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Limitations and withdrawals of medical intervention in pediatric critical care
M Levetown1, M M Pollack, T T Cuerdon
1Department of Critical Care Medicine, Children's National Medical Center, Washington, DC 20010.
Insights
Medical intervention restrictions, including do not resuscitate (DNR) orders, were common in pediatric intensive care units (PICUs). Imminent death, not quality of life, was the primary reason for these life-altering decisions.
Area of Science:
- Pediatric Critical Care Medicine
- Medical Ethics
- Healthcare Policy
Background:
- Restrictions on medical interventions are critical decisions in pediatric intensive care units (PICUs).
- Understanding the patterns and justifications for these restrictions is essential for improving end-of-life care.
- Three levels of intervention restriction are commonly considered: do not resuscitate (DNR), additional limitations beyond DNR, and withdrawal of care.
Purpose of the Study:
- To investigate the utilization and implementation of three distinct levels of medical intervention restriction in PICUs.
- To analyze the characteristics of pediatric patients subject to these restrictions.
- To identify the primary justifications and practices associated with limiting medical interventions.
Main Methods:
- A study involving 16 randomly selected PICUs across diverse settings.
- Analysis of 119 pediatric patients who underwent intervention restrictions out of 5415 total admissions.
- Data collection focused on patient profiles, chronic conditions, reasons for restrictions, and implementation details.
Main Results:
- Restrictions were implemented in all surveyed PICUs, affecting 79% of patients who died.
- Acute conditions, particularly CNS and respiratory issues, were the main drivers for restrictions (61%).
- Survival rates significantly decreased with increased restriction levels: DNR (35%), additional limitations (9%), and withdrawal (2%).
Conclusions:
- Medical intervention restrictions are a standard practice across PICUs.
- While chronic disease was present, acute illness predominantly precipitated restriction decisions.
- The primary justification for restrictions was imminent death, rather than concerns about quality of life or excessive burden.
Objective:
To investigate the use and implementation in pediatric intensive care units (PICUs) of three levels of restriction of medical intervention: do not resuscitate (DNR), additional limitations of medical interventions beyond DNR, and withdrawal of care.
Design:
Consecutive patients admitted between December 1989 and January 1992.
Setting:
A total of 16 PICUs randomly selected to represent variability in size, teaching status, and presence or absence of a pediatric intensivist and unit coordination.
Main Outcome Measures:
Profiles of children undergoing restrictions of medical interventions including the influence of chronic disease, the justifications for restrictions, and description of implementation practices.
Patients:
All pediatric admissions undergoing restrictions (n = 119) drawn from 5415 consecutive PICU admissions.
Results:
A total of 94 (79%) of the restriction patients died during the PICU course, representing 38% of all deaths. A total of 73 restrictions (61%) resulted from acute disease, most involving the central nervous system or respiratory system. Restrictions were evenly divided between DNR (39%), additional limitations of medical intervention beyond DNR (27%), and withdrawals of medical intervention (34%). Survival decreased with increasing levels of restriction from 35% of DNR patients to 9% of patients with additional limitations and 2% of withdrawal patients. Imminent death was cited as the justification for restrictions in 70% of cases, no relational potential was cited in 22%, and excessive burden was cited in 8%.
Conclusions:
Restrictions of medical intervention were used in all PICUs surveyed. Although severe chronic disease was common among restriction patients, acute disease was the predominant event precipitating placement of restrictions. Imminent death, not quality of life or excessive burden, was the most common justification.
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