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

Pediatric Advance Care Planning: A Scoping Review

To assess current practice and provide a basis for a provincial template, clinicians at a Canadian pediatric hospice reviewed the literature surrounding pediatric advance care planning (pACP) documentation, process, and implementation for children/youth. The scoping review protocol was developed in accordance with the Joanna Briggs Institute methodology for scoping reviews, and was prospectively registered on the Open Science Framework. MEDLINE, Embase, CINAHL, the Web of Science Core Collection, and Google Scholar, as well as sources of unpublished studies and grey literature, were reviewed. Sixty-four articles met the criteria. Fifteen pACP documentation forms/tools were also identified. Overall, the included articles highlighted that pACP should be a structured, collaborative and iterative process between the family and a trusted or relevant healthcare provider, encompassing medical and non-medical issues. Few articles provided insights into specific elements recommended for advance directive forms. Identified strategies for implementation included a structured, step-by-step pACP interventional tool along with ongoing training, mentorship, and defined organizational structures for the clinician. No single specific ACP tool was acknowledged as the gold standard. Use of a pACP tool, along with ongoing provider education and communication skill development, standardized/accessible documentation, and system-wide quality improvement support, were noted as integral components of pACP.

Prognostic and Goals-of-Care Communication in the PICU: A Systematic Review

OBJECTIVE

Admission to the PICU may result in substantial short- and long-term morbidity for survivors and their families. Engaging caregivers in discussion of prognosis is challenging for PICU clinicians. We sought to summarize the literature on prognostic, goals-of-care conversations (PGOCCs) in the PICU in order to establish current evidence-based practice, highlight knowledge gaps, and identify future directions.

DATA SOURCES

PubMed (MEDLINE and PubMed Central), EMBASE, CINAHL, PsycINFO, and Scopus.

STUDY SELECTION

We reviewed published articles (2001-2022) that examined six themes within PGOCC contextualized to the PICU: 1) caregiver perspectives, 2) clinician perspectives, 3) documentation patterns, 4) communication skills training for clinicians, 5) family conferences, and 6) prospective interventions to improve caregiver-clinician communication.

DATA EXTRACTION

Two reviewers independently assessed eligibility using Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology.

DATA SYNTHESIS

Of 1,420 publications screened, 65 met criteria for inclusion with several key themes identified. Parent and clinician perspectives highlighted the need for clear, timely, and empathetic prognostic communication. Communication skills training programs are evaluated by a participant's self-perceived improvement. Caregiver and clinician views on quality of family meetings may be discordant. Documentation of PGOCCs is inconsistent and most likely to occur shortly before death. Only two prospective interventions to improve caregiver-clinician communication in the PICU have been reported. The currently available studies reflect an overrepresentation of bereaved White, English-speaking caregivers of children with known chronic conditions.

CONCLUSIONS

Future research should identify evidence-based communication practices that enhance caregiver-clinician PGOCC in the PICU and address: 1) caregiver and clinician perspectives of underserved and limited English proficiency populations, 2) inclusion of caregivers who are not physically present at the bedside, 3) standardized communication training programs with broader multidisciplinary staff inclusion, 4) improved design of patient and caregiver educational materials, 5) the development of pediatric decision aids, and 6) inclusion of long-term post-PICU outcomes as a measure for PGOCC interventions.

Care management trajectories of infants with life-limiting conditions who died before 12 months of age; a retrospective patient health record review

PURPOSE

To characterise the care management trajectories of infants with life-limiting conditions, who died before 12 months, including clinical decision-making processes, identification of triggers that led to changes in care management from cure-orientated to palliative care and specialist palliative care team involvement.

DESIGN AND METHODS

Retrospective patient health record review of infants with life-limiting conditions who died before 12 months of age and received care at three hospitals in Western Australia. Two data analysis methods; directed content analysis and process mapping.

RESULTS

A total of 45 patient health records were reviewed. Process mapping led to typology of care management encompassing four trajectories; early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until a significant point; and early treatment limits. Standardised advance care planning processes were used for just over 10% of infants. There was specialist palliative care team involvement for 25% of infants.

