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Darchinger B, Härlein J, Fley G. [Withdrawal of Life-Sustaining Treatment in the PICU From the Nursing Staff's Perspective: Integrative Review]. Pflege 2024. [PMID: 38651458 DOI: 10.1024/1012-5302/a000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Withdrawal of Life-Sustaining Treatment in the PICU From the Nursing Staff's Perspective: Integrative Review Abstract: Background: Withdrawal of life sustaining measures is a common mode of treatment prior to the death of a critically ill child and has implications for all involved. The perspective of nurses has not yet been considered in this context. Aim: How do nurses experience the termination of life-sustaining measures in the paediatric intensive care unit? What is their role in this process? Methods: An integrative review was conducted to answer the research question. The literature search was performed in October 2022 in the CINAHL, Medline and PsycINFO databases. Results: Three qualitative and five quantitative studies were included. The confrontation with emotions, uncertainties in the decision-making process, challenges and conflicts in collaboration, in interacting with those involved and in the provision of care determine the experience of nurses during treatment withdrawal. The nurses as involved in the decision-making process and representative of interests are influenced by intrarole conflicts. Conclusion: Nursing professionals need support to cope with their experiences in the context of treatment withdrawal in children. In addition to surveying the type and scope of support measures, interprofessional guidelines must be developed when life-sustaining measures are withdrawn. This includes future research to specify the role of nurses in treatment withdrawal and includes, for example, the description of specific tasks, necessary skills or the extent of involvement in decision-making.
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Affiliation(s)
- Britta Darchinger
- Kinder-Intensiv-Pflege-Station, Kinderklinik und Kinderpoliklinik, Dr. von Haunersches Kinderspital der LMU München, Deutschland
- Evangelische Hochschule für angewandte Wissenschaften Nürnberg, Deutschland
| | - Jürgen Härlein
- Evangelische Hochschule für angewandte Wissenschaften Nürnberg, Deutschland
| | - Gabriele Fley
- Evangelische Hochschule für angewandte Wissenschaften Nürnberg, Deutschland
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2
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Francoeur C, Silva A, Hornby L, Wollny K, Lee LA, Pomeroy A, Cayouette F, Scales N, Weiss MJ, Dhanani S. Pediatric Death After Withdrawal of Life-Sustaining Therapies: A Scoping Review. Pediatr Crit Care Med 2024; 25:e12-e19. [PMID: 37678383 PMCID: PMC10756696 DOI: 10.1097/pcc.0000000000003358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Evaluate literature on the dying process in children after withdrawal of life sustaining measures (WLSM) in the PICU. We focused on the physiology of dying, prediction of time to death, impact of time to death, and uncertainty of the dying process on families, healthcare workers, and organ donation. DATA SOURCES MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, and Web of Science. STUDY SELECTION We included studies that discussed the dying process after WLSM in the PICU, with no date or study type restrictions. We excluded studies focused exclusively on adult or neonatal populations, children outside the PICU, or on organ donation or adult/pediatric studies where pediatric data could not be isolated. DATA EXTRACTION Inductive qualitative content analysis was performed. DATA SYNTHESIS Six thousand two hundred twenty-five studies were screened and 24 included. Results were grouped into four categories: dying process, perspectives of healthcare professionals and family, WLSM and organ donation, and recommendations for future research. Few tools exist to predict time to death after WLSM in children. Most deaths after WLSM occur within 1 hour and during this process, healthcare providers must offer support to families regarding logistics, medications, and expectations. Providers describe the unpredictability of the dying process as emotionally challenging and stressful for family members and staff; however, no reports of families discussing the impact of time to death prediction were found. The unpredictability of death after WLSM makes families less likely to pursue donation. Future research priorities include developing death prediction tools of tools, provider and parental decision-making, and interventions to improve end-of-life care. CONCLUSIONS The dying process in children is poorly understood and understudied. This knowledge gap leaves families in a vulnerable position and the clinical team without the necessary tools to support patients, families, or themselves. Improving time to death prediction after WLSM may improve care provision and enable identification of potential organ donors.
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Affiliation(s)
- Conall Francoeur
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Amina Silva
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Laura Hornby
- Consultant, Canadian Blood Services, Hamilton, ON, Canada
| | - Krista Wollny
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
| | - Laurie A Lee
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Consultant, Canadian Blood Services, Hamilton, ON, Canada
- Faculty of Nursing, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada
- School of Nursing, Queen's University, Kingston, ON, Canada
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
- Dynamical Analysis Lab, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Transplant Québec, Montréal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | | | - Florence Cayouette
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
| | - Nathan Scales
- Dynamical Analysis Lab, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Matthew J Weiss
- Department of Pediatrics, CHU de Quebec - University of Laval, Montreal, QC, Canada
- Transplant Québec, Montréal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Sonny Dhanani
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
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Sullivan MD, Owattanapanich N, Schellenberg M, Matsushima K, Lewis MR, Lam L, Martin M, Inaba K. Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients. Injury 2023; 54:111088. [PMID: 37833232 DOI: 10.1016/j.injury.2023.111088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST. METHODS The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients. RESULTS Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h. CONCLUSIONS More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.
