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PEDIATRICS Vol. 112 No. 5 November 2003, pp. e371-e371

ELECTRONIC ARTICLE

Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit

Daniel Garros, MD^*, Rhonda J. Rosychuk, PhD and Peter N. Cox, MD^*

^* Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada

Objective. Approximately 60% of deaths in pediatric intensive care units follow limitation or withdrawal of life-sustaining treatment (LST). We aimed to describe the circumstances surrounding decision making and end-of-life care in this setting.

Methods. We conducted a prospective, descriptive study based on a survey with the intensivist after every consecutive death during an 8-month period in a single multidisciplinary pediatric intensive care unit. Summary statistics are presented as percentage, mean ± standard deviation, or median and range; data are compared using the Mantel-Haenszel test and shown as survival curves.

Results. Of the 99 observed deaths, 27 involved failed cardiopulmonary resuscitation; of the remaining 72, 39 followed withdrawal/limitation (W/LT) of LST, 20 were do not resuscitate (DNR), and 13 were brain deaths (BDs). Families initiated discussions about forgoing LST in 24% (17 of 72) of cases. Consensus between caregivers and staff about forgoing LST as the best approach was reached after the first meeting with 51% (35 of 68) of families; 46% (31 of 68) required 2 meetings (4 not reported). In the DNR group, the median time to death after consensus was 24 hours and for W/LT was 3 hours. LST was later withdrawn in 11 of 20 DNR cases. The family was present in 76% (45 of 59) of cases when LST was forgone. The dying patient was held by the family in 78% (35 of 45) of these occasions.

Conclusions. More than 1 formal meeting was required to reach consensus with families about forgoing LST in almost half of the patients. Families often held their child at the time of death. The majority of children died quickly after the end-of-life decision was made.

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Key Words: withdrawal of therapy • death • futility • pediatric intensive care • ethics • attitude of health personnel • critical care • decision making • drug utilization • passive euthanasia • human • intensive care units • life support care • palliative care

Abbreviations: ICU, intensive care unit • LST, life-sustaining treatment • PICU, pediatric intensive care unit • HSC, Hospital for Sick Children • BD, brain death • DNR, do not resuscitate • RES, resuscitation • ALS, advanced life support • W/LT, withdrawal or limitation of therapy • CPR, cardiopulmonary resuscitation • LOS, length of stay • ECLS, extracorporeal life support • NMB, neuromuscular blocking agent

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Received for publication Mar 28, 2003; Accepted Jul 16, 2003.

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