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Sarpal A, Miller MR, Martin CM, Sibbald RW, Speechley KN. Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers. Front Pediatr 2024; 12:1272648. [PMID: 38304746 PMCID: PMC10830678 DOI: 10.3389/fped.2024.1272648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/03/2024] [Indexed: 02/03/2024] Open
Abstract
Background Potentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited. Objectives Determine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate. Methods Prospective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0-17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale. Results Of 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty. Conclusions While treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.
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Affiliation(s)
- Amrita Sarpal
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Michael R. Miller
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Claudio M. Martin
- Lawson Health Research Institute, London, ON, Canada
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Robert W. Sibbald
- Department of Ethics, London Health Sciences Centre, London, ON, Canada
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kathy N. Speechley
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Pienaar MA, Sempa JB, Luwes N, Solomon LJ. An Artificial Neural Network Model for Pediatric Mortality Prediction in Two Tertiary Pediatric Intensive Care Units in South Africa. A Development Study. Front Pediatr 2022; 10:797080. [PMID: 35281234 PMCID: PMC8916561 DOI: 10.3389/fped.2022.797080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 02/01/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES The performance of mortality prediction models remain a challenge in lower- and middle-income countries. We developed an artificial neural network (ANN) model for the prediction of mortality in two tertiary pediatric intensive care units (PICUs) in South Africa using free to download and use software and commercially available computers. These models were compared to a logistic regression model and a recalibrated version of the Pediatric Index of Mortality 3. DESIGN This study used data from a retrospective cohort study to develop an artificial neural model and logistic regression model for mortality prediction. The outcome evaluated was death in PICU. SETTING Two tertiary PICUs in South Africa. PATIENTS 2,089 patients up to the age of 13 completed years were included in the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The AUROC was higher for the ANN (0.89) than for the logistic regression model (LR) (0.87) and the recalibrated PIM3 model (0.86). The precision recall curve however favors the ANN over logistic regression and recalibrated PIM3 (AUPRC = 0.6 vs. 0.53 and 0.58, respectively. The slope of the calibration curve was 1.12 for the ANN model (intercept 0.01), 1.09 for the logistic regression model (intercept 0.05) and 1.02 (intercept 0.01) for the recalibrated version of PIM3. The calibration curve was however closer to the diagonal for the ANN model. CONCLUSIONS Artificial neural network models are a feasible method for mortality prediction in lower- and middle-income countries but significant challenges exist. There is a need to conduct research directed toward the acquisition of large, complex data sets, the integration of documented clinical care into clinical research and the promotion of the development of electronic health record systems in lower and middle income settings.
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Affiliation(s)
- Michael A Pienaar
- Paediatric Critical Care Unit, Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa
| | - Joseph B Sempa
- Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Nicolaas Luwes
- Department of Electrical, Electronic and Computer Engineering, Faculty of Engineering, Built Environment and Information Technology, Central University of Technology, Bloemfontein, South Africa
| | - Lincoln J Solomon
- Paediatric Critical Care Unit, Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa
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Abstract
INTRODUCTION Studies have suggested 5-20% of paediatric ICU patients may receive care felt to be futile. No data exists on the prevalence and impact of futile care in the Paediatric Cardiac ICU. The aim is to determine the prevalence and economic impact of futile care. MATERIALS AND METHOD Retrospective cohort of patients with congenital cardiac disease 0-21 years old, with length of stay >30 days and died (2015-2018). Documentation of futility by the medical team was retrospectively and independently reviewed. RESULTS Of the 127 deaths during the study period, 51 (40%) had hospitalisation >30 days, 13 (25%) had received futile care and 26 (51%) withdrew life-sustaining treatment. Futile care comprised 0.69% of total patient days with no difference in charges from patients not receiving futile care. There was no difference in insurance, single motherhood, education, income, poverty, or unemployment in families continuing futile care or electing withdrawal of life-sustaining treatment. Black families were less likely than White families to elect for withdrawal (p = 0.01), and Hispanic families were more likely to continue futile care than non-Hispanics (p = 0.044). CONCLUSIONS This is the first study to examine the impact of futile care and characteristics in the paediatric cardiac ICU. Black families were less likely to elect for withdrawal, while Hispanic families more likely to continue futile care. Futile care comprised 0.69% of bed days and little burden on resources. Cultural factors should be investigated to better support families through end-of-life decisions.
