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Mariani GL, Contrera PJ, Virasoro MDLA, Portela MC, Urquizu Handal MI, Ávila AS, Fernández AL, Fernandez Riera P, Cardigni G, Vain NE. End-of-Life Care for Newborn Infants: A Multicenter Real-Life Prospective Study. Neonatology 2024:1-9. [PMID: 38801819 DOI: 10.1159/000538814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/07/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Most neonatal deaths in industrialized countries follow a process of redirection of care. The objectives of this study were to describe how neonates die in a middle-income country, whether there was redirection of care, and the reason for this decision. METHODS This was a prospective, multicenter, cross-sectional study. Neonates who died in the delivery room or in the neonatal intensive care unit in 97 hospitals over a 6-month period were included. After each neonatal death, one investigator interviewed a member of the healthcare team who had been involved in the end-of-life care process. Perinatal data, conditions that led to death, whether there was redirection of care, and details of the end-of-life process were recorded. RESULTS Data from 697 neonatal deaths were analyzed, which represent 80% of the total deaths occurring in Argentina in that period. The main causes of death were complications of prematurity (47%) and congenital anomalies (27%). Overall, 32% of neonates died after a process of redirection of care, and this was less frequent in the neonatal intensive care unit (28%) than in the delivery room (70%, p < 0.001). The reasons for withholding/withdrawing care were inevitable death (75%) and severe compromise of expected quality of life (25%). Redirection of care consisted in withholding therapies in 66% and withdrawal in 34%. A diagnosis of a major congenital anomaly increased the odds of redirection of care (OR 5.45; 95% CI: 3.59-8.27). CONCLUSION Most neonates who die in Argentina do so while receiving full support. Redirection of care mainly follows a condition of inevitable death.
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Affiliation(s)
- Gonzalo Luis Mariani
- Servicio de Neonatología Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pamela Judith Contrera
- Servicio de Neonatología, Sanatorio de la Trinidad San Isidro, Provincia de Buenos Aires, Buenos Aires, Argentina
| | | | - María Constanza Portela
- Servicio de Neonatología Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
- Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" (CEMIC), sede Saavedra, Buenos Aires, Argentina
| | - María Ines Urquizu Handal
- Servicio de Neonatología, Sanatorio de la Trinidad San Isidro, Provincia de Buenos Aires, Buenos Aires, Argentina
- Servicio de Neonatología, Sanatorio de la Trinidad Ramos Mejía, Provincia de Buenos Aires, Buenos Aires, Argentina
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Aldana Soledad Ávila
- Servicio de Neonatología, Sanatorio de la Trinidad Ramos Mejía, Provincia de Buenos Aires, Buenos Aires, Argentina
- Dirección de Salud Perinatal y Niñez, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | | | - Patricia Fernandez Riera
- Dirección de Salud Perinatal y Niñez, Ministerio de Salud de la Nación, Buenos Aires, Argentina
- Servicio de Neonatología, Hospital Británico, Buenos Aires, Argentina
| | - Gustavo Cardigni
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
| | - Néstor Eduardo Vain
- Servicio de Neonatología, Sanatorio de la Trinidad Palermo, Buenos Aires, Argentina
- Facultad de Medicina Universidad de Buenos Aires, Buenos Aires, Argentina
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Kwon JE, Kim YH. Changes in the End-of-Life Process in Patients with Life-Limiting Diseases through the Intervention of the Pediatric Palliative Care Team. J Clin Med 2023; 12:6588. [PMID: 37892726 PMCID: PMC10607513 DOI: 10.3390/jcm12206588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Kyungpook National University Children's Hospital initiated pediatric palliative care (PPC) services in January 2019, focusing on children and adolescents with life-limiting conditions (LLC). A study examined changes in the end-of-life processes in patients with LLC before and after a PPC intervention. This study included 48 deceased patients under 18 years at the hospital, divided into two groups: January 2015 to December 2016 without PPC (25 patients, Period 1) and January 2019 to April 2022 with PPC (23 patients, Period 2). Analysis of medical records revealed the following: no age/sex differences; more active advanced care planning in Period 2 (15/23 vs. 7/25, p = 0.01); discussing withholding/withdrawing treatment increased in Period 2 (91.3% vs. 64.0%, p = 0.025); intubation and CPR were less frequent in Period 2 (intubation 2/23 vs. 19/25, p = 0.000; CPR 3/23 vs. 11/25, p = 0.018); Period 1 had more deaths in the ICU (18/25 vs. 10/23, p = 0.045); and 3 patients in Period 2 chose home deaths. A survey in Period 2 revealed high satisfaction with emotional support (91.7%), practical assistance (91.6%), and symptom management (83.3%). PPC facilitated discussions on advanced care planning and treatment choices, ensuring peaceful and prepared farewells for children with LLC and their families.
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Affiliation(s)
| | - Yeo Hyang Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Pediatric Palliative Care Center, Kyungpook National University Children’s Hospital, Daegu 41404, Republic of Korea;
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Rotta AT, Alibrahim O. End-of-life care in Brazilian pediatric intensive care units: challenges and opportunities. J Pediatr (Rio J) 2023; 99:312-314. [PMID: 37148909 PMCID: PMC10373140 DOI: 10.1016/j.jped.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2023] Open
Affiliation(s)
- Alexandre T Rotta
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
| | - Omar Alibrahim
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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Verhagen AAE. Neonatal euthanasia in the context of palliative and EoL care. Semin Fetal Neonatal Med 2023; 28:101439. [PMID: 37105858 DOI: 10.1016/j.siny.2023.101439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Neonatal deaths can be categorized in 5 modes along the dimension of intervention and physiology. This classification can be helpful to analyze the choices that can be made in end-of-life care in the NICU. In the Netherlands, neonatal euthanasia became an optional 6th mode of death since publication and legalization of the Groningen Protocol. This paper summarizes the history, legal status and ethical justification of the Groningen Protocol, and describes end-of-life practice in the subsequent years. Since the implementation of the Groningen Protocol, the practice of neonatal euthanasia has almost disappeared. Simultaneously, there has been spectacular growth in neonatal palliative care programs in the Netherlands. Is there still a need for this last-resort option?
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Affiliation(s)
- A A Eduard Verhagen
- University Medical Center Groningen, Dept of Pediatrics, University of Groningen, PO Box 30.001, 9700RB, Groningen, the Netherlands.
