Futility and inappropriate care in pediatric intensive care: a cross-sectional survey

Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers

Background

Potentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited.

Objectives

Determine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate.

Methods

Prospective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0-17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale.

Results

Of 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty.

Conclusions

While treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.

Futility in the paediatric cardiac ICU

INTRODUCTION

Studies have suggested 5-20% of paediatric ICU patients may receive care felt to be futile. No data exists on the prevalence and impact of futile care in the Paediatric Cardiac ICU. The aim is to determine the prevalence and economic impact of futile care.

MATERIALS AND METHOD

Retrospective cohort of patients with congenital cardiac disease 0-21 years old, with length of stay >30 days and died (2015-2018). Documentation of futility by the medical team was retrospectively and independently reviewed.

RESULTS

Of the 127 deaths during the study period, 51 (40%) had hospitalisation >30 days, 13 (25%) had received futile care and 26 (51%) withdrew life-sustaining treatment. Futile care comprised 0.69% of total patient days with no difference in charges from patients not receiving futile care. There was no difference in insurance, single motherhood, education, income, poverty, or unemployment in families continuing futile care or electing withdrawal of life-sustaining treatment. Black families were less likely than White families to elect for withdrawal (p = 0.01), and Hispanic families were more likely to continue futile care than non-Hispanics (p = 0.044).

CONCLUSIONS

This is the first study to examine the impact of futile care and characteristics in the paediatric cardiac ICU. Black families were less likely to elect for withdrawal, while Hispanic families more likely to continue futile care. Futile care comprised 0.69% of bed days and little burden on resources. Cultural factors should be investigated to better support families through end-of-life decisions.

Nurses' Perceptions of Futile Care: A Qualitative Study

Health care professionals believe that futile care must not be provided; however, there is no clear agreement over the definition and the manifestations of futile care. The aim of this study was to explore Iranian nurses' perceptions of futile care. In this qualitative exploratory study, the conventional content analysis approach was used for collecting and analyzing the study data. Three main themes were extracted from the data: nonfutility of care: care tantamount with outcome; sense of burnout; and subjectivity and relativity of medical futility concept.

Awareness during pediatric anesthesia: what is the position of European pediatric anesthesiologists?

BACKGROUND

The incidence of awareness in the pediatric population is reported as high as 1 : 125. An online survey was conducted about the current perception and practice of members of the British and French pediatric anesthesia societies regarding awareness during general anesthesia.

METHODS

Following the approval of the executive committees of the British and French pediatric anesthesia societies, members with a valid email contact address were invited to participate in a web-based survey. Perceived risk factors, use of awareness monitors, pre- and postoperative discussions of awareness as well as personal experience were enquired.

RESULTS

A total of 302 (51%) responded to the email survey. More than 60% indicated that awareness is a problem in pediatric anesthesia with the majority estimating an incidence of 1 : 1000. Almost half (49%) the respondents believe that awareness is age-dependent and 50% are not concerned below 1 month of age. More than 86% of respondents do not discuss the risk of awareness with the parents or actively look for awareness despite 27% reporting at least one episode in their practice. Intra-operative monitoring almost exclusively consists of clinical signs and endtidal anesthetic concentrations. Bispectral index (BIS) monitoring is routinely used by approximately 10% of the surveyed members.

CONCLUSIONS

This survey demonstrates that European pediatric anesthesiologists perceive awareness as a major problem. However, none seems to address the issue openly or looks for its presence routinely. The vast majority of pediatric anesthesiologists rely almost exclusively on clinical monitoring and endtidal anesthetic concentrations for its detection.