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Affiliation(s)
- Michael D Sullivan
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Natthida Owattanapanich
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Lydia Lam
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Matthew Martin
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA.
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Rothschild CB, Chaiyachati BH, Finck KR, Atwood MA, Leuthner SR, Christian CW. A Venn diagram of vulnerability: The convergence of pediatric palliative care and child maltreatment a narrative review, and a focus on communication. CHILD ABUSE & NEGLECT 2022; 128:105605. [PMID: 35367899 PMCID: PMC11000825 DOI: 10.1016/j.chiabu.2022.105605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
Child maltreatment and end-of-life care independently represent two of the most emotion-laden and uncomfortable aspects of pediatric patient care. Their overlap can be uniquely distressing. This review explores ethical and legal principles in such cases and provides practical advice for clinicians. The review focuses on three archetypal scenarios of overlap: life-limiting illness in a child for whom parental rights have been terminated; life-threatening injury under CPS investigation; and complex end-of-life care which may warrant CPS involvement. While each scenario presents unique challenges, one consistent theme is the centrality of effective communication. This includes empathic communication with families and thoughtful communication with providers and community stakeholders. In almost all cases, everyone genuinely wants to do what is in the best interest of the child in these unthinkable circumstances. Transparent and collaborative communication can ensure that broad perspectives are considered to ensure that each child gets the best possible care in a manner adherent with ethical and legal standards, as they apply to each case.
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Affiliation(s)
| | - Barbara H Chaiyachati
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kara R Finck
- Interdisciplinary Child Advocacy Clinic, University of Pennsylvania Carey Law School, Philadelphia, PA, USA
| | - Melissa A Atwood
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steven R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cindy W Christian
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Machado DS, Garros D, Montuno L, Avery LK, Kittelson S, Peek G, Moynihan KM. Finishing Well: Compassionate Extracorporeal Membrane Oxygenation Discontinuation. J Pain Symptom Manage 2022; 63:e553-e562. [PMID: 35031504 DOI: 10.1016/j.jpainsymman.2021.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/20/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is associated with significant mortality. Provision of high-quality end-of-life (EOL) care for patients supported on ECMO entails specific physiological, pharmacological, and technical considerations. Limited guidance exists for clinicians on delivery of optimal EOL care on ECMO. In this article, we review the unique aspects of EOL care as they apply to ECMO support and propose a pragmatic, interdisciplinary framework for compassionate ECMO discontinuation in children and adults. The goal of compassionate ECMO discontinuation (CED) is to allow natural death from the underlying disease process while delivering high-quality EOL care to ensure a good death experience for patients and their families. The CED approach includes: 1) a family meeting to define goal-concordant EOL care and prepare families and patients for the dying process; 2) clinical preparation, including symptom management and discontinuation of other life-sustaining therapies; 3) technical aspects which necessarily vary according to patient factors and the circuit and cannulation strategy; and 4) bereavement support. The proposed CED considerations and checklist may serve as tools aiding provision of comprehensive, quality, individualized patient- and family-centered care for children and adults dying despite ECMO support. A structured CED may enhance EOL experiences for patients, family, and staff by providing a respectful and dignified death experience. Future research is required to determine feasibility and effectiveness of the framework, which must be adapted to the patient and institutional setting.
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Affiliation(s)
- Desiree S Machado
- Department of Pediatrics, Division of Pediatric Critical Care Medicine (D.S.M., L.K.A.), University of Florida, Gainesville, Florida, USA.