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Prognosis and futility in neurosurgical emergencies: A review. Clin Neurol Neurosurg 2020; 195:105851. [PMID: 32422469 DOI: 10.1016/j.clineuro.2020.105851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 11/22/2022]
Abstract
A patient with a life-threatening intracranial insult presents a difficult situation to the neurosurgeon. In a few short minutes the neurosurgeon must assess the patient's neurologic status, imaging, and medical condition then confer with the patient's proxy regarding treatment. This assessment ideally includes recognition of situations where aggressive care is futile and therefore such treatments should not be offered. The proxy discussion must involve surgical and nonsurgical management options and the impact of these options on survival and residual disability. Surgical decision-making is frequently difficult, even for designated proxies armed with advance directives, as these documents are usually vague with regard to acceptable functional outcomes. To complicate things further, when emergencies are off-hours, housestaff or physician extenders may need to represent the medical team in these discussions so that surgical treatment, if desired, can be arranged expeditiously. These difficulties sometimes lead to the performance of emergent surgical procedures in situations where poor outcome is certain, with deleterious effects to the patient, family, and healthcare system. It is clear then that neurosurgeons as well as their housestaff and extenders should have working knowledge of prognostic information relating to intracranial insults and familiarity with the complex ethical concept of medical futility. In this paper we review the relevant literature and our goal is to juxtapose these topics so as to provide a framework for decision making in that critical time.
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Seino Y, Kurosawa H, Shiima Y, Niitsu T. End-of-life care in the pediatric intensive care unit: Survey in Japan. Pediatr Int 2019; 61:859-864. [PMID: 31247125 DOI: 10.1111/ped.13924] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 05/03/2019] [Accepted: 06/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND End-of-life (EOL) care is an important topic in critical care medicine, but EOL discussions with families can be difficult and stressful for intensivists. The aim of this study was to clarify the current practices and barriers facing pediatric intensive care unit (PICU) EOL care and to identify the requisites for excellent PICU EOL care in Japan. METHODS A survey was conducted in 29 facilities across Japan in 2016. The questionnaire consisted of 19 multiple-choice questions and one open-ended question. RESULTS Twenty-seven facilities responded to the survey. Only 19% had educational programs on EOL care for fellows or residents. Although 21 hospitals (78%) had a multidisciplinary palliative care team, only eight of these teams were involved in EOL care in PICUs. Mental health care for health-care providers provided by a psychiatrist was rare (4%). The free comments were categorized as individual, team, environment, legal/ethics, or culture. Commonly raised individual issues included "lack of experience and knowledge about EOL care", "fear of making the decision to end care", and "reluctance to be involved in EOL care because of its complex process". Team issues included "insufficient frequency of conferences" and "non-multidisciplinary approach". Legal and ethics issues were "lack of legal support" and "fear of lawsuits". CONCLUSIONS This study is the first to investigate the current conditions and barriers in PICU EOL care in Japan. Most of the facilities involved were not satisfied with current practices. A need was identified for relevant educational programs, as well as the importance of multidisciplinary and legal support.