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Leite MM, Bello FPS, Sakano TMS, Schvartsman C, da Costa Reis AGA. Analysis of death in children not submitted to cardiopulmonary resuscitation. J Pediatr (Rio J) 2022; 98:477-483. [PMID: 35139342 PMCID: PMC9510803 DOI: 10.1016/j.jped.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Describe the epidemiology of deaths in children not submitted to CPR, compare to a CPR group and evaluate patients' medical records of those not submitted to CPR. METHODS Observational cross-sectional study assessing deaths between 2015 and 2018 in a pediatric tertiary hospital, divided into two groups: CPR and no- CPR. The source of data included the cardiorespiratory arrest register, based on Utstein style. Children's medical records in no-CPR group were researched by hand. RESULTS 241 deaths were included, 162 in CPR group and 79 in the no-CPR group. Preexisting diseases were observed in 98.3% of patients and prior advanced intervention in 78%. Of the 241 deaths, 212 (88%) occurred in the PICU, being 138/162 (85.2%) in CPR group and 74/79 (93.7%) in no-CPR group (p = 0.018). Bradycardia as the initial rhythm was five times more frequent in the CPR group (OR 5.06, 95% CI 1.94-13,19). There was no statistically significant difference regarding age, gender, preexisting diseases, and period of the day of the occurrence of death. Medical records revealed factors related to the family decision-making process or the suitability of therapeutic effort. Discrepancies between the practice of CPR and medical records were identified in 9/79 (11,4%) records allocated to the no-CPR group. CONCLUSION Most deaths with CPR and with the no-CPR occurred in the PICU. Bradycardia as the initial rhythm was five times more frequent in the CPR group. Medical records reflected the complexity of the decision not to perform CPR. Discrepancies were identified between practice and medical records in the no-CPR group.
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Affiliation(s)
- Márcia Marques Leite
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil.
| | - Fernanda Paixão Silveira Bello
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil
| | - Tânia Miyuki Shimoda Sakano
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil
| | - Amélia Gorete Afonso da Costa Reis
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Pediatria, Hospital das Clínicas, Instituto da Criança, Pronto-Socorro, São Paulo, SP, Brazil
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Ekinci F, Yıldızdaş D, Horoz ÖÖ, İncecik F. Evaluation of Pediatric Brain Death and Organ Donation: 10-Year Experience in a Pediatric Intensive Care Unit in Turkey. Turk Arch Pediatr 2022; 56:638-645. [PMID: 35110065 PMCID: PMC8849511 DOI: 10.5152/turkarchpediatr.2021.21130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We aimed to investigate the rate of brain death (BD) determinations and organ donations (OD) in our tertiary pediatric intensive care unit (PICU), and to report the data on the demographic pattern and supplementary descriptive data on BD declarations. METHODS The study was designed as a retrospective, single-center, descriptive cohort study. We evaluated all children who were determined to meet the criteria for BD in our tertiary PICU between January 2011 and December 2020. RESULTS During study period, BD was identified in 24 patients among 225 total deaths (10.7%). Their median age was 85 months (8-214) and the male-to-female ratio was 1 : 1. The most common diagnosis was meningoencephalitis in 25%, followed by traumatic intracranial hemorrhage (16.7%). The median time from admission to PICU until BD diagnosis was 6.5 days. The time from the first BD physical examination to the declaration of BD was 27.5 hours. There was no statistically important difference between donors and non-donors. The apnea test (AT) was the most performed ancillary method (100%), followed by electroencephalogram (EEG) (66.7%), and magnetic resonance angiography or computed tomography angiography (MRA/ CTA) (54.2%). Hyperglycemia developed in 79.2% of the cases, and 70.8% developed diabetes insipidus (DI). Five patients (20.8%) were organ donors in study group. In the study, 13 solid organ and 4 tissue transplantations were performed after OD. CONCLUSION Awareness of the incidence and etiology may contribute to the timely diagnosis and declaration of brain death, and with the help of good donor care, may help in increasing OD rates in the pediatric population.
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Affiliation(s)
- Faruk Ekinci
- Department of Pediatric Intensive Care, Çukurova University School of Medicine, Adana, Turkey
| | - Dinçer Yıldızdaş
- Department of Pediatric Intensive Care, Çukurova University School of Medicine, Adana, Turkey
| | - Özden Özgür Horoz
- Department of Pediatric Intensive Care, Çukurova University School of Medicine, Adana, Turkey
| | - Faruk İncecik
- Department of Pediatric Neurology, Çukurova University School of Medicine, Adana, Turkey
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End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study. J Pediatr (Rio J) 2021; 97:525-530. [PMID: 33358967 PMCID: PMC9431998 DOI: 10.1016/j.jped.2020.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine the prevalence of life support limitation (LSL) in patients who died after at least 24h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered. METHODS Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24h of admission. RESULTS 53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a do-not-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support. CONCLUSIONS LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.
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Zhu Y, Zhu X, Xu L, Deng M. Clinical Factors Influencing End-of-Life Care in a Chinese Pediatric Intensive Care Unit: A Retrospective, post-hoc Study. Front Pediatr 2021; 9:601782. [PMID: 33898354 PMCID: PMC8058173 DOI: 10.3389/fped.2021.601782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: End-of-life(EOL) care decision-making for infants and children is a painful experience. The study aimed to explore the clinical factors influencing the EOL care to withhold/withdraw life-sustaining treatment (WLST) in Chinese pediatric intensive care unit (PICU). Methods: A 14-year retrospective study (2006-2019) for pediatric patients who died in PICU was conducted. Based on the mode of death, patients were classified into WLST group (death after WLST) and fCPR group (death after full intervention, including cardiopulmonary resuscitation). Intergroup differences in the epidemiological and clinical factors were determined. Results: There were 715 patients enrolled in this study. Of these patients, 442 (61.8%) died after WLST and 273 (38.2%) died after fCPR. Patients with previous hospitalizations or those who had been transferred from other hospitals more frequently chose WLST than fCPR (both P < 0.01), and the mean PICU stay duration was significantly longer in the WLST group (P < 0.05). WLST patients were more frequently complicated with chronic underlying disease, especially tumor (P < 0.01). Sepsis, diarrhea, and cardiac attack (all P < 0.05) were more frequent causes of death in the fCPR group, whereas tumor as a direct cause of death was more frequently seen in the WLST group. Logistic regression analysis demonstrated that previous hospitalization and underlying diseases diagnosed before admission were strongly associated with EOL care with WLST decision (OR: 1.6; P < 0.05 and OR: 1.6; P < 0.01, respectively). Conclusions: Pediatric patients with previous hospitalization and underlying diseases diagnosed before admission were associated with the EOL care to WLST.
