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Published on: January 17, 2011
End-of-life practices in seven Brazilian pediatric intensive care units
Patricia M Lago1, Jefferson Piva, Pedro Celiny Garcia
1Hospital de Clínicas de Porto Alegre (Brazil) and Pediatric and Child Health Post Graduation Program, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil. lagopatricia@terra.com.br
Insights
Life support limitation in Brazilian pediatric intensive care units (PICUs) has increased, showing regional disparities. Do-not-resuscitate orders are common, with limited documentation of withdrawing or withholding life support.
Area of Science:
- Pediatric Critical Care Medicine
- Bioethics
- Healthcare Management
Background:
- Life support limitation is a critical aspect of end-of-life care in pediatric intensive care units (PICUs).
- Understanding the incidence and practices surrounding life support limitation is crucial for improving pediatric palliative care.
- Regional variations in healthcare practices can significantly impact patient outcomes.
Purpose of the Study:
- To evaluate the incidence of life support limitation and associated medical practices in the final 48 hours of life for children in Brazilian PICUs.
- To identify regional differences in end-of-life care strategies within Brazilian pediatric intensive care settings.
Main Methods:
- A cross-sectional, multicenter, retrospective study involving medical chart reviews from seven Brazilian PICUs.
- Data collected from medical records of children who died in PICUs between January 2003 and December 2004, excluding deaths within 24 hours of admission and brain deaths.
- Trained pediatric intensive care residents used a standardized protocol to record demographic data and medical management in the last 48 hours of life.
Main Results:
- Out of 561 deaths, 97 were excluded. Cardiopulmonary resuscitation was performed in 57% of cases, with significant regional differences (p = .0003).
- Older age and longer PICU stay were associated with do-not-resuscitate orders (p = .025 and p = .001, respectively).
- Life support limitation decisions were clearly documented in only 52.5% of cases. Inotropic support was continued or increased in 66% of patients with do-not-resuscitate orders.
Conclusions:
- The incidence of life support limitation has increased in Brazilian PICUs, but significant regional variations persist.
- Do-not-resuscitate orders remain the predominant end-of-life practice.
- There is a notable scarcity of documented initiatives for withdrawing or withholding life support measures in Brazilian PICUs.
Objective:
To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs).
Design:
Cross-sectional multicenter retrospective study based on medical chart review.
Setting:
Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region).
Patients:
Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded.
Interventions:
Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (kappa = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student's t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data.
Measurements And Main Results:
Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders.
Conclusions:
The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.
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