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Affiliation(s)
- Yusuke Seino
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Yuko Shiima
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Takehiro Niitsu
- Depertment of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
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Rajasekaran S, Kort E, Hackbarth R, Davis AT, Sanfilippo D, Fitzgerald R, Zuiderveen S, Ndika AN, Beauchamp H, Olivero A, Hassan N. Red cell transfusions as an independent risk for mortality in critically ill children. J Intensive Care 2016; 4:2. [PMID: 26744626 PMCID: PMC4704419 DOI: 10.1186/s40560-015-0122-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/29/2015] [Indexed: 01/28/2023] Open
Abstract
Background Severity of illness is an important consideration in making the decision to transfuse as it is the sicker patient that often needs a red cell transfusion. Red blood cell (RBC) transfusions could potentially have direct effects and interact with presenting illness by contributing to pathologies such as multi-organ dysfunction and acute lung injury thus exerting a considerable impact on overall morbidity and mortality. In this study, we examine if transfusion is an independent predictor of mortality, or if outcomes are merely a result of the initial severity as predicted by Pediatric Risk of Mortality (PRISM) III, Pediatric Index of Mortality (PIM2), and day 1 Pediatric Logistic Organ Dysfunction (PELOD) scores. Methods A single center retrospective study was conducted using data from a prospectively maintained transfusion database and center-specific data at our pediatric ICU between January 2009 and December 2012. Multivariate regression was used to control for the effects of clinical findings, therapy, and severity scores, with mortality as the dependent variable. Likelihood ratios and area under the curve were used to test the fidelity of severity scores by comparing transfused vs. non-transfused patients. Results There were 4975 admissions that met entry criteria. In multivariate analysis, PRISM III scores and serum hemoglobin were significant predictors of transfusion (p < 0.05). Transfused and non-transfused subjects were distinctly disparate, so multivariate regression was used to control for differences. Severity scores, age, volume transfused, and vasoactive agents were significantly associated with mortality whereas hemoglobin was not. A substantial number of transfusions (45 %) occurred in the first 24 h, and patients transfused later (24–48 h) were more likely to die compared to this earlier time point. Likelihood ratio testing revealed statistically significant differences in severity scoring systems to predict mortality in transfused vs. non-transfused patients. Conclusions This study suggests that RBC transfusion is an important risk factor that is statistically independent of severity. The timing of transfusions that related strongest to mortality remained outside the purview of severity scoring, as these happened beyond the timing of data collection for most scoring systems.
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Affiliation(s)
- Surender Rajasekaran
- Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA
| | - Eric Kort
- Department of Pediatric Hospitalists, Helen DeVos Children's Hospital, Grand Rapids, MI USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA
| | - Richard Hackbarth
- Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA
| | - Alan T Davis
- Department of Research, Grand Rapids Medical Education Partners and Michigan State University, Grand Rapids, MI USA ; Department of Surgery, Michigan State University, Grand Rapids, MI USA
| | - Dominic Sanfilippo
- Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA
| | - Robert Fitzgerald
- Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA
| | - Sandra Zuiderveen
- Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA
| | - Akunne N Ndika
- Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA
| | - Hilary Beauchamp
- Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA
| | - Anthony Olivero
- Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA
| | - Nabil Hassan
- Department of Pediatric Critical Care Medicine, Helen DeVos Children's Hospital, 100 Michigan St N.E., Grand Rapids, MI 49503 USA ; Department of Pediatrics, Michigan State University College of Human Medicine. Grand Rapids, Grand Rapids, MI USA
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Meert KL, Keele L, Morrison W, Berg RA, Dalton H, Newth CJL, Harrison R, Wessel DL, Shanley T, Carcillo J, Clark A, Holubkov R, Jenkins TL, Doctor A, Dean JM, Pollack M. End-of-Life Practices Among Tertiary Care PICUs in the United States: A Multicenter Study. Pediatr Crit Care Med 2015; 16:e231-8. [PMID: 26335128 PMCID: PMC4562059 DOI: 10.1097/pcc.0000000000000520] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe variability in end-of-life practices among tertiary care PICUs in the United States. DESIGN Secondary analysis of data prospectively collected from a random sample of patients (n = 10,078) admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 4, 2011, and April 7, 2013. SETTING Seven clinical centers affiliated with the Collaborative Pediatric Critical Care Research Network. PATIENTS Patients included in the primary study were less than 18 years old, admitted to a PICU, and not moribund on PICU admission. Patients included in the secondary analysis were those who died during their hospital stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred and seventy-five (2.7%; range across sites, 1.3-5.0%) patients died during their hospital stay; of these, 252 (92%; 76-100%) died in a PICU. Discussions with families about limitation or withdrawal of support occurred during the initial PICU stay for 173 patients (63%; 47-76%; p = 0.27) who died. Of these, palliative care was consulted for 67 (39%; 12-46%); pain service for 11 (6%; 10 of which were at a single site); and ethics committee for six (3%, from three sites). Mode of death was withdrawal of support for 141 (51%; 42-59%), failed cardiopulmonary resuscitation for 53 (19%; 12-28%), limitation of support for 46 (17%; 7-24%), and brain death for 35 (13%; 8-20%); mode of death did not differ across sites (p = 0.58). Organ donation was requested from 101 families (37%; 17-88%; p < 0.001). Of these, 20 donated (20%; 0-64%). Sixty-two deaths (23%; 10-53%; p < 0.001) were medical examiner cases. Of nonmedical examiner cases (n = 213), autopsy was requested for 79 (37%; 17-75%; p < 0.001). Of autopsies requested, 53 (67%; 50-100%) were performed. CONCLUSIONS Most deaths in Collaborative Pediatric Critical Care Research Network-affiliated PICUs occur after life support has been limited or withdrawn. Wide practice variation exists in requests for organ donation and autopsy.