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Affiliation(s)
- Yueniu Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lili Xu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mengyan Deng
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Bobillo-Perez S, Segura S, Girona-Alarcon M, Felipe A, Balaguer M, Hernandez-Platero L, Sole-Ribalta A, Guitart C, Jordan I, Cambra FJ. End-of-life care in a pediatric intensive care unit: the impact of the development of a palliative care unit. BMC Palliat Care 2020; 19:74. [PMID: 32466785 PMCID: PMC7254653 DOI: 10.1186/s12904-020-00575-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this paper is to describe how end-of-life care is managed when life-support limitation is decided in a Pediatric Intensive Care Unit and to analyze the influence of the further development of the Palliative Care Unit. METHODS A 15-year retrospective study of children who died after life-support limitation was initiated in a pediatric intensive care unit. Patients were divided into two groups, pre- and post-palliative care unit development. Epidemiological and clinical data, the decision-making process, and the approach were analyzed. Data was obtained from patient medical records. RESULTS One hundred seventy-five patients were included. The main reason for admission was respiratory failure (86/175). A previous pathology was present in 152 patients (61/152 were neurological issues). The medical team and family participated together in the decision-making in 145 cases (82.8%). The family made the request in 10 cases (9 vs. 1, p = 0.019). Withdrawal was the main life-support limitation (113/175), followed by withholding life-sustaining treatments (37/175). Withdrawal was more frequent in the post-palliative group (57.4% vs. 74.3%, p = 0.031). In absolute numbers, respiratory support was the main type of support withdrawn. CONCLUSIONS The main cause of life-support limitation was the unfavourable evolution of the underlying pathology. Families were involved in the decision-making process in a high percentage of the cases. The development of the Palliative Care Unit changed life-support limitation in our unit, with differences detected in the type of patient and in the strategy used. Increased confidence among intensivists when providing end-of-life care, and the availability of a Palliative Care Unit may contribute to improvements in the quality of end-of-life care.
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Affiliation(s)
- Sara Bobillo-Perez
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Susana Segura
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Monica Girona-Alarcon
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Aida Felipe
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Monica Balaguer
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Lluisa Hernandez-Platero
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Anna Sole-Ribalta
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Carmina Guitart
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain.
- Paediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Passeig Sant Joan de Déu, 2, 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - Francisco Jose Cambra
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
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Modos de fallecimiento de los niños en Cuidados Intensivos en España. Estudio MOMUCIP (modos de muerte en UCIP). An Pediatr (Barc) 2019; 91:228-236. [DOI: 10.1016/j.anpedi.2019.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 11/21/2022] Open
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Modes of dying of children in Intensive Care Units in Spain: MOMUCIP study. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Fernandez HGC, Moreira MCN, Gomes R. Making decisions on health care for children / adolescents with complex chronic conditions: a review of the literature. CIENCIA & SAUDE COLETIVA 2019; 24:2279-2292. [PMID: 31269185 DOI: 10.1590/1413-81232018246.19202017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 08/30/2017] [Indexed: 11/21/2022] Open
Abstract
The profile of pediatric care has gone through changes in Brazil and in the world. This process becomes more visible in surveys that deal with hospital admission or specialized outpatient care data. This fact leads us to the idea that it is in such spaces that these children and subjects who care for them are more visible and negotiate decisions. We aim to perform a state of the art literature review on decision making discussions and definitions, analyzing the current research in light of the theoretical Mol perspectives on the actors' logics of chronic diseases care; And the perspective of care goods exchanges in the dialogue between Martins and Moreira, triggering the Theory of Gift. The synthesis of the literature shows that decision making may be understood as a care planning process in which family, patients and health professionals are involved, and is linked to the family-centered care model. In terms of difficulties, we point out the prevalence of a dynamic that favors a criticizable choice because of the risks of inequality, such as the lack of discussion on the options and the actuation of the family mostly in times of difficult decisions.
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Affiliation(s)
| | | | - Romeu Gomes
- Instituto Fernandes Figueira, Fiocruz. Av. Rui Barbosa 716, Flamengo. 22250-020 Rio de Janeiro RJ Brasil.
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Kawaguchi A, Saunders LD, Yasui Y, DeCaen A. Effects of Medical Transport on Outcomes in Children Requiring Intensive Care. J Intensive Care Med 2018; 35:889-895. [PMID: 30189782 DOI: 10.1177/0885066618796460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Atsushi Kawaguchi
- Department of Pediatrics, Pediatric Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - L Duncan Saunders
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Allan DeCaen
- Department of Pediatrics, Pediatric Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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Ethical, Cultural, Social, and Individual Considerations Prior to Transition to Limitation or Withdrawal of Life-Sustaining Therapies. Pediatr Crit Care Med 2018; 19:S10-S18. [PMID: 30080802 DOI: 10.1097/pcc.0000000000001488] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
As part of the invited supplement on Death and Dying in the PICU, we reviewed ethical, cultural, and social considerations for the bedside healthcare practitioner prior to engaging with children and families in decisions about limiting therapies, withholding, or withdrawing therapies in a PICU. Clarifying beliefs and values is a necessary prerequisite to approaching these conversations. Striving for medical consensus is important. Discussion, reflection, and ethical analysis may determine a range of views that may reasonably be respected if professional disagreements persist. Parental decisional support is recommended and should incorporate their information needs, perceptions of medical uncertainty, child's condition, and their role as a parent. Child's involvement in decision making should be considered, but may not be possible. Culturally attuned care requires early examination of cultural perspectives before misunderstandings or disagreements occur. Societal influences may affect expectations and exploration of such may help frame discussions. Hospital readiness for support of social media campaigns is recommended. Consensus with family on goals of care is ideal as it addresses all parties' moral stance and diminishes the risk for superseding one group's value judgments over another. Engaging additional supportive services early can aid with understanding or resolving disagreement. There is wide variation globally in ethical permissibility, cultural, and societal influences that impact the clinician, child, and parents. Thoughtful consideration to these issues when approaching decisions about limitation or withdrawal of life-sustaining therapies will help to reduce emotional, spiritual, and ethical burdens, minimize misunderstanding for all involved, and maximize high-quality care delivery.
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Modes of Death and the Dying Process in Brazilian PICU Over the Last 30 Years: Personal Reflections. Pediatr Crit Care Med 2018; 19:S59-S60. [PMID: 30080811 DOI: 10.1097/pcc.0000000000001516] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This text is part of the chapter 7 of a special issue supplement called "Death and Dying in PICU" having Christopher S. Parshuram and Karen Dryden-Palmer as the guest editors. I present my personal perception regarding the modes of death and the dying process in Brazilian PICU over the last 30 years. A big change in this regard was observed in our country from the 1980s to nowadays. The PICU mortality rate decreased significantly from over 20% to below 5% as well as the modes of death being observed that the life support limitation is far the most frequent death process in the PICU. Palliative care, in the last 10 years, increased its coverage in our country and being frequently offered as a complementary care to terminal ill patients in the PICU.
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Muñoz-Blanco S, Raisanen JC, Donohue PK, Boss RD. Enhancing Pediatric Palliative Care for Latino Children and Their Families: A Review of the Literature and Recommendations for Research and Practice in the United States. CHILDREN-BASEL 2017; 5:children5010002. [PMID: 29271924 PMCID: PMC5789284 DOI: 10.3390/children5010002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/15/2017] [Accepted: 12/20/2017] [Indexed: 11/16/2022]
Abstract
As the demand for pediatric palliative care (PC) increases, data suggest that Latino children are less likely to receive services than non-Latino children. Evidence on how to best provide PC to Latino children is sparse. We conducted a narrative review of literature related to PC for Latino children and their families in the United States. In the United States, Latinos face multiple barriers that affect their receipt of PC, including poverty, lack of access to health insurance, language barriers, discrimination, and cultural differences. Pediatric PC research and clinical initiatives that target the needs of Latino families are sparse, underfunded, but essential. Education of providers on Latino cultural values is necessary. Additionally, advocacy efforts with a focus on equitable care and policy reform are essential to improving the health of this vulnerable population.
