Circumstances surrounding dying in the paediatric intensive care unit

Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study

OBJECTIVE

Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not.

DESIGN

Secondary analysis of multicenter retrospective cohort study.

SETTING

Ten PICUs in the United States between 2009 and 2021.

PATIENTS

Nine hundred thirteen patients 0-21 years old who died after WLST.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality).

CONCLUSIONS

Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.

An Exploratory Study of ICU Pediatric Nurses' Feelings and Coping Strategies after Experiencing Children Death

BACKGROUND

This study aims to explore the feelings and experiences of nursing staff when faced with the death of a pediatric patient in the ICU.

METHODOLOGY

A qualitative study based on hermeneutic phenomenology was conducted through semi-structured interviews. Ten nurses (30% of staff) from the Pediatric Intensive Care Unit of a referral hospital were interviewed in April 2022. Text transcripts were analysed using latent content analysis.

RESULTS

Content analysis indicated that the interviewees had feelings of sadness and grief; they had a misconception of empathy. They had no structured coping strategies, and those they practiced were learned through personal experience, not by specific training; they reported coping strategies such as peer support, physical exercise, or strengthening ties with close family members, especially their children. The lack of skills to cope with the death and the absence of support from personnel management departments were acknowledged. This can lead to the presence of compassion fatigue.

CONCLUSIONS

The feelings that PICU nurses have when a child they care for die are negative feelings and sadness, and they possess coping strategies focused on emotions learned from their own experience and without institutional training support. This situation should not be underestimated as they are a source of compassion fatigue and burnout.

Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care

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.

Clinical Factors Influencing End-of-Life Care in a Chinese Pediatric Intensive Care Unit: A Retrospective, post-hoc Study

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.

Pediatric Palliative Care During End of Life: A Privilege of a Few in a Tertiary Referral Hospital From Colombia

BACKGROUND

We aim to describe the access to palliative care (PC) in hospitalized children during end-of-life care and compare the circumstances surrounding the deaths of hospitalized children as a basis for implementing a pediatric PC program at our institution.

METHODS

We performed a retrospective chart review of deceased pediatric patients at a tertiary referral hospital in Colombia. The study group was selected by randomly drawing a sample of 100 observations from the 737 deceased children from 2013 to 2016. A 1:1 propensity score (PS) matching was performed to compare the characteristics and outcomes between PC and non-PC treated patients.

RESULTS

We included 87 patients. After PS matching, we found that patients under the care of non-PC physicians were more likely to die in the pediatric intensive care unit (non-PC: 6/10 vs PC: 1/10; P = .02), to be on vasopressor agents and mechanical ventilation (non-PC: 7/10 vs PC: 1/10; P = .02), and to receive cardiopulmonary resuscitation at the end of life (non-PC: 5/10 vs PC: 0/10; P = .03). In contrast, a significantly higher proportion of patients under the care of the pediatric PC team died with comfort measures (non-PC: 2/10 vs 8/10; P = .02) and nonescalation of care in physician orders (non-PC: 5/10 vs PC: 10/10; 0.03).

CONCLUSION

In this study, only 10 of 87 patients were treated by the pediatric PC team at the end of life. The latter finding is concerning and is a call to action to improve access to pediatric PC at our institution.

Discrepancies Between Clinical Diagnoses and Autopsy Findings in Critically Ill Children: A Prospective Study

OBJECTIVES

To evaluate the discrepancies between clinical and autopsy diagnoses in patients who died in the pediatric intensive care units (PICUs) of a tertiary care university hospital.

METHODS

A prospective study of all consecutive autopsies discussed at monthly mortality conferences over 5 years. Discrepancies between premortem and autopsy diagnoses were classified according to modified Goldman et al criteria.

RESULTS

From January 1, 2011, to December 31, 2015, a total of 2,679 children were admitted to the two PICUs of our hospital; 257 (9.6%) died, 150 (58.4%) underwent autopsy, and 123 were included. Complete concordance between clinical and postmortem diagnoses was observed in 86 (69.9%) patients; 20 (16.3%) had a class I discrepancy, and eight (6.5%) had a class II discrepancy. Comparing 2011 and 2015, the rate of major discrepancies decreased from 31.6% to 15%.

CONCLUSIONS

Our results emphasize the importance of autopsy to clarify the cause of death and its potential contribution to improvement of team performance and quality of care.

Mortality patterns among critically ill children in a Pediatric Intensive Care Unit of a developing country

BACKGROUND AND AIM

Advances in biomedical technology have made medical treatment to be continued beyond a point, at which it does not confer an advantage but may increase the suffering of patients. In such cases, continuation of care may not always be useful, and this has given rise to the concept of limitation of life-sustaining treatment. Our aim was to study mortality patterns over a 6-year period in a Pediatric Intensive Care Unit (PICU) in a developing country and to compare the results with published data from other countries.

