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Withdrawal and limitation of life support in paediatric intensive care
1Paediatric Intensive Care Unit, University Malaya Medical Centre, 50603 Kuala Lumpur, Malaysia.
Insights
Limitation of treatment is the most common cause of death in pediatric intensive care units (PICUs) in developing countries. Active withdrawal of life support is increasing but still uncommon, requiring consideration of cultural factors.
Area of Science:
- Pediatric Intensive Care
- End-of-Life Care
- Global Health
Background:
- Understanding end-of-life care practices is crucial in pediatric intensive care units (PICUs).
- Developing countries face unique challenges in managing withdrawal or limitation of life support.
Purpose of the Study:
- To compare death modes and factors influencing life support decisions in a developing country's PICU.
- To analyze trends in life support withdrawal and limitation over time.
Main Methods:
- Retrospective analysis of 148 children (< 12 years) who died in a PICU.
- Data collected from January 1995 to December 1995 and January 1997 to June 1998.
Main Results:
- Limitation of treatment was the most frequent mode of death (68/148).
- Withdrawal of life support increased from 0% to 8% between study periods.
- Paediatricians predominantly initiated care restriction discussions, often based on expected imminent death.
Conclusions:
- Limitation of treatment is prevalent in developing country PICUs; active withdrawal is less common.
- Paediatricians are becoming more proactive in end-of-life care but must navigate sociocultural and religious factors.
Objectives:
To compare the modes of death and factors leading to withdrawal or limitation of life support in a paediatric intensive care unit (PICU) in a developing country.
Methods:
Retrospective analysis of all children (< 12 years) dying in the PICU from January 1995 to December 1995 and January 1997 to June 1998 (n = 148).
Results:
The main mode of death was by limitation of treatment in 68 of 148 patients, failure of active treatment including cardiopulmonary resuscitation in 61, brain death in 12, and withdrawal of life support with removal of endotracheal tube in seven. There was no significant variation in the proportion of limitation of treatment, failure of active treatment, and brain death between the two periods; however, there was an increase in withdrawal of life support from 0% in 1995 to 8% in 1997-98. Justification for limitation was based predominantly on expectation of imminent death (71 of 75). Ethnic variability was noted among the 14 of 21 patients who refused withdrawal. Discussions for care restrictions were initiated almost exclusively by paediatricians (70 of 75). Diagnostic uncertainty (36% v 4.6%) and presentation as an acute illness were associated with the use of active treatment.
Conclusions:
Limitation of treatment is the most common mode of death in a developing country's PICU and active withdrawal is still not widely practised. Paediatricians in developing countries are becoming more proactive in managing death and dying but have to consider sociocultural and religious factors when making such decisions.