| | - Daniel Garros
- Department of Pediatrics, Division of Pediatric Critical Care Medicine & John Dossetor Health Ethics Centre (D.G.), Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Lauriedale Montuno
- Mother of Mila Grace Montuno, Bereavement Coordinator (L.M.), Conquering CHD Organization
| | - Leslie K Avery
- Department of Pediatrics, Division of Pediatric Critical Care Medicine (D.S.M., L.K.A.), University of Florida, Gainesville, Florida, USA
| | - Sheri Kittelson
- Department of Internal Medicine, Division of Palliative Care (S.K.), University of Florida, Gainesville, Florida, USA
| | - Giles Peek
- Department of Surgery, Congenital Heart Center (G.P.), University of Florida, Gainesville, Florida, USA
| | - Katie M Moynihan
- Department of Cardiology, Division of Cardiovascular Critical Care (K.M.M.), Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics (K.M.M.), Harvard Medical School, Boston, Massachusetts, USA; Kids Critical Care Research (K.M.M.), Children's Hospital Westmead, Sydney, Australia
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6
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Moynihan KM, Ziniel SI, Johnston E, Morell E, Pituch K, Blume ED. A "Good Death" for Children with Cardiac Disease. Pediatr Cardiol 2022; 43:744-755. [PMID: 34854941 DOI: 10.1007/s00246-021-02781-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 11/17/2021] [Indexed: 11/25/2022]
Abstract
Children with heart disease often experience symptoms and medically intense end-of-life care. Our study explored bereaved parents' perceptions of a "good death" via a mail survey to 128 parents of children with heart disease who died in two centers. Parental perceptions of end-of-life circumstances were assessed by closed-ended questions including level of agreement with the question: "would you say your child experienced a good death?" and open-ended comments were contributed. Medical therapies at end-of-life and mode of death were retrieved through chart review. Of 50 responding parents, 44 (response rate: 34%) responded to the "good death" question; 16 (36%) agreed strongly, 15 (34%) agreed somewhat, and 30% disagreed (somewhat: 7, 16%; strongly: 6, 14%). Half the children were on mechanical support and 84% intubated at death. Of children with cardiopulmonary resuscitation (CPR) at end-of-life, 71% of parents disagreed with the "good death" question compared with 22% of parents whose child died following discontinuation of life-sustaining therapy or comfort measures (OR 9.1, 95% CI 1.3, 48.9, p < 0.01). Parent-reported circumstances associated with disagreement with the "good death" question included cure-oriented goals-of-care (OR 16.6, 95% CI 3.0, 87.8, p < 0.001), lack of advance care planning (ACP) (OR 12.4 95% CI 2.1, 65.3 p < 0.002), surprise regarding timing of death (OR 11.7, 95% CI 2.6, 53.4 p < 0.002), and experience of pain (OR 42.1, 95% CI 2.3, 773.7 p < 0.02). Despite high medical intensity, many bereaved parents of children with cardiac disease agree a "good death" was experienced. A "good death" was associated with greater preparedness, ACP, non-cure-oriented goals-of-care, pain control, and CPR avoidance.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Avenue, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sonja I Ziniel
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Emily Johnston
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emily Morell
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Kenneth Pituch
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, MS BCH3215, 300 Longwood Avenue, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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7
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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Nilson C, Vieira AC, de Moura Bubadué R, Stein RT, Lago PM. Decision-Making Process for the Implementation of the Child Therapeutic Support Limitation Plan: Nurses' Experiences. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580221100777. [PMID: 35538400 PMCID: PMC9102201 DOI: 10.1177/00469580221100777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Aim: To present nurses’ experience in the decision-making process for implementing a therapeutic support limitation plan in the PICU. Method: Qualitative exploratory research was conducted through semi-structured interviews with 25 intensive care nurses from January to June 2019. The textual corpus was then submitted for content analysis. Results: Two categories emerged: the nurse and decision-making process of the TSLP and ambivalence of the participating nurse’s feelings in implementing the TSLP. These categories are interrelated in that the decision-making process mobilizes the ambivalence of the participating nurses’ feelings. Final considerations and implications for practice: The starting point of communication between the health teams consists of acquiring information about the concerned child’s end-of-life care plan with no prospect of cure and with some form of therapeutic limit admitted to the PICU. Therefore, this study helps to map possible research gaps on the topic and mobilize researchers to build educational materials, protocols, and tools for comprehensive care that can be used by nurses when faced with ethical dilemma, such as decision-making through TSLP.
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Affiliation(s)
- Cristine Nilson
- Clinical Hospital of Porto Alegre of Federal University of Rio Grande do Sul (HCPA/UFRGS), Porto Alegre, RS, Brazil
| | | | | | - Renato Tetelbom Stein
- Faculty of Medicine, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
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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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Abstract
PURPOSE OF REVIEW Children with medical or surgical critical illness or injury require skillful attention to physical, emotional, psychological, and spiritual needs, whereas their families need support and guidance in facing life-threatening or life-changing events and gut-wrenching decisions. This article reviews current evidence and best practices for integrating palliative care into the pediatric intensive care unit (PICU), with a focus on surgical patients. RECENT FINDINGS Palliative care is best integrated in a tiered approach, with primary palliative care provided by the PICU and surgical providers for all patients and families, including basic symptom management, high-quality communication, and end-of-life care. Secondary and tertiary levels of care involve unit or team-based 'champions' with additional expertise, and subspecialty palliative care teams, respectively. PICU and surgical providers should be able to provide primary palliative care, to identify patients and families for whom a palliative care consult would be helpful, and should be comfortable introducing the concept of palliative care to families. SUMMARY This review provides a framework and tools to enable PICU and surgical providers to integrate palliative care best practices into patient and family care.
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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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Joong A, Derrington SF, Patel A, Thrush PT, Allen KY, Marino BS. Providing Compassionate End of Life Care in the Setting of Mechanical Circulatory Support. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00206-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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