CONCLUSION

Only a proportion of infants received early integration of palliative care principles and practices. Infants and their families may benefit from earlier integration of palliative care, and standardised processes for advance care planning that are done in parallel to treatment.

PRACTICE IMPLICATIONS

There is opportunity to further enhance the delivery of palliative care to infants with life-limiting conditions and optimise the experience for families through education for health professionals, implementation of advance care planning and standardisation through policies and clinical practice guidelines.

Initiation of paediatric advance care planning: Cross-sectional survey of health professionals reported behaviour

BACKGROUND

Globally, initiation of paediatric advance care planning discussions is advocated early in the illness trajectory; however, evidence suggests it occurs at crisis points or close to end of life. Few studies have been undertaken to ascertain the prevalence and determinants of behaviour related to initiation by the healthcare professional.

METHOD

Underpinned by the Capability, Opportunity, Motivation-Behaviour (COM-B) model for behaviour change, a cross-sectional online survey was conducted in United Kingdom and Ireland using a purposive sample of health professionals. Descriptive and inferential statistics were applied and nonparametric statistical analysis used. Open-ended questions were mapped and correlations between COM-B and demographic profiles identified.

RESULTS

Responses (n = 140): Paediatric advance care planning was viewed positively; however, initiation practices were found to be influenced by wide ranging diagnoses and disease trajectories. Whilst some tools and protocols exist, they were not used in a systematic manner, and initiation behaviour was often not guided by them. Initiation was unstandardized, individually led, guided by intuition and experience and based on a range of prerequisites. Such behaviour, combined with inconsistencies in professional development, resulted in varying practice when managing clinical deterioration. Professionals who felt adequately trained initiated more conversations (capability). Those working in palliative care specialties, hospice settings and doctors initiated more discussions (opportunity). There was no difference in Motivation between professions, clinical settings or specialisms, although 25% (n = 35) of responses indicated discomfort discussing death and 34% (n = 49) worried about families' emotional reaction.

CONCLUSION

Although advocated, paediatric advance care planning is a complex process, commonly triggered by the physical deterioration and rarely underpinned by support tools. The COM-B framework was useful in identifying fundamental differences in initiation behaviour; however, further research is required to explore the complexity of initiation behaviour and the system within which the care is being delivered to identify influences on initiation.

The Motion of the Italian National Bioethics Committee on Aggressive Treatment towards Children with Limited Life Expectancy

The motion of the Italian National Bioethics Committee entitled "Aggressive treatment or therapeutic obstinacy on young children with limited life expectancy" comprises a premise that rejects therapeutic obstinacy and makes 12 recommendations. Recommendation no. 1 states the general rules: it ascribes a cardinal role to a shared care plan, it supports pain management therapy and pain relief, it opposes ineffective and disproportionate clinical treatment and defensive medicine. The other recommendations are correlated to the enacting of a national law establishing clinical ethics committees in paediatric hospitals; participation of parents and their fiduciaries in the decision-making processes; recourse to courts only as extrema ratio in the event of irremediable disagreement between the medical team and the family members; accompaniment at the end of life also through continuous deep sedation combined with pain therapy; access to palliative care; the need to reinforce research on pain and suffering in children; clinical trials and research studies conducted in children; the training of doctors, healthcare personnel and psychologists, to support parents in emotional and practical terms; the facilitation of the closeness of parents to children in extremely precarious clinical conditions; the relevant role of the associations of parents of sick children. Comments are made, in particular, about the innovative recommendations respectively relating to the adoption of care planning, the establishment, by law, of clinical ethics committees in paediatric hospitals and the limitation of recourse to courts-only as extrema ratio-in the event of irremediable disagreement between the medical team and the family members.

Treatment limitation and advance planning: Hospital-wide audit of paediatric death

AIM

To examine paediatric deaths following withdrawal or withholding of medical treatment (WWMT) from a hospital-wide perspective and identify changes over a 10 year period.

