End-of-life care in the pediatric ICU

The elements of end-of-life care provision in paediatric intensive care units: a systematic integrative review

BACKGROUND

Deaths in paediatric intensive care units (PICUs) are not uncommon. End-of-life care in PICUs is generally considered more challenging than other settings since it is framed within a context where care is focused on curative or life-sustaining treatments for children who are seriously ill. This review aimed to identify and synthesise literature related to the essential elements in the provision of end-of-life care in the PICU from the perspectives of both healthcare professionals (HCPs) and families.

METHODS

A systematic integrative review was conducted by searching EMBASE, CINAHL, MEDLINE, Nursing and Allied Health Database, PsycINFO, Scopus, Web of Science, and Google Scholar databases. Grey literature was searched via Electronic Theses Online Service (EthOS), OpenGrey, Grey literature report. Additionally, hand searches were performed by checking the reference lists of all included papers. Inclusion and exclusion criteria were used to screen retrieved papers by two reviewers independently. The findings were analysed using a constant comparative method.

RESULTS

Twenty-one studies met the inclusion criteria. Three elements in end-of-life care provision for children in the PICUs were identified: 1) Assessment of entering the end-of-life stage; 2) Discussion with parents and decision making; 3) End of life care processes, including care provided during the dying phase, care provided at the time of death, and care provided after death.

CONCLUSION

The focus of end-of-life care in PICUs varies depending on HCPs' and families' preferences, at different stages such as during the dying phase, at the time of death, and after the child died. Tailoring end-of-life care to families' beliefs and rituals was acknowledged as important by PICU HCPs. This review also emphasises the importance of HCPs collaborating to provide the optimum end-of-life care in the PICU and involving a palliative care team in end-of-life care.

Palliation, end-of-life care and burns; practical issues, spiritual care and care of the family - A narrative review II

Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. This second article discusses practical issues around palliative care for burn patients, such as pain and fluid management, withdrawal of ventilator support and wound care, as well as spiritual and family issues. This paper forms part two, of two narrative reviews on the topic of palliation, end-of-life care and burns. The first part considered concepts, decision-making and communication. It was published in volume 10, issue 2, June 2020, pages 95–98.

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Mortality of burns presented to a burns unit in Africa is about 10%.

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Resources in Africa to manage burn patients are scarce and patients with massive burns may not be offered curative burn care.

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There are no guidelines for palliative care in burn patients.

End-of-life care in the pediatric intensive care unit: Survey in Japan

BACKGROUND

End-of-life (EOL) care is an important topic in critical care medicine, but EOL discussions with families can be difficult and stressful for intensivists. The aim of this study was to clarify the current practices and barriers facing pediatric intensive care unit (PICU) EOL care and to identify the requisites for excellent PICU EOL care in Japan.

METHODS

A survey was conducted in 29 facilities across Japan in 2016. The questionnaire consisted of 19 multiple-choice questions and one open-ended question.

RESULTS

Twenty-seven facilities responded to the survey. Only 19% had educational programs on EOL care for fellows or residents. Although 21 hospitals (78%) had a multidisciplinary palliative care team, only eight of these teams were involved in EOL care in PICUs. Mental health care for health-care providers provided by a psychiatrist was rare (4%). The free comments were categorized as individual, team, environment, legal/ethics, or culture. Commonly raised individual issues included "lack of experience and knowledge about EOL care", "fear of making the decision to end care", and "reluctance to be involved in EOL care because of its complex process". Team issues included "insufficient frequency of conferences" and "non-multidisciplinary approach". Legal and ethics issues were "lack of legal support" and "fear of lawsuits".

CONCLUSIONS

This study is the first to investigate the current conditions and barriers in PICU EOL care in Japan. Most of the facilities involved were not satisfied with current practices. A need was identified for relevant educational programs, as well as the importance of multidisciplinary and legal support.