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Affiliation(s)
- Kathleen L Meert
- 1Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI. 2Department of Anesthesia and Critical Care Medicine, Valley Children's Hospital, Madera, CA. 3Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA. 4Department of Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ. 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA. 6Department of Pediatrics, Mattel Children's Hospital at University of California at Los Angeles, Los Angeles, CA. 7Department of Pediatrics, Children's National Medical Center, Washington, DC. 8Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, MI. 9Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 10Department of Pediatrics, University of Utah School of Medicine, University of Utah, Salt Lake City, UT. 11Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD. 12Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO
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Mitchell S, Dale J. Advance Care Planning in palliative care: a qualitative investigation into the perspective of Paediatric Intensive Care Unit staff. Palliat Med 2015; 29:371-9. [PMID: 25721360 DOI: 10.1177/0269216315573000] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The majority of children and young people who die in the United Kingdom have pre-existing life-limiting illness. Currently, most such deaths occur in hospital, most frequently within the intensive care environment. AIM To explore the experiences of senior medical and nursing staff regarding the challenges associated with Advance Care Planning in relation to children and young people with life-limiting illnesses in the Paediatric Intensive Care Unit environment and opportunities for improvement. DESIGN Qualitative one-to-one, semi-structured interviews were conducted with Paediatric Intensive Care Unit consultants and senior nurses, to gain rich, contextual data. Thematic content analysis was carried out. SETTING/PARTICIPANTS UK tertiary referral centre Paediatric Intensive Care Unit. Eight Paediatric Intensive Care Unit consultants and six senior nurses participated. FINDINGS Four main themes emerged: recognition of an illness as 'life-limiting'; Advance Care Planning as a multi-disciplinary, structured process; the value of Advance Care Planning and adverse consequences of inadequate Advance Care Planning. Potential benefits of Advance Care Planning include providing the opportunity to make decisions regarding end-of-life care in a timely fashion and in partnership with patients, where possible, and their families. Barriers to the process include the recognition of the life-limiting nature of an illness and gaining consensus of medical opinion. Organisational improvements towards earlier recognition of life-limiting illness and subsequent Advance Care Planning were recommended, including education and training, as well as the need for wider societal debate. CONCLUSIONS Advance Care Planning for children and young people with life-limiting conditions has the potential to improve care for patients and their families, providing the opportunity to make decisions based on clear information at an appropriate time, and avoid potentially harmful intensive clinical interventions at the end of life.
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Affiliation(s)
- Sarah Mitchell
- Birmingham Children's Hospital, Birmingham, UK Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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Siddiqui NUR, Ashraf Z, Jurair H, Haque A. Mortality patterns among critically ill children in a Pediatric Intensive Care Unit of a developing country. Indian J Crit Care Med 2015; 19:147-50. [PMID: 25810609 PMCID: PMC4366912 DOI: 10.4103/0972-5229.152756] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND AIM Advances in biomedical technology have made medical treatment to be continued beyond a point, at which it does not confer an advantage but may increase the suffering of patients. In such cases, continuation of care may not always be useful, and this has given rise to the concept of limitation of life-sustaining treatment. Our aim was to study mortality patterns over a 6-year period in a Pediatric Intensive Care Unit (PICU) in a developing country and to compare the results with published data from other countries. MATERIALS AND METHODS Retrospective cohort study was conducted in a PICU of a tertiary care hospital in Pakistan. Data were drawn from the medical records of children aged 1-month - 16 years of age who died in PICU, from January 2007 to December 2012. RESULTS A total of 248 (from an admitted number of 1919) patients died over a period of 6 years with a mortality rate 12.9%. The median age of children who died was 2.8 years, of which 60.5% (n = 150) were males. The most common source of admission was from the emergency room (57.5%, n = 143). The most common cause of death was limitation of life-sustaining treatment (63.7%, n = 158) followed by failed cardiopulmonary resuscitation (28.2%, n = 70) and brain death (8.1%, n = 20). We also found an increasing trend of limitation of life-sustaining treatment do-not-resuscitate (DNR) over the 6-year reporting period. CONCLUSION We found limitation of life support treatment (DNR + Withdrawal of Life support Treatment) to be the most common cause of death, and parents were always involved in the end-of-life care decision-making.
