Withdrawal of mechanical ventilation in pediatric and neonatal intensive care units

Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study

OBJECTIVE

Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not.

DESIGN

Secondary analysis of multicenter retrospective cohort study.

SETTING

Ten PICUs in the United States between 2009 and 2021.

PATIENTS

Nine hundred thirteen patients 0-21 years old who died after WLST.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality).

CONCLUSIONS

Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.

Pediatric Death After Withdrawal of Life-Sustaining Therapies: A Scoping Review

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.

Cuidados intensivos y cuidados paliativos pediátricos

La tecnificación biomédica de la segunda mitad del siglo XX ha llevado a considerar a la ciencia omnipotente. Esto ha influido en las instituciones sanitarias y en el personal de salud, y ha llevado a cambios en las conceptualizaciones de salud, enfermedad y muerte. La tecnificación de las unidades de cuidados intensivos dirigidas a revertir enfermedades graves ha priorizado el aspecto biológico de la persona, deshumanizando la medicina. Los cuidados paliativos pediátricos rescatan la integralidad del ser humano y proporcionan cuidados apropiados y respetuosos, acordes a la dignidad de la persona, especialmente al final de la vida, lo que constituye una propuesta humanizadora.

Palliation, end-of-life care and burns; practical issues, spiritual care and care of the family - A narrative review II

Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. This second article discusses practical issues around palliative care for burn patients, such as pain and fluid management, withdrawal of ventilator support and wound care, as well as spiritual and family issues. This paper forms part two, of two narrative reviews on the topic of palliation, end-of-life care and burns. The first part considered concepts, decision-making and communication. It was published in volume 10, issue 2, June 2020, pages 95–98.

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Mortality of burns presented to a burns unit in Africa is about 10%.

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Resources in Africa to manage burn patients are scarce and patients with massive burns may not be offered curative burn care.

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There are no guidelines for palliative care in burn patients.

Predicting extubation outcomes using the Heart Rate Characteristics index in preterm infants: a cohort study

A strategy of early extubation to noninvasive respiratory support in preterm infants could be boosted by the availability of a decision support tool for clinicians. Using the Heart Rate Characteristics index (HRCi) with clinical parameters, we derived and validated predictive models for extubation readiness and success.Peri-extubation demographic, clinical and HRCi data for up to 96 h were collected from mechanically ventilated infants in the control arm of a randomised trial involving eight neonatal centres, where clinicians were blinded to the HRCi scores. The data were used to produce a multivariable regression model for the probability of subsequent re-intubation. Additionally, a survival model was produced to estimate the probability of re-intubation in the period after extubation.Of the 577 eligible infants, data from 397 infants (69%) were used to derive the pre-extubation model and 180 infants (31%) for validation. The model was also fitted and validated using all combinations of training (five centres) and test (three centres) centres. The estimated probability for the validation episodes showed discrimination with high statistical significance, with an area under the curve of 0.72 (95% CI 0.71-0.74; p<0.001). Data from all infants were used to derive models of the predictive instantaneous hazard of re-intubation adjusted for clinical parameters.Predictive models of extubation readiness and success in real-time can be derived using physiological and clinical variables. The models from our analyses can be accessed using an online tool available at www.heroscore.com/extubation, and have the potential to inform and supplement the confidence of the clinician considering extubation in preterm infants.

An ethically-justifiable, practical approach to decision-making surrounding conjoined-twin separation

Conjoined twins present unique ethical and palliative care challenges. We present an ethically-justifiable, practical approach to decision-making with regards to surgical separation. These decisions must account for the short- and long-term prognoses for each infant prior to, and after, separation. Other considerations include the benefits and burdens of separation and the family's values and goals. Caregivers should recognize that decisions surrounding separation may be unduly influenced by social biases. The palliative care team aids in developing goals of care to guide decision-making by promoting communication between the medical team and family. They play an important role in supporting families regardless of the planned course of treatment. This support may be social or spiritual in nature, and is promoted by the interdisciplinary structure of the team. Early involvement of palliative care services facilitates complex decision making and can aid in the transition from cure-oriented therapies to support if needed during and after the dying process.

Ethical and end of life considerations for neonates requiring ECMO support

ECMO has proven to be a life-saving intervention for a variety of disease entities with a high rate of survival in the neonatal population. However, ECMO requires clinical teams to engage in many ethical considerations. Even with ongoing improvements in technology and expertise, some patients will not survive a course of ECMO. An unsuccessful course of ECMO can be difficult to accept and cause a great deal of angst. These questions can result in real conflict both within the care team, and between the care team and the family. Herein we explore a range of ethical considerations that may be encountered when caring for a patient on ECMO, with a particular focus on those courses where it appears likely that the patient will not survive. We then consider how a palliative care approach may provide a tool set to help engage the team and family in confronting the difficult decision to discontinue ECMO.

