pediatric hospital.

PATIENTS

All patients who had life-sustaining treatment withdrawn over a 5-yr period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 125 charts were examined to obtain 50 in which the terminal event preceding death was withdrawal of life-sustaining treatment. Data are expressed as median (1st, 3rd quartiles). Median hospital stay before death was 20 days (1st and 3rd quartiles, 8 and 30). Median time from decision to withdraw life-sustaining treatment to actual withdrawal was 30 mins (1st and 3rd quartiles, 10 and 180). All interventions were simultaneously discontinued in 80% of patients with mechanical ventilation followed by vasopressors being most common. No patients had stepwise reduction in ventilator rate before discontinuing the mechanical ventilation. Devices were rarely removed from patients including endotracheal tubes. Time from withdrawal of life-sustaining treatment to death was 15 mins (5, 30); only seven patients took >60 mins to die. Multivariable analysis (Kruskal-Wallis test) of various factors revealed simultaneous withdrawal of life-sustaining treatment, female gender, and not having received renal therapy as hastening death.

CONCLUSIONS

Forgoing life-sustaining treatment in a small cohort of children at a single institution follows a pattern: Most cases occur after prolonged intensive care unit stays, withdrawal of treatment occurs almost immediately after the decision to withdraw, most treatments are withdrawn simultaneously rather than sequentially, and most patients die within minutes of life-sustaining treatment cessation. This is the first pediatric study to report the time to death after withdrawal of life-sustaining treatment and factors associated with shorter time to death in children.

Decisions concerning potentially life-sustaining treatments in paediatric nephrology: a multicentre study in French-speaking countries

BACKGROUND

Few studies have looked at how decisions are made to withhold or to withdraw potentially life-sustaining treatments (LST) in paediatric nephrology. The aim of this work was to evaluate such practices in all nephrology centres in French-speaking European countries, so that guidelines could be discussed and drawn up by professionals.

METHODS

We used semi-directed interviews to question health care professionals prospectively. We also retrospectively analysed the medical files of all children (n = 50) for whom a decision to withhold or to withdraw LST had been made in the last 5 years. The doctors (n = 31) who had been involved in the decision-making process were interviewed.

RESULTS

All 31 of the French-speaking paediatric nephrology centres in Europe were included in this study. Of these, 18 had made decisions in the previous 5 years about withholding or withdrawing LST. Resultant quality of life, based on long-term living conditions, was the principal criterion used to make the decisions. Relational aspects of life and the child's prognosis were also considered. The decision-making processes were not always collective, even though interactions between doctors and the rest of the medical team seemed to be key elements to them. The parents' involvement in the decision-making process differed between centres.

CONCLUSIONS

The criteria used to decide whether to withhold or to withdraw LST are not standardized, and no specific guidelines exist.

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.