Withdrawal of life-support in paediatric intensive care - a study of time intervals between discussion, decision and death

BMC Pediatrics

James Tibballs¹  Felix Oberender² 

[1] Departments of Paediatrics & Pharmacology, University of Melbourne Royal Children's Hospital, Melbourne, Victoria, VIC 3052, Australia;Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, VIC 3052, Australia

关键词: organ donation after cardiac death;    death;    terminal care;    end-of-life care;    time;    withdrawal and withholding of life-sustaining treatment;   

Others  :  1172170
DOI  :  10.1186/1471-2431-11-39

 received in 2011-01-13, accepted in 2011-05-21,  发布年份 2011

【 摘 要 】

Background

Scant information exists about the time-course of events during withdrawal of life-sustaining treatment. We investigated the time required for end-of-life decisions, subsequent withdrawal of life-sustaining treatment and the time to death.

Methods

Prospective, observational study in the ICU of a tertiary paediatric hospital.

Results

Data on 38 cases of withdrawal of life-sustaining treatment were recorded over a 12-month period (75% of PICU deaths). The time from the first discussion between medical staff and parents of the subject of withdrawal of life-sustaining treatment to parents and medical staff making the decision varied widely from immediate to 457 hours (19 days) with a median time of 67.8 hours (2.8 days). Large variations were subsequently also observed from the time of decision to actual commencement of the process ranging from 30 minutes to 47.3 hrs (2 days) with a median requirement of 4.7 hours. Death was apparent to staff at a median time of 10 minutes following withdrawal of life support varying from immediate to a maximum of 6.4 hours. Twenty-one per cent of children died more than 1 hour after withdrawal of treatment. Medical confirmation of death occurred at 0 to 35 minutes thereafter with the physician having left the bedside during withdrawal in 18 cases (48%) to attend other patients or to allow privacy for the family.

Conclusions

Wide case-by-case variation in timeframes occurs at every step of the process of withdrawal of life-sustaining treatment until death. This knowledge may facilitate medical management, clinical leadership, guidance of parents and inform organ procurement after cardiac death.

【 授权许可】

   
2011 Oberender and Tibballs; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Carter BS, Howenstein M, Gilmer MJ, Throop P, France D, Whitlock JA: Circumstances surrounding the deaths of hospitalized children: opportunities for pediatric palliative care. Pediatrics 2004, 114:e361-e366.
• [2]Moore P, Kerridge I, Gillis J, Jacobe S, Isaacs D: Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature. J Paediatr Child Health 2008, 44:404-408.
• [3]Ramnarayan P, Craig F, Petros A, Pierce C: Characteristics of deaths occurring in hospitalised children: changing trends. J Med Ethics 2007, 33:255-260.
• [4]Singh J, Lantos J, Meadow W: End-of-life after birth: death and dying in a neonatal intensive care unit. Pediatrics 2004, 114:1620-1626.
• [5]Stark Z, Hynson J, Forrester M: Discussing withholding and withdrawing of life-sustaining medical treatment in paediatric inpatients: audit of current practice. J Paediatr Child Health 2008, 44:399-403.
• [6]Latour JM, Fulbrook P, Albarran JW: EfCCNa survey: European intensive care nurses' attitudes and beliefs towards end-of-life care. Nurs Crit Care 2009, 14:110-121.
• [7]Tibballs J: Legal basis for ethical withholding and withdrawing life-sustaining medical treatment from infants and children. J Paediatr Child Health 2007, 43:230-236.
• [8]Murphy P, Manara A, Bell D, Smith M: Controlled non-heart beating organ donation: neither the whole solution nor a step too far. Anaesthesia 2008, 63:526-530.
• [9]Richards B, Rogers WA: Organ donation after cardiac death: legal and ethical justifications for antemortem interventions. Med J Aust 2007, 187:168-170.
• [10]Tibballs J: Organ donation after cardiac death: legal and ethical justifications for antemortem interventions. Med J Aust 2008, 188:186-187.
• [11]Balfour-Lynn IM, Tasker RC: At the coalface--medical ethics in practice. Futility and death in paediatric medical intensive care. J Med Ethics 1996, 22:279-281.
• [12]Garros D, Rosychuk RJ, Cox PN: Circumstances surrounding end of life in a pediatric intensive care unit. Pediatrics 2003, 112:e371.
• [13]Devictor DJ, Nguyen DT: Forgoing life-sustaining treatments in children: a comparison between Northern and Southern European pediatric intensive care units. Pediatr Crit Care Med 2004, 5:211-215.
• [14]Lago PM, Piva J, Garcia PC, Troster E, Bousso A, Sarno MO, Torreao L, Sapolnik R: End-of-life practices in seven Brazilian pediatric intensive care units. Pediatr Crit Care Med 2008, 9:26-31.
• [15]Burns JP, Mitchell C, Outwater KM, Geller M, Griffith JL, Todres ID, Truog RD: End-of-life care in the pediatric intensive care unit after the forgoing of life-sustaining treatment. Crit Care Med 2000, 28:3060-3066.
• [16]ANZICS Centre for Outcome and Resource Evaluation In Report of the Australian and New Zealand Paediatric Intensive Care Registry 2009. Australian & New Zealand Intensive Care Society; 2010.
• [17]McCallum DE, Byrne P, Bruera E: How children die in hospital. J Pain Symptom Manage 2000, 20:417-423.
• [18]Zawistowski CA, DeVita MA: A descriptive study of children dying in the pediatric intensive care unit after withdrawal of life-sustaining treatment. Pediatr Crit Care Med 2004, 5:216-223.
• [19]Meadow W, Lagatta J, Andrews B, Caldarelli L, Keiser A, Laporte J, Plesha-Troyke S, Subramanian M, Wong S, Hron J, Golchin N, Schreiber M: Just, in time: ethical implications of serial predictions of death and morbidity for ventilated premature infants. Pediatrics 2008, 121:732-740.
• [20]Australian and New Zealand Intensive Care Society In The ANZICS Statement on Death and Organ Donation. 3rd edition. Melbourne: ANZICS; 2008.
• [21]Naim MY, Hoehn KS, Hasz RD, White LS, Helfaer MA, Nelson RM: The Children's Hospital of Philadelphia's experience with donation after cardiac death. Crit Care Med 2008, 36:1729-1733.
• [22]Durall AL, Laussen PC, Randolph AG: Potential for donation after cardiac death in a children's hospital. Pediatrics 2007, 119:e219-e224.
• [23]Pleacher KM, Roach ES, Van der WW, Antommaria AH, Bratton SL: Impact of a pediatric donation after cardiac death program. Pediatr Crit Care Med 2009, 10:166-170.