The Use of Simulation to Improve Resident Communication and Personal Experience at End-of-Life Care

Pediatric residents report they are not sufficiently trained to communicate with families at a child's death. We performed a study to prove feasibility and assess whether simulation improves their communication and experience. Residents were assigned to intervention using simulation or control group. Communication was assessed by standardized patients and audiotapes of simulated encounters when they delivered bad news. Residents' perceptions of their communication were polled. The majority reported they never witnessed end-of-life discussions. All residents perceived themselves to be more capable at pronouncing the death of a child, and informing a family of a death after participating in either the interventional simulation or a bereavement retreat. Despite training within a pediatric intensive care unit, pediatric residents have little exposure to end-of-life discussions. Pediatric end-of-life simulation increases exposure of residents to end-of-life care and improves residents' perceptions of their communication.

How is life support withdrawn in intensive care units: A narrative review

PURPOSE

Decisions to withdraw life-sustaining therapy (WDLS) are relatively common in intensive care units across Canada. As part of preliminary work to develop guidelines for WDLS, we performed a narrative review of the literature to identify published studies of WDLS.

MATERIALS AND METHODS

A search of MEDLINE and EMBASE databases was performed. The results were reviewed and only articles relevant to WDLS were included. Any references within these articles deemed to be relevant were subsequently included.

RESULTS

The initial search identified 3687 articles. A total of 100 articles of interest were identified from the initial search and a review of their references. The articles were primarily composed of observational data and expert opinion. The information from the literature was organized into 6 themes: preparation for WDLS, monitoring parameters, pharmacologic symptom management, withdrawing life-sustaining therapies, withdrawal of mechanical ventilation, and bereavement.

CONCLUSIONS

This review describes current practices and opinions about WDLS, and also demonstrates the significant practice variation that currently exists. We believe that the development of guidelines to help increase transparency and standardize the process will be an important step to ensuring high quality care during WDLS.

Infants' best interests in end-of-life care for newborns

BACKGROUND AND OBJECTIVES

Pediatric bioethics presumes that decisions should be taken in the child's best interest. If it's ambiguous whether a decision is in the child's interest, we defer to parents. Should parents be permitted to consider their own interests in making decisions for their child? In the Netherlands, where neonatal euthanasia is legal, such questions sometimes arise in deciding whether to hasten the death of a critically ill, suffering child. We describe the recommendations of a national Dutch committee. Our objectives were to analyze the role of competing child and family interests and to provide guidance on end-of-life decisions for doctors caring for severely ill newborns.

METHODS

We undertook literature review, 7 consensus meetings in a multidisciplinary expert commission, and invited comments on draft report by specialists' associations.

RESULTS

Initial treatment is mandatory for most ill newborns, to clarify the prognosis. Continuation of treatment is conditional on further diagnostic and prognostic data. Muscle relaxants can sometimes be continued after withdrawal of artificial respiration without aiming to shorten the child's life. When gasping causes suffering, or protracted dying is unbearable for the parents, muscle relaxants may be used to end a newborn's life. Whenever muscle relaxants are used, cases should be reported to the national review committee.

CONCLUSIONS

New national recommendations in the Netherlands for end-of-life decisions in newborns suggest that treatment should generally be seen as conditional. If treatment fails, it should be abandoned. In those cases, palliative care should be directed at both infant and parental suffering. Sometimes, this may permit interventions that hasten death.

A new framework to evaluate the quality of a neonatal death

Management of the infant in the neonatal intensive care unit (NICU) focuses on stabilization and survival but sometimes death is an inevitable outcome. Dying neonates deserve a good death. It is unknown whether we are providing neonates with a good death. This article introduces a framework describing components needed for a good death in the NICU. Initially based on an adult model, this new framework incorporates appropriate components of Emanuel and Emanuel's framework ( 1998 ) and puts them into a context applicable to neonates. The proposed concepts and relationships will require future testing and revision as indicated by the evidence.

Support for mothers, fathers and families after perinatal death

BACKGROUND

Provision of an empathetic, sensitive, caring environment and strategies to support mothers, fathers and their families experiencing perinatal death are now an accepted part of maternity services in many countries. Interventions such as psychological support or counselling, or both, have been suggested to improve outcomes for parents and families after perinatal death.

OBJECTIVES

To assess the effect of any form of intervention (i.e. medical, nursing, midwifery, social work, psychology, counselling or community-based) on parents and families who experience perinatal death.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and article bibliographies.

SELECTION CRITERIA

Randomised trials of any form of support aimed at encouraging acceptance of loss, bereavement counselling, or specialised psychotherapy or counselling for mothers, fathers and families experiencing perinatal death.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility of trials.

MAIN RESULTS

No trials were included.