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Affiliation(s)
- Sara Muñoz-Blanco
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
| | - Jessica C Raisanen
- Clinical Ethics, Johns Hopkins Berman Institute of Bioethics, Baltimore, MD 21205, USA.
| | - Pamela K Donohue
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
| | - Renee D Boss
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
- Clinical Ethics, Johns Hopkins Berman Institute of Bioethics, Baltimore, MD 21205, USA.
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Suzuki F, Takeuchi M, Tachibana K, Isaka K, Inata Y, Kinouchi K. Life-Sustaining Treatment Status at the Time of Death in a Japanese Pediatric Intensive Care Unit. Am J Hosp Palliat Care 2017; 35:767-771. [PMID: 29179574 DOI: 10.1177/1049909117743474] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Fumiko Suzuki
- 1 Department of Anesthesiology and Palliative Care, Nissay Hospital, Osaka, Japan
| | - Muneyuki Takeuchi
- 2 Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kazuya Tachibana
- 3 Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kanako Isaka
- 2 Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yu Inata
- 2 Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keiko Kinouchi
- 3 Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
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Abstract
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.
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Affiliation(s)
- V Gonzalo Morales
- Pediatra, Unidad de Cuidados Intensivos Pediátricos y Programa de Magíster en Bioética, Clínica Alemana-Universidad del Desarrollo y Unidad de Cuidados Intensivos Pediátricos, Hospital Roberto del Río, Universidad de Chile.
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Trotta EDA, Scarpa FC, Halal MGE, Goldim JR, Carvalho PRA. Health professionals' perceptions about the decision-making process in the care of pediatric patients. Rev Bras Ter Intensiva 2016; 28:335-340. [PMID: 27737415 PMCID: PMC5051194 DOI: 10.5935/0103-507x.20160057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/20/2016] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the perceptions of physicians, nurses and nursing technicians of their participation in the decision-making process surrounding life support limitation in terminally ill pediatric patients, with comparisons by professional category. METHODS A cross-sectional study was conducted in the pediatric intensive care unit of a tertiary public university hospital with the participation of physicians, nurses and nursing technicians. The MacArthur Admission Experience Survey Voice Scale was used to assess and quantify the perceptions of professionals who assisted 17 pediatric patients with life support limitation within 24 hours after the outcome of each patient was determined. All professionals working in the unit (n = 117) who were potentially eligible for the study received a free and informed consent form prior to the occurrence of the cases studied. RESULTS Study participants included 25/40 (62.5%) physicians, 10/17 (58.8%) nurses and 41/60 (68.3%) nursing technicians, representing 65% of the eligible professionals identified. The questionnaire return rate was higher for physicians than technicians (p = 0.0258). A perceived lack of voice was reported in all three professional categories at varying rates that were lower for physicians than for nurses and nursing technicians (p < 0.00001); there was no difference between the latter (p = 0.7016). In the three professional categories studied, three subscale items were reported. For two of the three statements, there were significant differences between physicians and nurses (p = 0.004) and between physicians and nursing technicians (p = 0.001). For one of the statements, there was no difference among the three professional categories. CONCLUSION Respondents perceived a lack of voice in the decision-making process at varying rates across the three categories of studied professionals who assisted terminally ill pediatric patients with life support limitation, with physicians expressing lowered rates of perceived coercion.
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Affiliation(s)
| | - Fernanda Cristina Scarpa
- Unidade de Terapia Intensiva Pediátrica, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Michel George El Halal
- Unidade de Terapia Intensiva Pediátrica, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - José Roberto Goldim
- Serviço de Bioética, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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Meert KL, Keele L, Morrison W, Berg RA, Dalton H, Newth CJL, Harrison R, Wessel DL, Shanley T, Carcillo J, Clark A, Holubkov R, Jenkins TL, Doctor A, Dean JM, Pollack M. End-of-Life Practices Among Tertiary Care PICUs in the United States: A Multicenter Study. Pediatr Crit Care Med 2015; 16:e231-8. [PMID: 26335128 PMCID: PMC4562059 DOI: 10.1097/pcc.0000000000000520] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe variability in end-of-life practices among tertiary care PICUs in the United States. DESIGN Secondary analysis of data prospectively collected from a random sample of patients (n = 10,078) admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 4, 2011, and April 7, 2013. SETTING Seven clinical centers affiliated with the Collaborative Pediatric Critical Care Research Network. PATIENTS Patients included in the primary study were less than 18 years old, admitted to a PICU, and not moribund on PICU admission. Patients included in the secondary analysis were those who died during their hospital stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred and seventy-five (2.7%; range across sites, 1.3-5.0%) patients died during their hospital stay; of these, 252 (92%; 76-100%) died in a PICU. Discussions with families about limitation or withdrawal of support occurred during the initial PICU stay for 173 patients (63%; 47-76%; p = 0.27) who died. Of these, palliative care was consulted for 67 (39%; 12-46%); pain service for 11 (6%; 10 of which were at a single site); and ethics committee for six (3%, from three sites). Mode of death was withdrawal of support for 141 (51%; 42-59%), failed cardiopulmonary resuscitation for 53 (19%; 12-28%), limitation of support for 46 (17%; 7-24%), and brain death for 35 (13%; 8-20%); mode of death did not differ across sites (p = 0.58). Organ donation was requested from 101 families (37%; 17-88%; p < 0.001). Of these, 20 donated (20%; 0-64%). Sixty-two deaths (23%; 10-53%; p < 0.001) were medical examiner cases. Of nonmedical examiner cases (n = 213), autopsy was requested for 79 (37%; 17-75%; p < 0.001). Of autopsies requested, 53 (67%; 50-100%) were performed. CONCLUSIONS Most deaths in Collaborative Pediatric Critical Care Research Network-affiliated PICUs occur after life support has been limited or withdrawn. Wide practice variation exists in requests for organ donation and autopsy.
