Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature

ArticleinJournal of Paediatrics and Child Health 44(7-8):404-8 · July 2008with14 Reads
DOI: 10.1111/j.1440-1754.2008.01353.x · Source: PubMed
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 Meetings between the medical team and family were documented for 15 of 16 children (93.8%) before treatment was withdrawn.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.
    • "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. "
    [Show abstract] [Hide abstract] 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.
    Full-text · Article · Nov 2015
    • "[2,29] The families of children with chronic conditions may have more time to respond and accept an outcome of death. [2] Advances in biology, science, and medical technology have intensely altered the medical landscape and our place in it. [13] The capacity to extend life beyond the point of which it may appear to have little or no benefit has forced us to scrutinize difficult questions regarding human identity, personhood, rights, and responsibilities with regard to access to medical care, the goals of health care, and the way managing dying patients. "
    [Show abstract] [Hide abstract] ABSTRACT: 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. 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. 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. 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.
    Full-text · Article · Mar 2015
    • "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 permission202122232425. In addition, difficulty in reaching consensus is usually resolved over time [26,27], and the approach to the use of sedatives and neuromuscular blockers is subject to individual preferences [23,28,29]. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees. Methods: 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. Results: 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. Conclusions: 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.
    Full-text · Article · Jun 2014
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