METHODS

A retrospective review of medical records was conducted for all paediatric inpatient deaths at the Royal Children's Hospital, Melbourne from April 2015 to April 2016, and results were compared to 2007 data from our centre. χ² tests were used for comparisons.

RESULTS

A total of 101 deaths occurred in the inpatient setting in 2015-2016. Most deaths followed WWMT (88/101, 87%) and occurred in children with pre-existing chronic conditions (85/101, 85%). There was a shift to earlier discussions with parents regarding WWMT compared to 10 years prior. Cases where discussions began prior to the last admission increased from 4 to 19% (P = 0.004). There was increased paediatric palliative care (PPC) involvement (10 vs. 37%, P < 0.001), and a slightly greater proportion of children died outside of intensive care (16 vs. 22%, P = 0.25). In 2015-2016, subgroup analysis showed that children who died as inpatients but outside of intensive care were 76% more likely to have PPC involved than those who died in intensive care (P < 0.001). Their families were 51% more likely to have discussed WWMT with medical staff before the last admission (P < 0.001).

CONCLUSIONS

The last decade has seen an increase in PPC involvement and advance discussions around WWMT at our centre. Both of these are associated with death outside of intensive care.

Comparison of End-of-Life Care Practices Between Children With Complex Chronic Conditions and Neonates Dying in an ICU Versus Non-ICUs: A Substudy of the Pediatric End-of-LIfe CAre Needs in Switzerland (PELICAN) Project

OBJECTIVES

To describe and compare characteristics of care provided at the end of life for children with chronic complex conditions and neonates who died in an ICU with those who died outside an ICU.

DESIGN

Substudy of a nation-wide retrospective chart review.

SETTING

Thirteen hospitals, including 14 pediatric and neonatal ICUs, two long-term institutions, and 10 community-based organizations in the three language regions of Switzerland.

PATIENTS

One hundred forty-nine children (0-18 yr) who died in the years 2011 or 2012. Causes of death were related to cardiac, neurologic, oncological, or neonatal conditions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical characteristics, therapeutic procedures, circumstances of death, and patterns of decisional processes were extracted from the medical charts. Ninety-three (62%) neonates (median age, 4 d) and children (median age, 23 mo) died in ICU, and 56 (38%) with a median age of 63 months outside ICU. Generally, ICU patients had more therapeutic and invasive procedures, compared with non-ICU patients. Changes in treatment plan in the last 4 weeks of life, such as do-not-resuscitate orders occurred in 40% of ICU patients and 25% of non-ICU patients (p < 0.001). In the ICU, when decision to withdraw life-sustaining treatment was made, time to death in children and newborns was 4:25 and 3:00, respectively. In institutions where it was available, involvement of specialized pediatric palliative care services was recorded in 15 ICU patients (43%) and in 18 non-ICU patients (78%) (p = 0.008).

CONCLUSIONS

This nation-wide study demonstrated that patients with a complex chronic condition who die in ICU, compared with those who die outside ICU, are characterized by fast changing care situations, including when to withdraw life-sustaining treatment. This highlights the importance of early effective communication and shared decision making among clinicians and families.

Defining a "Good Death" in the Pediatric Intensive Care Unit

BACKGROUND

Societal attitudes about end-of-life events are at odds with how, where, and when children die. In addition, parents' ideas about what constitutes a "good death" in a pediatric intensive care unit vary widely.

OBJECTIVE

To synthesize parents' perspectives on end-of-life care in the pediatric intensive care unit in order to define the characteristics of a good death in this setting from the perspectives of parents.

METHODS

A concept analysis was conducted of parents' views of a good death in the pediatric intensive care unit. Empirical studies of parents who had experienced their child's death in the inpatient setting were identified through database searches.

RESULTS

The concept analysis allowed the definition of antecedents, attributes, and consequences of a good death. Empirical referents and exemplar cases of care of a dying child in the pediatric intensive care unit serve to further operationalize the concept.