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Affiliation(s)
- Kathleen L Meert
- 1Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI. 2Department of Anesthesia and Critical Care Medicine, Valley Children's Hospital, Madera, CA. 3Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA. 4Department of Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ. 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA. 6Department of Pediatrics, Mattel Children's Hospital at University of California at Los Angeles, Los Angeles, CA. 7Department of Pediatrics, Children's National Medical Center, Washington, DC. 8Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, MI. 9Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 10Department of Pediatrics, University of Utah School of Medicine, University of Utah, Salt Lake City, UT. 11Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD. 12Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO
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Fallahzadeh MA, Abdehou ST, Hassanzadeh J, Fallhzadeh F, Fallahzadeh MH, Malekmakan L. Pattern of in-hospital pediatric mortality over a 3-year period at University teaching hospitals in Iran. Indian J Crit Care Med 2015. [PMID: 26195856 PMCID: PMC4478671 DOI: 10.4103/0972-5229.158257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Introduction: Causes of death are different and very important for policy makers in different regions. This study was designed to analyze the data for our in-patient children mortality. Materials and Methods: In this cross-sectional study from March 2011 to March 2013, all patients from 2 months to 18 years who died in pediatric intensive care unit, emergency room or medical pediatric wards in the teaching hospitals were studied. Results: From a total of 18,915 admissions during a 2-year-period, 256 deaths occurred with a mean age of 4.3 ± 5 years and mortality 1.35%. An underlying disease was present in 70.7% of the patients and in 88.5% of them the leading causes of death were related to the underlying diseases. The most common underlying diseases were congenital heart disease and cardiomyopathy in 50 (27.6%). The four main causes of deaths were sepsis (14.8%), pneumonia (14.5%), congestive heart failure (9.8%), and hepatic encephalopathy (9.8%). Conclusion: We may conclude that after sepsis and pneumonia, congestive heart failure, and hepatic encephalopathy are the leading causes of death. Most patients who died had underlying diseases including malignancies, heart and liver diseases as the most common causes.
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Affiliation(s)
| | - Sophia T Abdehou
- Department of Pediatric, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Jafar Hassanzadeh
- Department of Pediatric, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mohammad Hossein Fallahzadeh
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran, John C. McDonald Regional Transplant Center, Shreveport, Louisiana, USA
| | - Leila Malekmakan
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran, John C. McDonald Regional Transplant Center, Shreveport, Louisiana, USA
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Siddiqui NUR, Ashraf Z, Jurair H, Haque A. Mortality patterns among critically ill children in a Pediatric Intensive Care Unit of a developing country. Indian J Crit Care Med 2015; 19:147-50. [PMID: 25810609 PMCID: PMC4366912 DOI: 10.4103/0972-5229.152756] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Naveed-ur-Rehman Siddiqui
- From: Department of Pediatric and Child Health, Aga Khan University Medical College, Karachi, Pakistan
| | - Zohaib Ashraf
- Aga Khan University Medical College, Karachi, Pakistan
| | - Humaira Jurair
- From: Department of Pediatric and Child Health, Aga Khan University Medical College, Karachi, Pakistan
| | - Anwarul Haque
- From: Department of Pediatric and Child Health, Aga Khan University Medical College, Karachi, Pakistan
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Sprung CL, Paruk F, Kissoon N, Hartog CS, Lipman J, Du B, Argent A, Hodgson RE, Guidet B, Groeneveld ABJ, Feldman C. The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments. J Crit Care 2014; 29:890-5. [PMID: 25151218 DOI: 10.1016/j.jcrc.2014.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/23/2014] [Accepted: 06/21/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees. METHODS Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared. RESULTS Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent. CONCLUSIONS Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.
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Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Fathima Paruk
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, Children's Hospital and Sunny Hill Health Centre for Children, University British Columbia, Vancouver, British Columbia, Canada
| | - Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine, Center for Sepsis Control and Care, Jena, Germany
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Womens Hospital and The University of Queensland, Herston, Queensland, Australia
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Andrew Argent
- School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - R Eric Hodgson
- Department of Anaesthesia and Critical Care, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal eThekwini-Durban, KwaZulu-Natal, South Africa
| | - Bertrand Guidet
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Vernaz S, Casanova L, Blanc F, Lebel S, Ughetto F, Paut O. [To maintain or to withdraw life support? Variations on the methods of ending life in a pediatric intensive care unit over a period of 6 years]. ACTA ACUST UNITED AC 2014; 33:400-4. [PMID: 24907188 DOI: 10.1016/j.annfar.2014.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 04/05/2014] [Indexed: 11/16/2022]
Abstract
Since 2005, forgoing live-support (FLS) is allowed by the French law (known as the Leonetti law) for end-of-life patients only. This study aims at describing the variations over time in the use of the following methods to end life: FLS, brain death and cardiopulmonary resuscitation failure (CPR failure). It is a single retrospective study from 2007 to 2012. The Cochran-Armitage trend test is used in the statistical analysis. Over six years, 263 of the 5100 children who were hospitalized in our intensive care unit died, which represents a 5.2% mortality rate. FLS increased yearly from 31% of the deaths in 2007, to 71% in 2012 (P=0.0008). The rate of CPR failure decreased over the same period (P=0.0015). The rate of brain death remained constant. Following to the Leonetti law, FLS increase, and palliative cares develop without any increase of mortality.
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Affiliation(s)
- S Vernaz
- Service de réanimation pédiatrique, hôpital de la Timone, faculté de médecine, université Aix-Marseille, 27, boulevard Jean-Moulin, 13005 Marseille, France.
| | - L Casanova
- Département de médecine générale, Aix-Marseille université, 27, boulevard Jean-Moulin, 13005, Marseille, France
| | - F Blanc
- Service de réanimation pédiatrique, hôpital de la Timone, faculté de médecine, université Aix-Marseille, 27, boulevard Jean-Moulin, 13005 Marseille, France
| | - S Lebel
- Service de réanimation pédiatrique, hôpital de la Timone, faculté de médecine, université Aix-Marseille, 27, boulevard Jean-Moulin, 13005 Marseille, France
| | - F Ughetto
- Service de réanimation pédiatrique, hôpital de la Timone, faculté de médecine, université Aix-Marseille, 27, boulevard Jean-Moulin, 13005 Marseille, France
| | - O Paut
- Service de réanimation pédiatrique, hôpital de la Timone, faculté de médecine, université Aix-Marseille, 27, boulevard Jean-Moulin, 13005 Marseille, France
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Ciofi degli Atti ML, Cuttini M, Ravà L, Rinaldi S, Brusco C, Cogo P, Pirozzi N, Picardo S, Schiavi F, Raponi M. Performance of the pediatric index of mortality 2 (PIM-2) in cardiac and mixed intensive care units in a tertiary children's referral hospital in Italy. BMC Pediatr 2013; 13:100. [PMID: 23799966 PMCID: PMC3695834 DOI: 10.1186/1471-2431-13-100] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 06/20/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mortality rate of patients admitted to Intensive Care Units is a widely adopted outcome indicator. Because of large case-mix variability, comparisons of mortality rates must be adjusted for the severity of patient illness at admission. The Pediatric Index of Mortality 2 (PIM-2) has been widely adopted as a tool for adjusting mortality rate by patients' case mix. The objective of this study was to assess the performance of PIM-2 in children admitted to intensive care units after cardiac surgery, other surgery, or for other reasons. METHODS This was a prospective cohort study, conducted in a 607 inpatient-bed tertiary-care pediatric hospital in Italy, with three pediatric intensive care Units (PICUs) and one cardiac Unit (CICU). In 2009-11, all consecutive admissions to PICUs/CICU of children aged 0-16 years were included in the study. Discrimination and calibration measures were computed to assess PIM-2 performance. Multivariable logistic regression analysis was used to assess the association of patients' main reason for intensive care admission (cardiac-surgical, other-surgical, medical), age, Unit and year with observed mortality, adjusting for PIM-2 score. RESULTS PIM-2 data collection was completed for 91.2% of total PICUs/CICU patient admissions (2912), and for 94.8% of patients who died in PICUs/CICU (129). Overall observed mortality was 4.4% (95% CI, 3.7-5.2), compared to 6.4% (95% CI, 5.5-7.3) expected mortality. Standardised mortality ratio was 0.7 (95% CI: 0.6-0.8). PIM-2 discrimination was fair (area under the curve, 0.79; 95% CI: 0.75-0.83). Calibration was less satisfactory, mainly because of the over two-fold overprediction of deaths in the highest risk group (114.7 vs 53; p < 0.001), and particularly in cardiac-surgical patients. Multivariable logistic analysis showed that risk of death was significantly reduced in cardiac-surgical patients and in those aged 1 month to 12 years, independently from PIM-2. CONCLUSIONS The children age distribution and the proportion of cardiac-surgical patients should be taken into account when interpreting SMRs estimated using the PIM-2 prediction model in different Units. A new calibration study of PIM-2 score might be needed, and more appropriate cardiac-focused risk-adjustment models should be developed. The role of age on risk of death needs to be further explored.