AUTHORS' CONCLUSIONS

Primary healthcare interventions and a strong family and social support network are invaluable to parents and families around the time a baby dies. However, due to the lack of high-quality randomised trials conducted in this area, the true benefits of currently existing interventions aimed at providing support for mothers, fathers and families experiencing perinatal death is unclear. Further, the currently available evidence around the potential detrimental effects of some interventions (e.g. seeing and holding a deceased baby) remains inconclusive at this point in time. However, some well-designed descriptive studies have shown that, under the right circumstances and guided by compassionate, sensitive, experienced staff, parents' experiences of seeing and holding their deceased baby is often very positive. The sensitive nature of this topic and small sample sizes, make it difficult to develop rigorous clinical trials. Hence, other research designs may further inform practice in this area. Where justified, methodologically rigorous trials are needed. However, methodologically rigorous trials should be considered comparing different approaches to support.

[Problems for assessing the newborns' pain in palliative care]

Several pain scales are available for newborns, but the assessment of pain in these preverbal beings, who are in continuing neurological development, remains challenging for healthcare teams. Although neonates at the end of life are particularly vulnerable to pain and discomfort, no assessment tool has been validated in this specific population. The difficulties for assessing pain in this context are copies of those potentially encountered in other situations. Questions arise about the limits of the available scales, about possible alterations of responses to a noxious stimulus in particular contexts (extreme immaturity, brain lesions), about possibly painful situations in palliative care, about the nature of scales to choose. Data show a perception of pain at a cortical level by extremely immature infants and the ability for neonates with significant neurological injury to express pain behaviours. For some potentially painful situations (dyspnoea, gasps, hunger) neonatal data are virtually nonexistent. Fundamental scientific data and clinical data from adults and children can give some answers. One will choose scales for which the staff is trained, easily usable (preference for behavioural scales), validated for all gestational ages, reliable in the event of neurological impairment or sedation. An assessment of prolonged pain (EDIN scale or COMFORT Behaviour scale) combined with measures of acute pain (DAN or NFCS scales) is recommended. These scales should be better validated for populations of newborns and situations that are specific to palliative care. A better assessment of the parental perception and of their distress about the discomfort or pain of their child is warranted.

The French Society of Neonatology's proposals for neonatal end-of-life decision-making

BACKGROUND

Opinions and practice regarding end-of-life decisions in neonatal medicine show considerable variations between countries. A recent change of the legal framework, together with an ongoing debate among French neonatologists, led the French Society of Neonatology to reconsider and update its previous recommendations.

OBJECTIVES

To propose a set of recommendations on the ethical principles to be respected in the making and application of end-of-life decisions.

METHODS

A multidisciplinary working group on ethical issues in perinatal medicine composed of neonatologists, obstetricians and ethicists.

RESULTS

Withholding or withdrawing life-sustaining treatment may be acceptable, and unreasonable therapeutic obstinacy is condemned. This implies that the child's best interests must always be the central consideration. Although the parents must be involved in the decision process so that they form an alliance with the healthcare team, and a collegial approach is of utmost importance, any crucial decision affecting the patient's life calls for individual medical responsibility. Because every newborn is rightfully an integral member of a human family, his or her dignity must be preserved. The goal of palliative care is to preserve the quality of a life, also at its end. The intention underlying an act has to be analyzed perceptively. Euthanasia, i.e. to perform an act with the deliberate intention to cause or hasten a patient's death, is legally and morally forbidden. Conversely, to withhold or withdraw a life-sustaining treatment can be justified when the intention is to cease opposing, in an unreasonable manner, the natural course of a disease.

CONCLUSIONS

This statement provides the principles identified by French neonatologists on which to base their decisions concerning the ending of life. Arguments are set forth, discussed and compared with international statements and previously published considerations.

[Implementing palliative care for newborns in various care settings. Part 3 of "Palliative care in the neonatal period"]

Palliative care in newborns may take place in the delivery room and then continued either in maternity wards or in the neonatal unit. For babies developing a chronic condition, going home may be advantageous. The population concerned includes babies born with a severe intractable congenital malformation and certain extremely preterm newborn babies at the limits of viability. Care procedures as well as withholding and withdrawing treatments are reviewed.

Supporting bereaved parents: practical steps in providing compassionate perinatal and neonatal end-of-life care. A North American perspective

Providing compassionate bereavement support challenges care-givers in perinatal medicine. A practical and consistent approach tailored to individual families may increase the care-giver's ability to relieve parental grief. This approach includes: (1) clear and consistent communication compassionately delivered; (2) shared decision-making; (3) physical and emotional support; and (4) follow-up medical, psychological and social care. Challenges to providing comprehensive end-of-life care include care-giver comfort, consistency of care, cultural and legal barriers, and lack of adequate training.