MATERIALS AND METHODS

Retrospective cohort study was conducted in a PICU of a tertiary care hospital in Pakistan. Data were drawn from the medical records of children aged 1-month - 16 years of age who died in PICU, from January 2007 to December 2012.

RESULTS

A total of 248 (from an admitted number of 1919) patients died over a period of 6 years with a mortality rate 12.9%. The median age of children who died was 2.8 years, of which 60.5% (n = 150) were males. The most common source of admission was from the emergency room (57.5%, n = 143). The most common cause of death was limitation of life-sustaining treatment (63.7%, n = 158) followed by failed cardiopulmonary resuscitation (28.2%, n = 70) and brain death (8.1%, n = 20). We also found an increasing trend of limitation of life-sustaining treatment do-not-resuscitate (DNR) over the 6-year reporting period.

CONCLUSION

We found limitation of life support treatment (DNR + Withdrawal of Life support Treatment) to be the most common cause of death, and parents were always involved in the end-of-life care decision-making.

Diagnostic errors in the pediatric and neonatal ICU: a systematic review

OBJECTIVE

Diagnostic errors lead to preventable hospital morbidity and mortality. ICU patients may be at particularly high risk for misdiagnosis. Little is known about misdiagnosis in pediatrics, including PICU and neonatal ICU. We sought to assess diagnostic errors in PICU and neonatal ICU settings by systematic review.

DATA SOURCES

We searched PubMed, Embase, CINAHL, and Cochrane.

STUDY SELECTION

We identified observational studies reporting autopsy-confirmed diagnostic errors in PICU or neonatal ICU using standard Goldman criteria.

DATA EXTRACTION

We abstracted patient characteristics, diagnostic error description, rates and error classes using standard Goldman criteria for autopsy misdiagnoses and calculated descriptive statistics.

DATA SYNTHESIS

We screened 329 citations, examined 79 full-text articles, and included 13 studies (seven PICU; six neonatal ICU). The PICU studies examined a total of 1,063 deaths and 498 autopsies. Neonatal ICU studies examined a total of 2,124 neonatal deaths and 1,259 autopsies. Major diagnostic errors were found in 19.6% of autopsied PICU and neonatal ICU deaths (class I, 4.5%; class II, 15.1%). Class I (potentially lethal) misdiagnoses in the PICU (43% infections, 37% vascular) and neonatal ICU (62% infections, 21% congenital/metabolic) differed slightly. Although missed infections were most common in both settings, missed vascular events were more common in the PICU and missed congenital conditions in the neonatal ICU.

CONCLUSION

Diagnostic errors in PICU/neonatal ICU populations are most commonly due to infection. Further research is needed to better quantify pediatric intensive care-related misdiagnosis and to define potential strategies to reduce their frequency or mitigate misdiagnosis-related harm.

Organ donation after cardiac death in children: acceptance of a protocol by multidisciplinary staff

BACKGROUND

Organ donation after cardiac death is increasingly implemented, with outcomes similar to those of organ donation after brain death. Many hospitals hesitate to implement a protocol for donation after cardiac death because of the potential negative reactions among health care providers.

OBJECTIVES

To determine the acceptance of a protocol for donation after cardiac death among multidisciplinary staff in a pediatric intensive care unit.

METHODS

An anonymous, 15-question, Likert-scale questionnaire (scores 1-5) was used to determine the opinions of staff about donation after brain death and after cardiac death in a pediatric intensive care unit of a tertiary-care university hospital.

RESULTS

Survey response rate was 67% (n = 60). All physicians, 89% of nurses, and 82% of the remaining staff members stated that they understood the difference between donation after brain death and donation after cardiac death; staff supported both types of donation, at rates of 90% and 85%, respectively. Staff perception was the same for each type of donation (ρ = 0.82; r = 0.92; P < .001). The 20 staff members who provided care directly to patients who were donors after cardiac death considered such donation worthwhile. However, 60% of those providers offered suggestions to improve the established protocol for donation.

CONCLUSIONS

The multidisciplinary staff has accepted organ donation after cardiac death and has fully integrated this kind of donation without reported differences from their acceptance of donation after brain death.

Short-term and long-term mortality following pediatric intensive care

BACKGROUND

The aim of the present study was to examine short-term and long-term mortality following discharge from the pediatric intensive care unit (PICU).

METHODS

This was a prospective observational study. Data collected consisted of demographics, severity scores, procedures, treatment, need for and duration of mechanical ventilation (MV), length of PICU and hospital stay, and mortality at PICU and hospital discharge, at 3 and 6 months and at 1 and 2 years.