CONCLUSIONS

Conceptual knowledge of what constitutes a good death from a parent's perspective may allow pediatric nurses to care for dying children in a way that promotes parents' coping with bereavement and continued bonds and memories of the deceased child. The proposed conceptual model synthesizes characteristics of a good death into actionable attributes to guide bedside nursing care of the dying child.

When a Child Dies in the PICU: Practice Recommendations From a Qualitative Study of Bereaved Parents

OBJECTIVES

Around the world, the PICU is one of the most common sites for hospitalized children to die. Although ensuring the best possible care experience for these children and their families is important, clear recommendations for end-of-life and bereavement care, arising from the parents themselves, remain limited within current literature. This report aims to describe bereaved parents' recommendations for improvements in end-of-life care and bereavement follow-up when a child dies in intensive care.

DESIGN

Thematic analysis of incidental data from a larger grounded theory study.

SETTING

Four Australian PICUs.

SUBJECTS

Twenty-six bereaved parents participated in audio-recorded, semi-structured interviews in 2015-2016. Interviews explored their experiences of having a child die in intensive care and their experiences of end-of-life care and bereavement follow-up. Data pertaining to this report were analyzed via thematic analysis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Bereaved parents identified several areas for care delivery and improvement across three time periods: during hospitalization; during the dying phase; and during bereavement. During hospitalization, parents' recommendations focused on improved communication, changes to the physical environment, better self-care resources, and provision of family support. During the dying phase, parents suggested private, de-medicalized rooms, familiar staff members, and support to leave the hospital. Recommendations for care after death focused mainly on the provision of ongoing support from the hospital or local bereavement services, as well as improved information delivery.

CONCLUSIONS

Findings from this study offer many concrete recommendations for improvements in care both during and after a child's death. These recommendations range from simple practice changes to larger organizational modifications, offering many potential avenues for change and improvement both on an individual healthcare provider level and within individual PICUs.

Retrospective Review of Limitations of Care for Inpatients at a Free-Standing, Tertiary Care Children's Hospital

Limited studies exist regarding the timing, location, or physicians involved in do-not-resuscitate (DNR) order placement in pediatrics. Prior pediatric studies have noted great variations in practice during end-of-life (EOL) care. This study aims to analyze the timing, location, physician specialties, and demographic factors influencing EOL care in pediatrics. We examined the time preceding and following the implementation of a pediatric palliative care team (PCT) via a 5-year, retrospective chart review of all deceased patients previously admitted to inpatient services. Thirty-five percent (167/471) of the patients in our study died with a DNR order in place. Sixty-two percent of patients died in an ICU following DNR order placement. A difference was noted in DNR order timing between patients on general inpatient units and those discharged to home compared with those in the ICUs (p = 0.02). The overall DNR order rate increased following the initiation of the PCT from 30.8% to 39.2% (p = 0.05), but no change was noted in the rate of death in the ICUs. Our study demonstrates a variation in the timing of death following DNR order placement when comparing ICUs and general pediatric floors. Following the initiation of the PCT, we saw increased DNR frequency but no change in the interval between a DNR order and death.

Modes of Death Within a Children's Hospital

: media-1vid110.1542/5804909711001PEDS-VA_2017-4182Video Abstract BACKGROUND: Knowledge about how children die in pediatric hospitals is limited, and this hinders improvement in hospital-based end-of-life care.

METHODS

We conducted a retrospective chart review of all the patients who died in a children's hospital between July 2011 and June 2014, collecting demographic and diagnostic information, hospital length of stay, location of death, and palliative care consultation. A qualitative review of provider notes and resuscitation records was used to create 5 mutually exclusive modes of death, which were then assigned to each patient. Analysis included the calculation of descriptive statistics and multinomial logistic regression modeling.