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Abstract
Both dying children and their families are treated with disrespect when the presumption of consent to cardiopulmonary resuscitation (CPR) applies to all hospitalized children, regardless of prognosis and the likely efficacy of CPR. This "opt-out" approach to CPR fails to appreciate the nuances of the special parent-child relationship and the moral and emotional complexity of enlisting parents in decisions to withhold CPR from their children. The therapeutic goal of CPR is not merely to resume spontaneous circulation, but rather it is to provide circulation to vital organs to allow for treatment of the underlying proximal and distal etiologies of cardiopulmonary arrest. When the treating providers agree that attempting CPR is highly unlikely to achieve the therapeutic goal or will merely prolong dying, we should not burden parents with the decision to forgo CPR. Rather, physicians should carry the primary professional and moral responsibility for the decision and use a model of informed assent from parents, allowing for respectful disagreement. As emphasized in the palliative care literature, we recommend a directive and collaborative goal-oriented approach to conversations about limiting resuscitation, in which physicians provide explicit recommendations that are in alignment with the goals and hopes of the family and emphasize the therapeutic indications for CPR. Through this approach, we hope to help parents understand that "doing everything" for their dying child means providing medical therapies that ameliorate suffering and foster the intimacy of the parent-child relationship in the final days of a child's life, making the dying process more humane.
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Affiliation(s)
- Jonna D Clark
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA 98105-037, USA.
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Withholding or withdrawing life-sustaining treatments: an 8-yr retrospective review in a Spanish pediatric intensive care unit. Pediatr Crit Care Med 2011; 12:e383-5. [PMID: 21263365 DOI: 10.1097/pcc.0b013e31820aba5b] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the death rate of patients who died in our pediatric intensive care unit after a decision to withhold or withdraw life-sustaining treatment was made and to describe the epidemiologic data, clinical (acute and chronic) conditions, end-of-life care, and decision-making processes corresponding to these patients. DESIGN Long-term retrospective review of patients' charts. SETTING Mixed university-affiliated pediatric intensive care unit. PATIENTS Patients younger than 18 yrs old whose deaths occurred after life-sustaining treatment was withheld or withdrawn. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Epidemiologic and clinical data, the treatments received, the decision-making process, and the end-of-life pathway were evaluated. Ninety-seven of 311 deaths occurred after a medical decision to withhold life-sustaining treatment. Among these patients, the most common reason for admission was respiratory failure (44 of 97), followed by cardiopulmonary arrest and sepsis. In 50 of 97 there was a previously known neurologic condition before admission, 11 of 97 had a neoplasm or hematologic malignancy, 10 of 97 had a congenital heart disease, and 8 of 97 had a neuromuscular disease. The most common action for forgoing life-sustaining treatment was withdrawal of treatment (chiefly respiratory support). The median time for deciding to withhold or withdraw life-sustaining treatment was on day 3 of admission. A total of 85 of 97 deaths occurred within 48 hrs after the decision was made and action taken. The decision to forgo life-sustaining treatment was proposed by the family in 14 of 97 patients, and there was an explicit agreement between the medical staff and the patient's family in 88 of 97. In all cases, palliative analgesic/sedative treatment effectively maintained the child's comfort. CONCLUSIONS Withholding or withdrawing life-sustaining treatment was a frequent mode of death in our pediatric intensive care unit, occurring at a rate that falls in the midrange of literature values. The level of the parents' involvement with the team in the decision-making process, which was documented in 88 of 97 of the medical charts, was very high. Patients with chronic neurologic diseases or with severe cognitive sequelae constituted the main group in which the decision to forgo life-sustaining treatment was made.
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Forgoing life support: how the decision is made in European pediatric intensive care units. Intensive Care Med 2011; 37:1881-7. [DOI: 10.1007/s00134-011-2357-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 05/08/2011] [Indexed: 10/17/2022]
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Poles K, Szylit Bousso R. Dignified death: Concept development involving nurses and doctors in Pediatric Intensive Care Units. Nurs Ethics 2011; 18:694-709. [DOI: 10.1177/0969733011408043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this study was to develop the concept of the dignified death of children in Brazilian pediatric intensive care units (PICUs). The Hybrid Model for Concept Development was used to develop a conceptual structure of dignified death in PICUs in an attempt to define the concept. The fieldwork study was carried out by means of in-depth interviews with nine nurses and seven physicians working in PICUs. Not unexpectedly, the concept of dignified death was found to be a complex phenomenon involving aspects related to decisions made by the multidisciplinary team as well as those related to care of the child and the family. Knowledge of the concept’s dimensions can promote reflection on the part of healthcare professionals regarding the values and beliefs underlying their conduct in end-of-life situations. Our hope is that this study may contribute to theoretic and methodological development in the area of end-of-life care.