RESULTS

A total of 300 patients (196 boys and 104 girls), aged 54.26 ± 49.93 months, were included in the study. Median (interquartile range) Pediatric Risk of Mortality (PRISM III-24) score was 7 (3-11) and predicted mortality rate was 11.16%. MV rate was 67.3% (58.3% at admission) for 6.54 ± 14.15 days, and length of PICU and hospital stay was 8.85 ± 23.28 days and 20.69 ± 28.64 days, respectively. Mortality rate at discharge was 9.7% and cumulative mortality rate thereafter was 12.7%, 15.0%, 16.7%, 19.0%, and 19.0% at hospital discharge, 3 months, 6 months, 1 year and 2 years, respectively. Significant risk factors of PICU mortality were inotrope use, PRISM III-24 score >8, MV, arterial and central venous catheterization, nosocomial infection, complications, and cancer. Independent predictors of mortality at discharge were inotrope use and PRISM III-24 score, whereas predictors of mortality at 2 years were comorbidity and cancer.

CONCLUSIONS

A 2 year follow-up period seems sufficient for a comprehensive mortality analysis of PICU patients. Severity of critical illness is the key factor of short-term mortality, whereas comorbidity is the major determinant of long-term mortality.

Demographic profile and outcome analysis of pediatric intensive care patients

BACKGROUND

Demographic profile and outcome can vary in pediatric intensive care unit (PICU) patients. The aim of our study was to analyze demographic profile and outcome in a Greek PICU.

METHODS

Prospective observational study.

DATA COLLECTED

demographic profile; co morbidities; source and diagnosis at admission; Pediatric Risk of Mortality (PRISM III-24); Glasgow Coma Scale (GCS, pediatric); Injury Severity Score (ISS); procedures; treatment; mechanical ventilation (MV); MV days; length of stay (LOS) and the outcome at PICU discharge.

STATISTICAL ANALYSIS

Student's t-test; Mann-Whitney U test; Kruskall-Wallis test; χ(2) criterion with relative risk (RR) estimation; Cox regression analysis; as appropriate. Values are mean ± SD, p < 0.05.

RESULTS

300 patients (196 boys/104 girls), aged 54.26 ± 49.93 months, were admitted due to respiratory failure (22.3%), head trauma (15.3%), seizures (13.7%), coma (9.7%), postoperative care (7.7%), polytrauma (7%), accidents (5.3%), sepsis-septic shock (5.3%), cardiovascular diseases (4.7%), metabolic diseases (3.3%), multiple organ failure syndrome (3%) and miscellaneous diseases (2.7%). PRISM III-24 score was 8.97 ± 7.79 and predicted mortality rate was 11.16% ± 18.65. MV rate was 67.3% (58.3% at admission) for 6.54 ± 14.45 days, LOS 8.85 ± 23.28 days and actual PICU mortality rate 9.7%. Patients who died had statistically worse severity scores. Significant mortality risk factors were inotropic use, PRISM III-24 > 8, MV, arterial and central venous catheterization, nosocomial infections, complications, and cancer. COX regression analysis showed that PRISM III-24 score and inotropic use were independent predictors of mortality.

CONCLUSIONS

Demographic profile followed similar patterns to relevant studies while there were major differences in case mix and the severity of the disease. Mortality rate (9.7%) was relatively high but better than predicted and in accordance with the characteristics of our population.

Brain injuries and neurological system failure are the most common proximate causes of death in children admitted to a pediatric intensive care unit

OBJECTIVE

Mortality rates from critical illness in children have declined over the past several decades, now averaging between 2% and 5% in most pediatric intensive care units. Although these rates, and mortality rates from specific disorders, are widely understood, the impact of acute neurologic injuries in such children who die and the role of these injuries in the cause of death are not well understood. We hypothesized that neurologic injuries are an important cause of death in children.

DESIGN

Retrospective review.

SETTING

Pediatric intensive care unit at Children's Hospital of Pittsburgh, an academic tertiary care center.

PATIENTS

Seventy-eight children who died within the pediatric intensive care unit from April 2006 to February 2008.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data regarding admission diagnosis, presence of chronic illness, diagnosis of brain injury, and cause of death were collected. Mortality was attributed to brain injury in 65.4% (51 of 78) of deaths. Ninety-six percent (28 of 29) of previously healthy children died with brain injuries compared with 46.9% (23 of 49) of chronically ill children (p < .05). The diagnosed brain injury was the proximate cause of death in 89.3% of previously healthy children and 91.3% with chronic illnesses. Pediatric intensive care unit and hospital length of stay was longer in those with chronic illnesses (38.8 ± 7.0 days vs. 8.9 ± 3.7 days and 49.2 ± 8.3 days vs. 9.0 ± 3.8 days, p < .05 and p < .001, respectively).

CONCLUSION

Brain injury was exceedingly common in children who died in our pediatric intensive care unit and was the proximate cause of death in a large majority of cases. Neuroprotective measures for a wide variety of admission diagnoses and initiatives directed to prevention or treatment of brain injury are likely to attain further improvements in mortality in previously healthy children in the modern pediatric intensive care unit.