RESULTS

We identified 579 patients who were deceased; 61% were <1 year of age. The ICU was the most common location of death (NICU 29.7%; PICU 27.8%; cardiac ICU 16.6%). Among the 5 modes of death, the most common was the withdrawal of life-sustaining technology (40.2%), followed by nonescalation (25.6%), failed resuscitation (22.8%), code then withdrawal (6.0%), and death by neurologic criteria (5.3%). After adjustment, patients who received a palliative care consultation were less likely to experience a code death (odds ratio 0.31; 95% confidence interval 0.13-0.75), although African American patients were more likely than white patients to experience a code death (odds ratio 2.46; 95% confidence interval 1.05-5.73), mostly because of code events occurring in the first 24 hours of hospitalization.

CONCLUSIONS

Most deaths in a children's hospital occur in ICUs after the withdrawal of life-sustaining technology. Race and palliative care involvement may influence the manner of a child's death.

Critical care nurses' experiences of caring for a dying child: A qualitative evidence synthesis

AIM

To synthesize qualitative research examining the experience of critical care nurses caring for a dying child.

BACKGROUND

Caring for a dying child remains one of the most difficult aspects of nursing, potentially leading to personal and professional distress. A thorough understanding of this experience for critical care nurses allows for improved delivery of care and support for the nurse.

DESIGN

A qualitative evidence synthesis was undertaken, informed by Thomas and Harden's thematic synthesis methodology.

DATA SOURCES

Studies were retrieved from CINAHL Plus, Scopus, OVID Medline, and Embase, alongside hand-searching reference lists in February 2016.

REVIEW METHODS

Two reviewers independently assessed each study using a multistep screening process and performed critical appraisal of each included study. Data were extracted onto a predeveloped tool and analysed using thematic analysis.

RESULTS

There is a blurred line between the role of the nurse as a person or a professional while caring for the child and family throughout hospitalization and during and after the death. Each stage of care involves tasks and emotions that highlight the changing dominance of the nurse as either a person or professional.

CONCLUSION

Personal, interpersonal, and contextual factors affect delivery of care and impact of the death of the child on the critical care nurse. Reviewing individual and institutional practices could improve provision of care, interprofessional collaboration, and support provided to staff involved.

Bereaved parents' experiences of the police in the paediatric intensive care unit

BACKGROUND

A child's death in the intensive care unit is often sudden and unexpected, requiring the involvement of the state coroner to investigate both the cause and the circumstances surrounding the death. This process often involves the police, who arrive in intensive care to identify the body and collect statements from the parents. At present, very little is known about parents' experiences of this process.

OBJECTIVES

To explore bereaved parents' experiences of police presence in intensive care, as part of routine coronial investigations. The findings arose from a larger study on bereaved parents' experiences of the death of a child in the intensive care unit.

METHODS

Secondary analysis of incidental data from a larger grounded theory study. Nine bereaved parents from two paediatric intensive care units (PICUs) mentioned police presence in the PICU during their original audio-recorded, semistructured interviews. These data were extracted, and thematic analysis techniques were used to identify key themes.

RESULTS

Three main concepts were identified with the parents' experiences: (i) timing of police interviews; (ii) the impacts of police presence; and (iii) the demeanour of the officers. Overall, the parents' experiences of police presence were negative. They felt that police arrived too soon after their child's death and took too long taking their statements, hindering their ability to say goodbye. The presence of police officers also made parents feel as though they were being accused of involvement in their child's death. Finally, several participants also experienced inappropriate or unsympathetic attitudes from the police officers attending their child's death.

CONCLUSIONS

Findings from our study indicate that parents' experiences of police presence in the PICU as part of a coronial investigation may be negative, leaving lasting impressions on their experiences of their child's death. These findings provide areas for improvements in care delivery and the treatment of newly bereaved parents during the early phases of a coronial investigation.