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Affiliation(s)
- Naveed-ur-Rehman Siddiqui
- From: Department of Pediatric and Child Health, Aga Khan University Medical College, Karachi, Pakistan
| | - Zohaib Ashraf
- Aga Khan University Medical College, Karachi, Pakistan
| | - Humaira Jurair
- From: Department of Pediatric and Child Health, Aga Khan University Medical College, Karachi, Pakistan
| | - Anwarul Haque
- From: Department of Pediatric and Child Health, Aga Khan University Medical College, Karachi, Pakistan
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Wilkinson D. Which newborn infants are too expensive to treat? Camosy and rationing in intensive care. JOURNAL OF MEDICAL ETHICS 2013; 39:502-506. [PMID: 23355229 DOI: 10.1136/medethics-2012-100745] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Are there some newborn infants whose short- and long-term care costs are so great that treatment should not be provided and they should be allowed to die? Public discourse and academic debate about the ethics of newborn intensive care has often shied away from this question. There has been enough ink spilt over whether or when for the infant's sake it might be better not to provide life-saving treatment. The further question of not saving infants because of inadequate resources has seemed too difficult, too controversial, or perhaps too outrageous to even consider. However, Roman Catholic ethicist Charles Camosy has recently challenged this, arguing that costs should be a primary consideration in decision-making in neonatal intensive care. In the first part of this paper I will outline and critique Camosy's central argument, which he calls the 'social quality of life (sQOL)' model. Although there are some conceptual problems with the way the argument is presented, even those who do not share Camosy's Catholic background have good reason to accept his key point that resources should be considered in intensive care treatment decisions for all patients. In the second part of the paper, I explore the ways in which we might identify which infants are too expensive to treat. I argue that both traditional personal 'quality of life' and Camosy's 'sQOL' should factor into these decisions, and I outline two practical proposals.
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Affiliation(s)
- Dominic Wilkinson
- Robinson Institute, Discipline of Obstetrics and Gynecology, University of Adelaide, North Adelaide, South Australia, Australia.
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11
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[Prolonged stay in pediatric intensive care units: mortality and healthcare resource consumption]. Med Intensiva 2011; 35:417-23. [PMID: 21620524 DOI: 10.1016/j.medin.2011.04.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 04/04/2011] [Accepted: 04/06/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To analyze mortality and resource consumption in patients with long stays in pediatric intensive care units (PICUs). DESIGN A retrospective, descriptive case series study. SCOPE Medical-surgical PICU in a third level hospital. PATIENTS Data were collected from patients with a stay of 28 days or more in PICU between 2006 and 2010. Of the 2118 patients assisted in this period, 83 (3.9%) required prolonged stay. STUDY VARIABLES Morbidity-mortality and resource consumption among patients with prolonged stay in the PICU. RESULTS Mortality was higher in patients with a long stay (22.9%) than in the rest of patients (2%) (p<0.001). In 52.6% of these patients, death occurred after withdrawal of treatment or after not starting resuscitation measures. Patients with prolonged stay showed a high incidence of nosocomial infection (96.3%) and an important consumption of healthcare resources (97.6% required conventional mechanical ventilation, 90.2% required transfusion of blood products, 86.7% required intravenous vasoactive drugs and 22.9% required extracorporeal membrane oxygenation [ECMO]). CONCLUSIONS Critical children with prolonged stay in the PICU show important morbidity and mortality, and an important consumption of healthcare resources. The adoption of specific measures permitting early identification of patients at risk of prolonged stay is needed in order to adapt therapeutic measures and available resources, and to improve treatment efficiency.
