End of life in the pediatric burn patient

Up to 60% of deaths in pediatric intensive care units occur after placing limits upon life-sustaining treatment. Two-thirds of limitations are made on the last day of life. Our aim was to characterize the timing, indications, and implementation of "do not resuscitate" (DNR) orders and the withdrawal of support from children with severe burns. A retrospective evaluation was conducted of all deaths in a pediatric burn unit over a 7-year period. Values are presented as mean +/- SD; two-tailed t-tests and Fisher's exact tests were used for analysis. Of the 29 deaths (total admissions = 1261; 2.3% death rate), 12 were of patients with DNR status. Active withdrawal of support occurred for 15 patients: 10 with DNR orders, 5 without. There was no difference in age, burn size, inhalation injury, etiology of injury, cause of death, intensive care unit days, or ventilator days between DNR patients and non-DNR patients. Of the 12 patients with DNR status, only five had orders indicating no cardiopulmonary resuscitation (CPR), no vasopressors, and no cardioversion. The mean time from DNR to death was 22.9 +/- 49.6 hours (median, 2.75 hours). Patients without DNR orders before death had more CPR attempts (0.8 +/- 0.6 vs. 0.3 +/- 0.6; P < .05). At the time of death, few patients with DNR orders were receiving vasopressors (two patients) or underwent CPR (1 patient). Of the 17 patients without DNR orders, 12 underwent resuscitative efforts: CPR (11), vasopressors (12), or cardioversion (9). No resuscitative efforts were undertaken for four children, two with DNR orders. For the acutely injured child there is a strong tendency to wait until the last possible hours of life to address limitation of life-sustaining measures. Documentation of limitation of care was not previously addressed in nearly a third of cases in which support was actively withdrawn. Once a decision to limit support was made, the majority of children proceeded rapidly to death. Further evaluation of the indications, timing, and implementation of DNR orders for children with severe burns is warranted.