At home with death: a natural child-death

Variables influencing end-of-life care in children and adolescents with cancer

BACKGROUND

The purpose of this study was to describe the variables influencing end-of-life care in children and adolescents dying of cancer.

MATERIALS AND METHODS

Records of 146 children with cancer who died at Children's Hospital were reviewed for demographics, diagnosis, location of death, withdrawal of life support, use of "do not resuscitate" (DNR) orders, and the length of time that those orders were in effect.

RESULTS

Ninety-five patients were evaluated. Fifty-nine died of progressive disease and 36 deaths were therapy-related. Sixty-four percent of disease-related deaths occurred at home with support from home care or hospice. Only 10% of all patients died while receiving maximal aggressive support in the intensive care unit. Age, diagnosis (solid tumor vs. leukemia), cause of death, length of last hospital admission, and the duration of DNR orders had a significant correlation with the place of death and referral to and use of hospice. Thirty-five percent of all patients had hospice support.

CONCLUSIONS

Most children who die of cancer die because of progressive disease at home with hospice support. Do not resuscitate orders were written for most patients who died. End-of-life decisions are influenced by patient diagnosis, cause of death, and age.

Medical education--addressing the needs of the dying child

This paper reviews the formulation of attitudes, the acquisition of knowledge and the development of skills which together enable medical practitioners to provide comprehensive palliative care for terminally ill children. Ideally, these should be developed to such an extent that a 'good death' can be achieved. Current medical education does not address these areas and the associated issues, including the breaking of bad news, understanding the grief reaction to serious illness and children's perceptions of death. Neither does training include how to take management decisions concerning informed consent, the transition from active treatment to palliative care, symptom control and choosing the place for care. These, and the unintentional attitude that regards the dying child as a 'medical failure', are discussed, together with the need to meet the needs of the parents and siblings, and the effects of bereavement. Finally, recommendations are made for undergraduate curricula and the need to emphasize the relationship of caring for the family unit, and not just the patient.

Children dead on arrival: predictors of short-term family follow-up

Approximately three fourths of the parents whose children were pronounced dead in one emergency department maintained contact with a professional for at least a month following the death. Families whose children died of trauma did not maintain contact as well as those whose children died of anticipated death, sudden infant death syndrome, or infection. Strong family support system, employed parents, and appropriate response at the time of death all correlated with continued contact with a professional and adequate coping after death (P values all less than 0.04). Prior professional support was a less significant factor in follow-up, and disorganized, isolated parents with histories of poor social adjustment were far less likely to maintain contact.