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ABSTRACT: Objective: Describe modes of death and factors involved in decision-making together with life support limitation (LSL) procedures.
Design: Prospective, descriptive, longitudinal, and noninterventional study.
Setting: Sixteen pediatric intensive care units in Argentina.
Patients: Every patient who died during a 1-yr period was included.
Measurements and Main Results: Age, sex, length of stay (LOS), primary and admission diagnosis, underlying chronic disease (CD), postoperative condition (PO). Deaths were classified in four groups: a) failed cardiopulmonary resuscitation (CPR); b) do-not-resuscitate (DNR) status; c) withholding or withdrawing life-sustaining treatment (WH/WD); and d) brain death (BD). Justifications were classified as a) imminent death; b) poor long-term prognosis; c) poor quality of life; and d) family request. Data were collected from medical records and interviews with the attending physicians. Descriptive statistics were performed. Differences among groups were analyzed through contingency tables and analysis of variance when required. Relative risks and confidence intervals of variables potentially related to LSL were analyzed, and logistic regression was performed. There were 6358 admissions and 457 deaths. CPR was performed in 52%, DNR in 16%, WH/WD in 20%, and BD in 11% of dead patients. BD patients were older, LOS and CD prevalence were higher in the WH/WD group. Inotropic drugs were the most frequently limited treatment in 110 patients (55%), CPR in 72 (35.6%), and mechanical ventilation in 63 (31%). Imminent death was the most frequently reported justification for LSL. CD and more staff were associated with a higher probability of LSL.
Conclusions: Most of the patients in Argentina underwent CPR before their death. We have a high proportion of patients with CD (65%) and low BD diagnosis. PO condition decreased LSL probability in chronically ill patients. Do-not-resuscitate orders and withholding new treatments were the most common LSL. Active withdrawal was exceptional. The Ethics Committee was consulted in 5% of the LSL population.
During the last few decades, pediatric intensive care units (PICUs) have improved so as to prolong life in many cases in which the only expected result was death. This improvement has led to a new paradigm in which death becomes always an avoidable circumstance in people's life. The death of a child is a rare event, and when life-sustaining treatment fails for a critically ill child, the tragedy is particularly difficult to accept. Unfortunately, there is a dark side associated with the increased ability to sustain life. Continued support may lead only to prolongation of suffering in children in whom treatment is very unlikely to be successful (1-4). Since 1990, several reports have been published describing life support limitation (LSL) as the most common mode of death in both adult and pediatric patients (5-14). This limitation involves a wide spectrum of practices, from simply avoiding treatment progression to active withdrawal of life-sustaining treatment, even when imminent death is the foreseen result.
Life-sustaining treatments, decision-making procedures, and patient and family involvement vary within the literature, and there is little known about these issues in Latin-American countries. In Argentina, recommendations have been published regarding adult and infant LSLs; however, there is no consensus about how this practice should be accomplished (15-21). There is poor, if any, published information on these issues, and discussion is far from being considered by society. Faced with the concept of child immortality, within an everything-possible scenario, death is, at best, a dismal failure, if not a negligence. We hypothesize that in Argentina, LSL is not as common as reported in the international literature. The purpose of this study was to describe modes of death and factors involved in decision making together with LSL procedures in Argentine PICUs.
Pediatric Critical Care Medicine 03/2003; 4(2):164-169. DOI:10.1097/01.PCC.0000059428.08927.A9 · 2.33 Impact Factor