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Decision making and end-of-life care in critically ill children
C Masri1, C A Farrell, J Lacroix
1Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Quebec, Canada.
Insights
End-of-life decisions for critically ill children in the pediatric intensive care unit (PICU) are common. Understanding conflict causes can improve end-of-life care and palliative care decisions.
Area of Science:
- Pediatric critical care medicine
- Medical ethics
- Palliative care
Background:
- End-of-life care decisions are frequent in pediatric intensive care units (PICUs).
- Critically ill children may require concurrent intensive and palliative care.
- Disagreements regarding end-of-life therapy are a significant concern.
Purpose of the Study:
- To review medical literature on end-of-life therapy decision-making in PICUs.
- To analyze data on disagreements concerning end-of-life care for critically ill children.
- To provide recommendations for improving end-of-life care decisions and conflict resolution.
Main Methods:
- Comprehensive literature search of peer-reviewed journals and book chapters.
- Inclusion of studies on end-of-life therapy and conflicts in PICU decision-making.
- Synthesis of findings from case series, descriptive studies, qualitative studies, and surveys.
Main Results:
- Key determinants of end-of-life decisions include child's age, cognitive status, functional status, pain, survival probability, and quality of life.
- Grave underlying conditions or unexpected severe events are risk factors for persistent conflict.
- Diverse study types, including systematic reviews and legal opinions, inform the decision-making process.
Conclusions:
- End-of-life care decisions are a common and complex aspect of PICU practice.
- Understanding the root causes of conflict is crucial for resolving disagreements.
- Integrated palliative care alongside intensive care can improve outcomes for critically ill children.
Objectives:
1) To comment on the medical literature on decision making regarding end-of-life therapy, 2) to analyze the data on disagreement about such therapy, including palliative care, and withholding and withdrawal practices for critically ill children in the pediatric intensive care unit (PICU), and 3) to make some general recommendations.
Data Sources And Study Selection:
All papers published in peer-reviewed journals, and all chapters on end-of-life therapy, or on conflict between parents and caregivers about end-of-life decisions in the PICU were retrieved.
Results:
We found three case series, three systematic descriptive studies, two qualitative studies, four surveys, and many legal opinions, editorials, reviews, guidelines, and book chapters. The main determinants of end-of-life decisions are the child's age, premorbid cognitive condition and functional status, pain or discomfort, probability of survival, and quality of life. Risk factors in persistent conflict between parents and caregivers about end-of-life care include a grave underlying condition or an unexpected and severe event.
Conclusion:
Making decisions about end-of-life care is a frequent event in the PICU. Children may need both intensive care and palliative care concurrently at different stages of their illness. Disagreements are more likely to be resolved if the root cause of the conflict is better understood.