Parents should not be excluded from decisions to forgo life-sustaining treatments!

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.

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.

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.

End-of-life care preferences of pediatric patients with cancer

PURPOSE

The viewpoint of the terminally ill child at the time of an end-of-life decision has not been formally investigated. We identified the preferences of children and adolescents with advanced cancer about their end-of-life care and the factors that influenced their decisions.

PATIENTS AND METHODS

Pediatric patients 10 or more years of age were interviewed within 7 days of participating in one of the following three end-of-life decisions: enrollment onto a phase I trial (n = 7), adoption of a do not resuscitate order (n = 5), or initiation of terminal care (n = 8). The patient, a parent, and the primary pediatric oncologist were interviewed separately by using open-ended interview questions.

RESULTS

Twenty patients, aged 10 to 20 years (mean, 17 years and 4 months), with a refractory solid tumor (n = 12), brain tumor (n = 4), or leukemia (n = 4) participated. Eighteen patients (90%) accurately recalled all of their treatment options and identified their own death as a consequence of their decision. The factors that were most frequently identified included the following: for patients, caring about others (n = 19 patients); for parents, the child's preferences (n = 18 parents); and for physicians, the patient's prognosis and comorbid conditions (n = 14 physicians).

CONCLUSION

These children and adolescents with advanced cancer realized that they were involved in an end-of-life decision, understood the consequences of their decision, and were capable of participating in a complex decision process involving risks to themselves and others. The decision factors most frequently reported by patients were relationship based; this finding is contrary to existing developmental theories.

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.