A Retrospective Review of Resuscitation Planning at a Children's Hospital

Resuscitation plans (RP) are an important clinical indicator relating to care at the end of life in paediatrics. A retrospective review of the medical records of children who had been referred to the Royal Children’s Hospital, Brisbane, Australia who died in the calendar year 2011 was performed. Of 62 records available, 40 patients (65%) had a life limiting condition and 43 medical records (69%) contained a documented RP. This study demonstrated that both the underlying condition (life-limiting or life-threatening) and the setting of care (Pediatric Intensive Care Unit or home) influenced the development of resuscitation plans. Patients referred to the paediatric palliative care (PPC) service had a significantly longer time interval from documentation of a resuscitation plan to death and were more likely to die at home. All of the patients who died in the paediatric intensive care unit (PICU) had a RP that was documented within the last 48 h of life. Most RPs were not easy to locate. Documentation of discussions related to resuscitation planning should accommodate patient and family centered care based on individual needs. With varied diagnoses and settings of care, it is important that there is inter-professional collaboration, particularly involving PICU and PPC services, in developing protocols of how to manage this difficult but inevitable clinical scenario.

Researching people who are bereaved: Managing risks to participants and researchers

Conducting qualitative research, especially in areas considered 'sensitive', presents many challenges. The processes involved in such research often expose both participants and the research team to a vast array of risks, which may cause damage to their personal, professional, social and cultural worlds. Historically, these risks have been considered independent of each other, with most studies exploring only the risks to participants or only risks to researchers. Additionally, most researchers only consider risks during data collection, frequently overlooking risks that might be present during other phases of the research project. We aim, therefore, to bring together this fractured literature to enable an integrated exploration of the current academic discourse relating to risks to participants with the literature exploring risks to researchers across all phases of the research process. This article draws on personal experiences to highlight ethical issues and risks encountered by both participants and researchers throughout all phases of a research project. Beginning in recruitment, we discuss the risk of secondary distress in participants arising from researcher contact and then explore the concept of informed consent during grief and bereavement research. We then focus on risks present during data collection, examining risks for participants, such as emotional distress, and potential safety risks for the research team. Finally, we consider the risks which arise in data analysis, including both confidentiality and the possibility of researcher burnout. Previous recommendations are summarised, with new management strategies suggested based on lessons learned along the way.

'Something normal in a very, very abnormal environment'--Nursing work to honour the life of dying infants and children in neonatal and paediatric intensive care in Australia

The majority of deaths of children and infants occur in paediatric and neonatal intensive care settings. For nurses, managing an infant/child's deterioration and death can be very challenging. Nurses play a vital role in how the death occurs, how families are supported leading up to and after the infant/child's death. This paper describes the nurses' endeavours to create normality amidst the sadness and grief of the death of a child in paediatric and neonatal ICU. Focus groups and individual interviews with registered nurses from NICU and PICU settings gathered data on how neonatal and paediatric intensive care nurses care for families when a child dies and how they perceived their ability and preparedness to provide family care. Four themes emerged from thematic analysis: (1) respecting the child as a person; (2) creating opportunities for family involvement/connection; (3) collecting mementos; and (4) planning for death. Many of the activities described in this study empowered parents to participate in the care of their child as death approached. Further work is required to ensure these principles are translated into practice.

Family Experience and PICU Death: A Meta-Synthesis

BACKGROUND AND OBJECTIVES

The PICU is the most common site for inpatient pediatric deaths worldwide. The impact of this clinical context on family experiences of their child's death is unclear. The objective of the study was to review and synthesize the best available evidence exploring the family experience of the death of their child in the PICU.

METHODS

Studies were retrieved from CINAHL Plus, OVID Medline, Scopus, PsycINFO, and Embase. Gray literature was retrieved from greylit.com, opengrey.edu, Trove, Worldcat, and Google scholar. Study selection was undertaken by 4 reviewers by using a multistep screening process, based on a previously developed protocol (International Prospective Register of Systematic Reviews 2015:CRD42015017463). Data was extracted as first-order constructs (direct quotes) or second-order constructs (author interpretations) onto a predeveloped extraction tool. Data were analyzed by thematic synthesis.

RESULTS

One main theme and 3 subthemes emerged. "Reclaiming parenthood" encompasses the ways in which the parental role is threatened when a child is dying in the PICU, with the subthemes "Being a parent in the PICU," "Being supported," and "Parenting after death" elucidating the ways parents work to reclaim this role. The review is limited by a language bias, and by the limitations of the primary studies.

