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Pediatric Death After Withdrawal of Life-Sustaining Therapies: A Scoping Review
Conall Francoeur1, Amina Silva2, Laura Hornby3
1Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada.
Insights
The dying process in children after withdrawal of life-sustaining measures (WLSM) is poorly understood. Improving time to death prediction after WLSM can enhance care and support for families and healthcare teams.
Area of Science:
- Pediatric critical care medicine
- Palliative and end-of-life care
- Bioethics
Background:
- The dying process in children following withdrawal of life-sustaining measures (WLSM) in the pediatric intensive care unit (PICU) is complex and understudied.
- Existing literature lacks comprehensive understanding of the physiological aspects, prediction of time to death, and the profound impact on families and healthcare professionals.
Purpose of the Study:
- To systematically evaluate the existing literature on the dying process in children after WLSM in the PICU.
- To explore the physiology of dying, predictability of time to death, and the psychological impact on families and healthcare workers.
- To identify implications for organ donation and future research priorities.
Main Methods:
- A comprehensive literature search was conducted across multiple databases (MEDLINE, Embase, Cochrane, PsycINFO, CINAHL, Web of Science).
- Studies focusing on the dying process after WLSM in the PICU were included, with no restrictions on date or study type.
- Inductive qualitative content analysis was employed to synthesize findings from the 24 included studies.
Main Results:
- Few validated tools exist for predicting time to death after WLSM in children; most deaths occur within one hour.
- The unpredictability of the dying process creates significant emotional challenges and stress for families and healthcare providers.
- Uncertainty surrounding the timing of death negatively impacts families' likelihood of considering organ donation.
Conclusions:
- The dying process in pediatric critical care is inadequately understood, leaving families and clinical teams without sufficient support tools.
- Enhancing the prediction of time to death following WLSM is crucial for improving end-of-life care provision.
- Improved understanding and prediction can facilitate better support for patients, families, and healthcare professionals, and potentially increase organ donor identification.
Objectives:
Evaluate literature on the dying process in children after withdrawal of life sustaining measures (WLSM) in the PICU. We focused on the physiology of dying, prediction of time to death, impact of time to death, and uncertainty of the dying process on families, healthcare workers, and organ donation.
Data Sources:
MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL, and Web of Science.
Study Selection:
We included studies that discussed the dying process after WLSM in the PICU, with no date or study type restrictions. We excluded studies focused exclusively on adult or neonatal populations, children outside the PICU, or on organ donation or adult/pediatric studies where pediatric data could not be isolated.
Data Extraction:
Inductive qualitative content analysis was performed.
Data Synthesis:
Six thousand two hundred twenty-five studies were screened and 24 included. Results were grouped into four categories: dying process, perspectives of healthcare professionals and family, WLSM and organ donation, and recommendations for future research. Few tools exist to predict time to death after WLSM in children. Most deaths after WLSM occur within 1 hour and during this process, healthcare providers must offer support to families regarding logistics, medications, and expectations. Providers describe the unpredictability of the dying process as emotionally challenging and stressful for family members and staff; however, no reports of families discussing the impact of time to death prediction were found. The unpredictability of death after WLSM makes families less likely to pursue donation. Future research priorities include developing death prediction tools of tools, provider and parental decision-making, and interventions to improve end-of-life care.
Conclusions:
The dying process in children is poorly understood and understudied. This knowledge gap leaves families in a vulnerable position and the clinical team without the necessary tools to support patients, families, or themselves. Improving time to death prediction after WLSM may improve care provision and enable identification of potential organ donors.
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