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Pediatric resident attitudes about technologic support of vegetative patients and the effects of parental input--a
J S Rubenstein1, S M Unti, R J Winter
1Department of Pediatrics, University of Rochester School of Medicine and Dentistry, NY 14642.
Objective:
To evaluate the change over time of attitudes about withdrawal of care from hopelessly ill children among a cohort of pediatric residents.
Design:
Prospective data collection via surveys.
Setting:
A pediatric residency program in a children's hospital.
Subjects:
Pediatric residents beginning training in 1987 and 1988; 29 residents completed the study.
Interventions:
Study participants completed a structured case-oriented questionnaire yearly from June 1988 through the completion of their residency training. The withholding of vasoactive agents or cardiopulmonary resuscitation, and the withdrawal of intravenous fluids, nutrition, or mechanical ventilation were the specific therapeutic options presented for a patient in a persistent vegetative state. The effects of time (further training) and parental wishes on resident decisions were assessed.
Measurements And Main Results:
No resident wanted to provide intensive care to a child in a persistent vegetative state who was in respiratory failure; all residents would withhold vasoactive agents and CPR from such a child. At the conclusion of training, most (97%) would withdraw mechanical ventilation. A minority would withdraw intravenous (IV) fluids (41%) or nutrition (35%). Residents became more willing to withdraw IV fluids from these patients (0/16 vs 6/16; P = .03) and to withhold or withdraw therapies in general (P = .03) over the course of their training. All of this change occurred over the first year of training. Parental wishes altered treatment plans for these patients significantly, both when parents desired additional treatment (P < .0001), and when parents wanted treatment stopped (P = .04). The residents' level of training had no effect on responses to parents' therapeutic requests.
Conclusion:
Although exposure to level of care issues occurs throughout pediatric residency training, almost all changes in trainees' attitudes occur during the first year. Efforts to promote effective learning and coping should be concentrated in this period.