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Long-term mechanical ventilation in pediatric respiratory failure: medical and ethical considerations
1Department of Pediatrics, University of Wisconsin, Madison.
Insights
Improved survival for mechanically ventilated children necessitates reevaluating care. Guidelines are proposed for ethical decisions regarding prolonged mechanical ventilation and life support in pediatric intensive care.
Area of Science:
- Pediatric critical care medicine
- Bioethics
- Respiratory medicine
Background:
- Advances in mechanical ventilation have improved survival rates for children with chronic respiratory disorders.
- This improved outlook presents ethical dilemmas in pediatric intensive care units (ICUs) regarding prolonged ventilation versus withdrawal of support.
- Increasing numbers of children are managed at home with life-support technology due to encouraging survival and quality of life.
Purpose of the Study:
- To review medical data on the survival of mechanically ventilated children.
- To discuss key ethical issues in decisions about withholding or withdrawing mechanical ventilation in pediatric patients.
- To propose guidelines for managing prolonged mechanical ventilation dilemmas in pediatric medical practice.
Main Methods:
- Review of medical literature on survival rates for children on mechanical ventilation.
- Analysis of ethical considerations in pediatric end-of-life care decisions.
- Development of procedural guidelines for managing complex cases.
Main Results:
- Survival and quality of life for children on long-term assisted ventilation are not discouraging.
- Ethical decision-making requires accurate prognostic information and avoidance of irreversible choices under uncertainty.
- Withdrawing treatment is ethically preferable to withholding it.
Conclusions:
- Ethical management of prolonged mechanical ventilation in children requires a fact-based, family-centered approach.
- Guidelines emphasize obtaining accurate prognosis, avoiding hasty decisions, and prioritizing family involvement.
- Clear communication channels and external consultations are crucial for resolving disagreements.
Abstract:
The outlook for survival of mechanically ventilated children with a variety of chronic respiratory disorders has improved to an extent that forces reexamination of traditional views of what is in these children's best interest with respect to medical care. In the ICU setting, this kind of situation represents a major dilemma in current pediatric medical practice since both alternatives (prolonged mechanical ventilation versus withholding/withdrawing) imply an unfavorable outcome. Because the survival and quality of life for children receiving long-term assisted ventilation are not highly discouraging, increasing numbers of pediatric patients are not being managed at home with life-support technology. This article reviews medical data on the survival of children managed with mechanical ventilation and discusses some of the key ethical issues pertaining to decisions about withholding/withdrawing assisted ventilation in infants and children. In addition, we suggest the following guidelines and procedures that might be useful in dealing with the prolonged mechanical ventilation dilemma in pediatric medical practice: (1) obtain the correct facts on prognosis (good ethics start with good facts); (2) avoid irreversible decisions under uncertainty; (3) remember that withdrawing treatment is ethically preferable to withholding; (4) resolve disagreements with the use of outside consultation; (5) include the entire family in the decision-making process; (6) remember that consent is a process, not an event, and requires regular discussions with the family; (7) one physician must be identified as the primary provider and communicator.