Implications of Pediatric Palliative Consultation for Intensive Care Unit Stay

Background: The impact of specialty pediatric palliative care (PPC) on intensive care unit (ICU) length of stay for children is unclear. Objective: To estimate the impact of PPC consultation by analyzing ICU stay as a dynamic outcome over the course of hospitalization. Patients and Methods: Retrospective cohort study of children hospitalized with diagnoses suggested as referral triggers for PPC at a large academic children's hospital. We assessed ICU stay according to PPC consultation and, using a patient-day analysis, applied multivariable mixed effects logistic regression to predict the odds of being in the ICU on a given day. Results: The analytic sample included 777 admissions (11,954 hospital days), of which 100 admissions (13%) included PPC consultation. Principal patient demographics were age 8 ± 6 years, 55% male sex, 71% white race, and 52% commercial insurance. Cardiac diagnoses were most frequent (29%) followed by gastrointestinal (22%) and malignant (20%) conditions. Although total ICU stay was longer for admissions, including PPC consultation (compared to admissions where PPC was not consulted), the odds of being in the ICU on a given day were reduced by 79% after PPC consultation (odds ratio [OR] = 0.21; 95% confidence interval [CI]: 0.13-0.34; p < 0.001) for children with cancer and 85% (OR = 0.15; 95% CI: 0.08-0.26; p < 0.001) for children with nononcologic conditions. Conclusions: Among children hospitalized with a diagnosis deemed eligible for specialty PPC, the likelihood of being in the ICU on a given day was strongly reduced after PPC consultation, supporting the value of PPC.

Nurses’ Experiences in End-of-Life Care in the PICU: A Qualitative Systematic Review

The experiences of end-of-life care by nurses in the pediatric intensive care unit are the subject of this systematic review. Six qualitative articles from three different countries were chosen for the review using methods from Joanna Briggs Institute. The themes discovered included the following: insufficient communication, emotional burden, moral distress from medical futility, strengthening resilience, and taking steps toward hospice. These themes are discussed in detail followed by recommendations for practice to assist nurses in their quest for a good death for their pediatric patients.

The Importance of Parental Connectedness and Relationships With Healthcare Professionals in End-of-Life Care in the PICU

OBJECTIVES

Support from healthcare professionals in a PICU is highly valuable for parents of dying children. The way they care for the patients and their families affects the parents' initial mourning process. This study explores what interaction with hospital staff is meaningful to parents in existential distress when their child is dying in the PICU.

DESIGN

Qualitative interview study.

SETTING

Level 3 PICU in the Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, and the Netherlands.

SUBJECTS

Thirty-six parents of 20 children who had died in this unit 5 years previously.

INTERVENTIONS

Parents participated in audio-recorded interviews in their own homes. The interviews were transcribed and analyzed using qualitative methods.

MEASUREMENTS AND MAIN RESULTS

Parents' narratives of their child's end-of-life stage in the PICU bespeak experiences of estrangement, emotional distancing, and loneliness. Significant moments shared with hospital staff that remained valuable even after 5 years primarily involved personal connectedness, reflected in frequent informational updates, personal commitment of professionals, and interpersonal contact with doctors and nurses.

CONCLUSIONS

Parents whose children died in the PICU value personal connectedness to doctors and nurses when coping with existential distress. Medical and nursing training programs should raise awareness of parents' need for contact in all interactions but especially in times of crisis and apprehension.

[Limitation of the therapeutic effort in pediatric intensive care]

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

Parental Physical Proximity in End-of-Life Care in the PICU

OBJECTIVE

Health professionals in PICUs support both child and parents when a child's death is imminent. Parents long to stay connected to their dying child but the high-tech environment and treatment implications make it difficult to stay physically close. This study explores in what sense physical aspects of end-of-life care in the PICU influence the parent-child relationship.

DESIGN

Retrospective, qualitative interview study.

SETTING

Level 3 PICU in Erasmus Medical Center in the Netherlands.

PARTICIPANTS

Thirty-six parents of 20 children who had died in this unit 5 years previously.

MEASUREMENTS AND MAIN RESULTS

Parents vividly remembered the damage done to the child's physical appearance, an inevitable consequence of medical treatment. They felt frustrated and hurt when they could not hold their child. Yet they felt comforted if facilitated to be physically close to the dying child, like lying with the child in one bed, holding the child in the hour of death, and washing the child after death.

CONCLUSIONS

End-of-life treatment in the PICU presents both a barrier and an opportunity for parents to stay physically connected to their child. Parents' experiences suggest that aspects of physicality in medical settings deserve more attention. Better understanding of the significance of bodily aspects-other than pain and symptom management-improves end-of-life support and should be part of the humane approach to families.