CONCLUSIONS

When a child dies in a PICU, many aspects of the technology, environment, and staff actions present a threat to the parental role both during and after the child's death. Reclaiming this role requires support from health care providers and the wider community.

Nursing care for the families of the dying child/infant in paediatric and neonatal ICU: nurses' emotional talk and sources of discomfort. A mixed methods study

BACKGROUND

The majority of in-hospital deaths of children occur in paediatric and neonatal intensive care units. For nurses working in these settings, this can be a source of significant anxiety, discomfort and sense of failure.

OBJECTIVES

The objectives of this study were to explore how NICU/PICU nurses care for families before and after death; to explore the nurses' perspectives on their preparedness/ability to provide family care; and to determine the emotional content of language used by nurse participants.

METHODS

Focus group and individual interviews were conducted with 22 registered nurses from neonatal and paediatric intensive care units of two major metropolitan hospitals in Australia. All data were audio recorded and transcribed verbatim. Transcripts were then analysed thematically and using Linguistic Inquiry to examine emotional content.

RESULTS

Four core themes were identified: preparing for death; communication challenges; the nurse-family relationship and resilience of nurses. Findings suggested that continuing to provide aggressive treatment to a dying child/infant whilst simultaneously caring for the family caused discomfort and frustration for nurses. Nurses sometimes delayed death to allow families to prepare, as evidenced in the Linguistic Inquiry analysis, which enabled differentiation between types of emotional talk such as anger talk, anxiety talk and sadness talk. PICU nurses had significantly more anxiety talk (p=0.018) than NICU nurses.

CONCLUSION

This study provided rich insights into the experiences of nurses who are caring for dying children including the nurses' need to balance the often aggressive treatments with preparation of the family for the possibility of their child's death. There is some room for improvement in nurses' provision of anticipatory guidance, which encompasses effective and open communication, focussed on preparing families for the child's death.

Neonatal palliative care in action: moving beyond the rhetoric and influencing policy

The purpose of this paper is to move beyond the rhetoric of espousing the importance and timeliness of palliative care for the neonatal population, and to explore how what is known can influence health and social policy. A recent Commonwealth of Australia Senate enquiry into palliative care raised concerns about the current lack of specialist perinatal and neonatal palliative care in Australia. Inherent to the difficulties of moving a neonatal palliative care model forwards are the identified barriers to palliative care practice in the clinical setting, which have been well defined. To inform policy, it is imperative that health professionals in the neonatal discipline are knowledgeable about legislative priorities and the public concerns regarding palliative care for neonates. This paper argues that there are several priorities for moving this model of care forwards, which include legislation that supports access to care such as development and funding support of perinatal hospices, continuity of care, caregiver support, research and in particular education for the health care professionals caring for dying babies and their families. To achieve this, we need to set national research priorities that reflect a truly collaborative partnership. It is time to move beyond the rhetoric.

Expressing ethical principles of treatment and care in a charter: what value?

More than ever before, public institutions are expected to have accessible guidelines on what they do, both for their staff and for those served by them. With this in mind, some principles of treatment and care of sick children were drafted for the Children's Hospital at Westmead. These were centred on ethics, primarily of what was best for the child. They were neither all-inclusive nor specific. They were labelled as a charter. They were rejected by a parent committee and met with unenthusiastic responses at meetings of hospital and ethics professionals. Reasons for this are unclear, but it is speculated that fear of the unknown and distrust of institutions may be factors. To date, the charter has not proved useful, except in provoking further discussion on how general guidelines are written, used and valued and on end-of-life decision-making more generally.

Ethics at the end of life: who should make decisions about treatment limitation for young children with life-threatening or life-limiting conditions?

