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Dying in the intensive care unit: collaborative multicenter study about forgoing life-sustaining treatment in
María Althabe1, Gustavo Cardigni, Juan C Vassallo
1Hospital de Pediatría "J. P. Garrahan," Buenos Aires, Argentina.
Insights
In Argentinian pediatric intensive care units, cardiopulmonary resuscitation (CPR) was common before death, with do-not-resuscitate orders and withholding treatments being frequent life support limitation (LSL) procedures. Active withdrawal of support was rare.
Area of Science:
- Pediatric Intensive Care Medicine
- Clinical Ethics
- End-of-Life Care Research
Background:
- Understanding end-of-life care practices in pediatric intensive care units (PICUs) is crucial for improving patient outcomes and supporting families.
- Life support limitation (LSL) encompasses various decisions made when curative treatment is no longer feasible or beneficial.
Purpose of the Study:
- To describe the modes of death and the factors influencing decision-making regarding life support limitation (LSL) in Argentinian PICUs.
- To analyze the procedures and justifications associated with LSL in a pediatric critical care setting.
Main Methods:
- A prospective, descriptive, longitudinal, and noninterventional study was conducted over one year in sixteen PICUs across Argentina.
- Data were collected from medical records and physician interviews for all patients who died during the study period.
- Statistical analyses included descriptive statistics, contingency tables, analysis of variance, and logistic regression to identify factors associated with LSL.
Main Results:
- Of 457 deaths, cardiopulmonary resuscitation (CPR) was performed in 52%, do-not-resuscitate (DNR) orders in 16%, withholding/withdrawing life-sustaining treatment (WH/WD) in 20%, and brain death (BD) in 11%.
- Imminent death was the most common justification for LSL. Chronic disease (CD) and increased staff presence were associated with a higher probability of LSL.
- Inotropic drugs, CPR, and mechanical ventilation were the most frequently limited treatments.
Conclusions:
- Cardiopulmonary resuscitation (CPR) was the most common intervention preceding death in this Argentinian PICU cohort.
- Do-not-resuscitate (DNR) orders and withholding new treatments were prevalent LSL strategies, while active withdrawal of support was infrequent.
- A high prevalence of chronic disease (65%) was noted, and postoperative condition negatively impacted LSL probability in chronically ill patients.
Objective:
Describe modes of death and factors involved in decision-making together with life support limitation (LSL) procedures.
Design:
Prospective, descriptive, longitudinal, and noninterventional study.
Setting:
Sixteen pediatric intensive care units in Argentina.
Patients:
Every patient who died during a 1-yr period was included.
Measurements And Main Results:
Age, sex, length of stay (LOS), primary and admission diagnosis, underlying chronic disease (CD), postoperative condition (PO). Deaths were classified in four groups: a) failed cardiopulmonary resuscitation (CPR); b) do-not-resuscitate (DNR) status; c) withholding or withdrawing life-sustaining treatment (WH/WD); and d) brain death (BD). Justifications were classified as a) imminent death; b) poor long-term prognosis; c) poor quality of life; and d) family request. Data were collected from medical records and interviews with the attending physicians. Descriptive statistics were performed. Differences among groups were analyzed through contingency tables and analysis of variance when required. Relative risks and confidence intervals of variables potentially related to LSL were analyzed, and logistic regression was performed. There were 6358 admissions and 457 deaths. CPR was performed in 52%, DNR in 16%, WH/WD in 20%, and BD in 11% of dead patients. BD patients were older, LOS and CD prevalence were higher in the WH/WD group. Inotropic drugs were the most frequently limited treatment in 110 patients (55%), CPR in 72 (35.6%), and mechanical ventilation in 63 (31%). Imminent death was the most frequently reported justification for LSL. CD and more staff were associated with a higher probability of LSL.
Conclusions:
Most of the patients in Argentina underwent CPR before their death. We have a high proportion of patients with CD (65%) and low BD diagnosis. PO condition decreased LSL probability in chronically ill patients. Do-not-resuscitate orders and withholding new treatments were the most common LSL. Active withdrawal was exceptional. The Ethics Committee was consulted in 5% of the LSL population.
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