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Affiliation(s)
- Kátia Poles
- University Center of Lavras (UNILAVRAS), Brazil,
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Au AK, Carcillo JA, Clark RSB, Bell MJ. Brain injuries and neurological system failure are the most common proximate causes of death in children admitted to a pediatric intensive care unit. Pediatr Crit Care Med 2011; 12:566-71. [PMID: 21037501 PMCID: PMC4854283 DOI: 10.1097/pcc.0b013e3181fe3420] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Mortality rates from critical illness in children have declined over the past several decades, now averaging between 2% and 5% in most pediatric intensive care units. Although these rates, and mortality rates from specific disorders, are widely understood, the impact of acute neurologic injuries in such children who die and the role of these injuries in the cause of death are not well understood. We hypothesized that neurologic injuries are an important cause of death in children. DESIGN Retrospective review. SETTING Pediatric intensive care unit at Children's Hospital of Pittsburgh, an academic tertiary care center. PATIENTS Seventy-eight children who died within the pediatric intensive care unit from April 2006 to February 2008. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data regarding admission diagnosis, presence of chronic illness, diagnosis of brain injury, and cause of death were collected. Mortality was attributed to brain injury in 65.4% (51 of 78) of deaths. Ninety-six percent (28 of 29) of previously healthy children died with brain injuries compared with 46.9% (23 of 49) of chronically ill children (p < .05). The diagnosed brain injury was the proximate cause of death in 89.3% of previously healthy children and 91.3% with chronic illnesses. Pediatric intensive care unit and hospital length of stay was longer in those with chronic illnesses (38.8 ± 7.0 days vs. 8.9 ± 3.7 days and 49.2 ± 8.3 days vs. 9.0 ± 3.8 days, p < .05 and p < .001, respectively). CONCLUSION Brain injury was exceedingly common in children who died in our pediatric intensive care unit and was the proximate cause of death in a large majority of cases. Neuroprotective measures for a wide variety of admission diagnoses and initiatives directed to prevention or treatment of brain injury are likely to attain further improvements in mortality in previously healthy children in the modern pediatric intensive care unit.
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Affiliation(s)
- Alicia K Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Cremer R, Hubert P, Grandbastien B, Moutel G, Leclerc F. Prevalence of questioning regarding life-sustaining treatment and time utilisation by forgoing treatment in francophone PICUs. Intensive Care Med 2011; 37:1648-55. [PMID: 21845503 DOI: 10.1007/s00134-011-2320-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 04/12/2011] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Robin Cremer
- Réanimation Pédiatrique, Hôpital Jeanne de Flandre, CHU de Lille, 59037 Lille Cedex, France.
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Lago PM, Nilson C, Piva JP, Halal MG, Carvalho Abib GMD, Garcia PCR, Vieira AC. Nurses’ participation in the end-of-life — process in two paediatric intensive care units in Brazil. Int J Palliat Nurs 2011; 17:264, 267-70. [DOI: 10.12968/ijpn.2011.17.6.264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Patrícia M Lago
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Cristine Nilson
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Jefferson Pedro Piva
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Michel Georges Halal
- Fellow, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | | | - Pedro Celiny R Garcia
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil
| | - Ana Cláudia Vieira
- Hospital São Lucas, Pontificia Universidade Catolica do Rio Grande do Sul, Brazil
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Lee KJ, Tieves K, Scanlon MC. Alterations in end-of-life support in the pediatric intensive care unit. Pediatrics 2010; 126:e859-64. [PMID: 20819890 DOI: 10.1542/peds.2010-0420] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our purpose was to examine alterations in end-of-life support in a multiinstitutional sample of PICUs. METHODS This was a retrospective, descriptive study. Variables collected included end-of-life support category, race, length of stay, operative status, reason for admission, and Pediatric Index of Mortality 2 score, as well as the number of ICU beds and the presence of trainees. RESULTS There were 1745 deaths at 35 institutions between January 1, 2004, and September 30, 2005. Of those, 1263 had complete data and were analyzed. The end-of-life support category distribution was as follows: brain death, 296 (23%); do not resuscitate, 205 (16%); limitation of support, 36 (3%); withdrawal of support, 579 (46%); no limitation, 124 (10%); no advance directives, 23 (2%). For further analyses, end-of-life support categories were grouped as limitation (ie, do not resuscitate, limitation of support, or withdrawal of support) versus no limitation (ie, no limitation or no advance directive). Brain death was not included in further analyses. The majority of deaths were in the limitation group (n=820 [85%]), and 12 (40%) of 30 institutions had 100% of deaths in this group. There were significant differences between institutions (P<.001). Decisions for limitation were seen less frequently in the black race (112 [76%] of 147 deaths; P=.037) and in institutions with no trainees (56 [69%] of 81 deaths; P<.001). CONCLUSIONS Decisions to limit support are common. Black race and an absence of trainees are associated with decreased frequency of limitation decisions.
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Affiliation(s)
- K Jane Lee
- Medical College of Wisconsin, Department of Pediatrics, 9000 W. Wisconsin Ave, MS B550B, Milwaukee, WI 53226, USA.
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35
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Endacott R, Benbenishty J, Seha M. Challenges and rewards in multi-national research. Intensive Crit Care Nurs 2010; 26:61-3. [PMID: 20079645 DOI: 10.1016/j.iccn.2009.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 12/14/2009] [Indexed: 12/16/2022]
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Abstract
O estudo teve por objetivo descrever os antecedentes, atributos e conseqüências do conceito de morte digna da criança. Utilizou-se a estratégia de análise de conceito para avaliar os 40 artigos, tendo como foco publicações nas áreas médica e de enfermagem, que estudaram ou focalizaram a morte digna da criança. Os atributos do conceito de morte digna da criança incluem: qualidade de vida, cuidado centrado na criança e na família, conhecimento específico sobre cuidados paliativos, decisão compartilhada, alívio do sofrimento da criança, comunicação clara, relacionamento de ajuda e ambiente acolhedor. Poucos artigos trazem a definição de morte digna da criança e, quando isso ocorre, essa definição é vaga e, muitas vezes, ambígua entre os vários autores. Esse aspecto indica que o conceito ainda não é consistentemente definido, demandando estudos de sua manifestação na prática clínica, contribuindo com os cuidados no final da vida em pediatria.
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Intercontinental differences in end-of-life attitudes in the pediatric intensive care unit: results of a worldwide survey. Pediatr Crit Care Med 2008; 9:560-6. [PMID: 18838925 DOI: 10.1097/pcc.0b013e31818d3581] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Stark Z, Hynson J, Forrester M. Discussing withholding and withdrawing of life-sustaining medical treatment in paediatric inpatients: audit of current practice. J Paediatr Child Health 2008; 44:399-403. [PMID: 18638331 DOI: 10.1111/j.1440-1754.2008.01352.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Zornitza Stark
- Department of Clinical Quality and Safety, Royal Children's Hospital, Melbourne, Victoria, Australia
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Moore P, Kerridge I, Gillis J, Jacobe S, Isaacs D. Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature. J Paediatr Child Health 2008; 44:404-8. [PMID: 18638332 DOI: 10.1111/j.1440-1754.2008.01353.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Devictor D, Latour JM, Tissières P. Forgoing life-sustaining or death-prolonging therapy in the pediatric ICU. Pediatr Clin North Am 2008; 55:791-804, xiii. [PMID: 18501766 DOI: 10.1016/j.pcl.2008.02.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Denis Devictor
- Pediatric Intensive Care, Hôpital de Bicêtre, AP-HP, Department of Research on Ethics, Paris-Sud 11 University, Bicêtre 94275, France.
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Abstract
OBJECTIVE To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). DESIGN Cross-sectional multicenter retrospective study based on medical chart review. SETTING Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region). PATIENTS Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. INTERVENTIONS Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (kappa = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student's t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. MEASUREMENTS AND MAIN RESULTS Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. CONCLUSIONS The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.
