Moore P, Kerridge I, Gillis J, et al. Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature
To examine withdrawal and limitation of life-sustaining treatment (WLST) in an Australian paediatric intensive care unit (PICU) and to compare this experience with published data from other countries.
Retrospective chart review and literature review.
Review of 12 months of patient records from a tertiary Australian children's teaching hospital. Medline search using relevant key words focusing on death and PICU.
Twenty of 27 deaths (74%) followed either WLST (n = 16) or Do Not Resuscitate (DNR) orders (n = 4); five children failed cardiopulmonary resuscitation (CPR); and two children were brain-dead. Meetings between the medical team and family were documented for 15 of 16 children (93.8%) before treatment was withdrawn. The average time between withdrawal of life support and death was 13 min. A review of the English-language literature revealed that 18-65% occurring in PICUs worldwide follow WLST and/or institution of DNR orders. Rates were higher (30-65%) in North America and Europe than elsewhere. Most PICU deaths occurred within 3 days of admission. North American and British parents appear to be involved in decisions regarding withdrawal and limitation of treatment more often than parents in other countries.
Withdrawal and limitation of life-sustaining treatment was more common in an Australian children's hospital ICU than has been reported from other countries. Details of discussion with parents, including the basis for any decision to WLST, were almost always documented in the patient's medical record.
Available from: Thomas C Foreman
- "Specifically, ethical issues involving withholding and withdrawing of life-sustaining interventions are of particular interest since it is often difficult for providers to determine when aggressive treatments may no longer be appropriate, and a change to palliative care indicated. (Heaney et al. 2007; Mani 2003; Moore et al. 2008; Reynolds et al. 2005) This difficulty may in part be due to simply having high-technology medical interventions available. The advances in medical knowledge and technology have allowed providers to keep the most critically-ill patients alive in cases where, historically, they would have died. "
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ABSTRACT: Intensivists require a specialized approach to learning and managing complex bioethical issues due to the immediacy, uncertainty and gravity of medical decisions made when caring for the critically ill. A systematic examination of the literature and solicited feedback from experienced Intensivists has demonstrated that the knowledge and skill required to understand and navigate complex bioethical dilemmas is not often taught with the rigor necessary for independent clinical practice. This prompted us to design a bioethics curriculum for adult critical care medicine trainees to fill a significant void in ethics knowledge and reasoning within critical care training. The curriculum consists of six self-learning, online, case-based modules, and interactive group discussions. It is to be integrated into an existing Critical Care Academic Half Day schedule and completed over a 1–2 year period. This paper presents a detailed explication of the problem, and puts forward our developed solution – a comprehensive bioethics curriculum.
Available from: AB Groeneveld
- "There are also regional differences worldwide on how decisions regarding withholding or withdrawing life-sustaining decisions are made and to what extent families are involved. In most cases, decisions are made after discussion among the medical team, and parents may be informed of the decision and may or may not be asked for their permission      . In addition, difficulty in reaching consensus is usually resolved over time  , and the approach to the use of sedatives and neuromuscular blockers is subject to individual preferences   . "
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Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees.
Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared.
Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent.
Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.
Available from: ndt.oxfordjournals.org
- "Paediatric DCD programmes may expand the donor pool substantially because withdrawal of life-sustaining treatment is a common setting in paediatric intensive care units (PICU). A review of literature reveals that 40–65% of deaths occurring in European PICUs follow withdrawal of treatment, which is up to three times as much as the percentage of children who die after brain death. Although this percentage of planned withdrawals of treatment overestimates the number of potential DCD donors, routine use of the paediatric DCD donor has the ability to significantly increase organ donation. "
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Although acceptable outcomes have been reported in kidney transplantation from donation after cardiac death (DCD), little is known about kidney transplantation from paediatric DCD. The objective of this study was to compare the outcome of kidney transplantation using paediatric DCD with the outcome of paediatric donation after brain death (DBD).Methods
Recipients from DCD and DBD donors <18 years of age transplanted in the Netherlands between January 1981 and July 2006 were included in this study. Ninety-one patients were transplanted with kidneys from paediatric DCD donors and 405 patients received grafts from paediatric DBD donors.ResultsGrafts from DCD donors were associated with higher percentage of primary non-function (9 versus 2%, P < 0.01) and delayed graft function (48 versus 8%, P < 0.001) compared with DBD donor grafts. Estimated glomerular filtration rate did not differ between groups (57 ± 17 versus 58 ± 21 mL/min at 1 year and 62 ± 14 versus 57 ± 22 mL/min at 5 years, respectively). After correction for confounding variables, the risk of graft failure was higher in the DCD group [hazard ratio 2.440 (95% confidence interval (CI) 1.280-4.650; P = 0.007]. Patient survival, however, was similar between groups [hazard ratio 1.559 (95% CI 0.848-2.867; P = 0.153)].Conclusions
Paediatric DCD kidneys represent a valuable source of donor kidneys that has not been fully utilized. Although transplantation of paediatric DCD kidneys is associated with a higher risk of graft failure than transplantation of paediatric DBD kidneys, results are comparable with adult donors. We therefore conclude that paediatric DCD kidneys can be safely added to the donor pool.
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