It is now ethical orthodoxy that parents should be involved in the decision-making about their children's health care. This extends to decisions about whether to continue or to limit life-sustaining medical treatment for a child with a life-limiting or life-threatening condition. What remains contested and uncertain is the extent and nature of parental involvement, especially in this emotionally charged situation. In particular, should it be the parents, who are the ultimate decision-makers, taking final responsibility, should it be a shared decision, or should it be a medical decision that parents are simply asked to consent to? One approach to this issue is to consider the in-principle ethical arguments and weigh their merits. The two key principles here are parental rights and authority, and the best interests of child, and the contested issue is what to do if these appear to clash. Another approach is to consider the principles in the practical clinical context. What would be the implications and consequences of adopting the model of parents as final decision-makers? Are parents able to carry out this role, and do they really want it? What is the effect on parents of taking this role? Answers to these questions could modify the in-principle ethical position. In this paper, we review the empirical evidence currently available on these questions, in relation to parents of infants and young children. Overall, the literature suggests that parents do want to be involved and do not suffer adverse psychological consequences from their involvement. However, the crucial ethical implication of the evidence is that the level and nature of parental involvement in decision-making should be negotiated with the parents in each case, because parents have a range of different views about taking final responsibility for decisions.

Withdrawal of life-support in paediatric intensive care--a study of time intervals between discussion, decision and death

Background

Scant information exists about the time-course of events during withdrawal of life-sustaining treatment. We investigated the time required for end-of-life decisions, subsequent withdrawal of life-sustaining treatment and the time to death.

Methods

Prospective, observational study in the ICU of a tertiary paediatric hospital.

Results

Data on 38 cases of withdrawal of life-sustaining treatment were recorded over a 12-month period (75% of PICU deaths). The time from the first discussion between medical staff and parents of the subject of withdrawal of life-sustaining treatment to parents and medical staff making the decision varied widely from immediate to 457 hours (19 days) with a median time of 67.8 hours (2.8 days). Large variations were subsequently also observed from the time of decision to actual commencement of the process ranging from 30 minutes to 47.3 hrs (2 days) with a median requirement of 4.7 hours. Death was apparent to staff at a median time of 10 minutes following withdrawal of life support varying from immediate to a maximum of 6.4 hours. Twenty-one per cent of children died more than 1 hour after withdrawal of treatment. Medical confirmation of death occurred at 0 to 35 minutes thereafter with the physician having left the bedside during withdrawal in 18 cases (48%) to attend other patients or to allow privacy for the family.

Conclusions

Wide case-by-case variation in timeframes occurs at every step of the process of withdrawal of life-sustaining treatment until death. This knowledge may facilitate medical management, clinical leadership, guidance of parents and inform organ procurement after cardiac death.

Alterations in end-of-life support in the pediatric intensive care unit

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.

Discussing withdrawing and withholding of life-sustaining medical treatment in a tertiary paediatric hospital: a survey of clinician attitudes and practices

AIM

To better understand current attitudes and practices relating to discussions concerning the withholding and withdrawing of life-sustaining medical treatment (WWLSMT) among medical staff in the paediatric setting.

METHODS

An anonymous online survey of paediatricians (senior medical staff - SMS) and paediatric trainees (junior medical staff - JMS) likely to be involved in the care of children with life limiting illness.

RESULTS

A total of 162 responses were obtained (response rate 42%). SMS indicated feeling more comfortable with their abilities to discuss WWLSMT than JMS. Barriers to discussing WWLSMT were numerous and included clinician concerns about family readiness for the discussion, prognostic uncertainty, family disagreement with the treating team regarding the child's prognosis/diagnosis and concerns about how to manage family requests for treatments that are not perceived to be in the child's best interests. Fifty-eight per cent of JMS and 35.8% of SMS reported receiving no specific communication training regarding WWLSMT. Most learned through experience and by observing more senior colleagues. There was a high level of support for additional training in this area and for the provision of resources such as discussion guidelines and a structured form for documenting the outcomes WWLSMT discussions.

CONCLUSION

The majority of JMS feel less comfortable with their abilities to facilitate these discussions than their senior colleagues. The results of this study suggest that although confidence correlates with experience, junior and senior clinicians are eager to improve their skills through ongoing professional development and the provision of resources. The education needs of JMS and SMS appear to be different.