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Stalmeier PFM, Lamers LM, Busschbach JJV, Krabbe PFM. On the assessment of preferences for health and duration: maximal endurable time and better than dead preferences. Med Care 2007; 45:835-41. [PMID: 17712253 DOI: 10.1097/mlr.0b013e3180ca9ac5] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Several studies revealed difficulties with the valuation and analysis of health states deemed worse than dead. These problems may be linked to maximal endurable time (MET) preferences, the phenomenon that for severe states better than dead (BTD), shorter durations are often preferred to longer durations. OBJECTIVE To test the association between the duration of health states and their valuation. METHODS A representative sample of 123 Dutch respondents (age range, 18-45 years) valued 5 EQ-5D health states. With a straightforward method using BTD preferences, respondents indicated whether a state of a certain duration is better, equal to, or worse than dead. To validate these BTD preferences, MET preferences (whether a longer duration of a health state is better, equal, or worse than a shorter duration) were collected. RESULTS BTD and MET preferences were strongly related (P < 0.001). For severe health states, although still judged as better than dead, BTD preferences curved downwards with increasing duration. Such curved BTD patterns occurred in 28% of the respondents, especially for more severe states (P < 0.001). CONCLUSIONS BTD preferences revealed that the value of moderate and severe states declines with increasing duration, suggesting that health and duration interact. For states worse than dead versus states better than dead, traditional valuation techniques have the drawback that different preference questions are used. Using BTD preferences, however, a single simple preference question can assess states better than dead, as well as states worse than dead.
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Affiliation(s)
- Peep F M Stalmeier
- Department of Medical Technology Assessment, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Abstract
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.
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Soares M, Terzi RGG, Piva JP. End-of-life care in Brazil. Intensive Care Med 2007; 33:1014-7. [PMID: 17410343 DOI: 10.1007/s00134-007-0623-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2007] [Accepted: 03/06/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Márcio Soares
- Centro de Tratamento Intensivo, Instituto Nacional de Câncer, 10 Andar, Pça. Cruz Vermelha 23, CEP 20230-130 Rio de Janeiro, Brazil.
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Casanueva-Mateos L, Ruiz-López P, Ignacio Sánchez-Díaz J, Ramos-Casado V, Belda-Holfheinz S, Llorente-de la Fuente A, Mar-Molinero F. Cuidados al final de la vida en la unidad de cuidados intensivos pediátricos. Empleo de técnicas de investigación cualitativa para el análisis del afrontamiento de la muerte y situaciones críticas. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1134-282x(07)71189-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Up to 60% of deaths in pediatric intensive care units occur after placing limits upon life-sustaining treatment. Two-thirds of limitations are made on the last day of life. Our aim was to characterize the timing, indications, and implementation of "do not resuscitate" (DNR) orders and the withdrawal of support from children with severe burns. A retrospective evaluation was conducted of all deaths in a pediatric burn unit over a 7-year period. Values are presented as mean +/- SD; two-tailed t-tests and Fisher's exact tests were used for analysis. Of the 29 deaths (total admissions = 1261; 2.3% death rate), 12 were of patients with DNR status. Active withdrawal of support occurred for 15 patients: 10 with DNR orders, 5 without. There was no difference in age, burn size, inhalation injury, etiology of injury, cause of death, intensive care unit days, or ventilator days between DNR patients and non-DNR patients. Of the 12 patients with DNR status, only five had orders indicating no cardiopulmonary resuscitation (CPR), no vasopressors, and no cardioversion. The mean time from DNR to death was 22.9 +/- 49.6 hours (median, 2.75 hours). Patients without DNR orders before death had more CPR attempts (0.8 +/- 0.6 vs. 0.3 +/- 0.6; P < .05). At the time of death, few patients with DNR orders were receiving vasopressors (two patients) or underwent CPR (1 patient). Of the 17 patients without DNR orders, 12 underwent resuscitative efforts: CPR (11), vasopressors (12), or cardioversion (9). No resuscitative efforts were undertaken for four children, two with DNR orders. For the acutely injured child there is a strong tendency to wait until the last possible hours of life to address limitation of life-sustaining measures. Documentation of limitation of care was not previously addressed in nearly a third of cases in which support was actively withdrawn. Once a decision to limit support was made, the majority of children proceeded rapidly to death. Further evaluation of the indications, timing, and implementation of DNR orders for children with severe burns is warranted.
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Affiliation(s)
- Michael Shay O'Mara
- Shriners Hospital for Children of Northern California, Department of Burns Surgery, Sacramento, California, USA
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ten Berge J, de Gast-Bakker DAH, Plötz FB. Circumstances surrounding dying in the paediatric intensive care unit. BMC Pediatr 2006; 6:22. [PMID: 16893468 PMCID: PMC1557849 DOI: 10.1186/1471-2431-6-22] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Accepted: 08/07/2006] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Death is inevitable in the paediatric intensive care unit (PICU). We aimed to describe the circumstances surrounding dying in a PICU. METHOD The chart records of all patients less than 18 years of age who died at the PICU between January first 2000 and July first 2005 were retrospectively analyzed. Information regarding sex, age, length of stay, admission, diagnosis, and the way a patient died was registered. Post mortem information regarding natural versus unnatural death, autopsy and donation was obtained. Non-survivors were allocated in five groups: do-not-resuscitate (DNR), withholding and/or withdrawal of therapy (W/W), failed cardiopulmonary resuscitation (failed CPR), brain death (BD), and terminal organ failure (TOF). RESULTS During the study period 87 (4.4%) of the 1995 admitted patients died. Non-survivors were more often admitted during the day (54%) and the week (68%). W/W was found in 27.6%, TOF in 26.4%, BD in 23.0%, failed CPR in 18.4%, and DNR in 4.6%. Forty-three percent died in the first two days, of which BD (40.5%) and failed CPR (37.8%) were most common. Seventy-five children (86%) died due to a natural cause. Autopsy permission was obtained in 19 of 54 patients (35%). The autopsies confirmed the clinical diagnosis in 11 patients, revealed new information in 5 patients, and in 3 patients the autopsy did not provide additional information. Nine patients were medically suitable for organ donation and 24 patients for tissue donation, whereas consent was only obtained in 2 cases in both groups. CONCLUSION We observed that 43% of the patients died within the first two days of admission due to BD and failed CPR, whereas after 4 days most patients died after W/W. Autopsy remains an useful tool to confirm clinical diagnoses or to provide new information. Only a small percentage of the deceased children is suitable for organ donation.
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Affiliation(s)
- Jetske ten Berge
- BSc, Department of Paediatric Intensive Care, VU Medical Center, Amsterdam, The Netherlands
| | - Dana-Anne H de Gast-Bakker
- Paediatrician, fellow paediatric intensive care, Department of Paediatric Intensive Care, VU Medical Center, Amsterdam, The Netherlands
| | - Frans B Plötz
- Paediatric intensivist, Department of Paediatric Intensive Care, VU Medical Center, Amsterdam, The Netherlands
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