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Abstract
O estudo teve por objetivo descrever os antecedentes, atributos e conseqüências do conceito de morte digna da criança. Utilizou-se a estratégia de análise de conceito para avaliar os 40 artigos, tendo como foco publicações nas áreas médica e de enfermagem, que estudaram ou focalizaram a morte digna da criança. Os atributos do conceito de morte digna da criança incluem: qualidade de vida, cuidado centrado na criança e na família, conhecimento específico sobre cuidados paliativos, decisão compartilhada, alívio do sofrimento da criança, comunicação clara, relacionamento de ajuda e ambiente acolhedor. Poucos artigos trazem a definição de morte digna da criança e, quando isso ocorre, essa definição é vaga e, muitas vezes, ambígua entre os vários autores. Esse aspecto indica que o conceito ainda não é consistentemente definido, demandando estudos de sua manifestação na prática clínica, contribuindo com os cuidados no final da vida em pediatria.
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14
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Moore P, Kerridge I, Gillis J, Jacobe S, Isaacs D. Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature. J Paediatr Child Health 2008; 44:404-8. [PMID: 18638332 DOI: 10.1111/j.1440-1754.2008.01353.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine withdrawal and limitation of life-sustaining treatment (WLST) in an Australian paediatric intensive care unit (PICU) and to compare this experience with published data from other countries. DESIGN Retrospective chart review and literature review. SOURCE OF DATA Review of 12 months of patient records from a tertiary Australian children's teaching hospital. Medline search using relevant key words focusing on death and PICU. RESULTS Twenty of 27 deaths (74%) followed either WLST (n = 16) or Do Not Resuscitate (DNR) orders (n = 4); five children failed cardiopulmonary resuscitation (CPR); and two children were brain-dead. Meetings between the medical team and family were documented for 15 of 16 children (93.8%) before treatment was withdrawn. The average time between withdrawal of life support and death was 13 min. A review of the English-language literature revealed that 18-65% occurring in PICUs worldwide follow WLST and/or institution of DNR orders. Rates were higher (30-65%) in North America and Europe than elsewhere. Most PICU deaths occurred within 3 days of admission. North American and British parents appear to be involved in decisions regarding withdrawal and limitation of treatment more often than parents in other countries. CONCLUSIONS Withdrawal and limitation of life-sustaining treatment was more common in an Australian children's hospital ICU than has been reported from other countries. Details of discussion with parents, including the basis for any decision to WLST, were almost always documented in the patient's medical record.
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Abstract
The Baby Doe rules, a set of federal regulations on the treatment of extremely ill infants, went into effect in 1985. Some scholars have argued that these rules are inappropriate given that they fail to pay attention to the patient's suffering. Instead, researchers suggest that, when dealing with a severely impaired infant, the best-interest standard be used. Other ethicists have found the best-interest standard also insufficient, deeming it to be supported by weak arguments rooted on the beholder's beliefs. In this article, alternative viewpoints that might be used to complement the best-interest standard and help support the rights of severely impaired infants to a natural and dignified death are reviewed. The use of palliative instead of intensive care for severely impaired newborns is also considered.
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Affiliation(s)
- Pedro Weisleder
- Division of Pediatric Neurology, Duke University Medical Center, Durham, NC, USA.
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Abstract
Patients and families in NICU and PICU settings can be well served by fundamental palliative care approaches during curative and end-of-life care.A wide variety of patients are suitable for these services. Although barriers exist to implementing these teams within the ICU, the concepts remain sound,and models for successful integration of practices in these settings exist.
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Affiliation(s)
- Brian S Carter
- Pediatric Advance Comfort Team, Department of Pediatrics, Vanderbilt Children's Hospital (Neonatology), 11111 Doctor's Office Tower, Nashville, TN 37232-9544, USA
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17
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Abstract
BACKGROUND Over recent years, there have been increasing concerns regarding an increase in the number of futile and inappropriate admissions to pediatric intensive care units (PICUs) in the United Kingdom (UK). METHODS A prospective cross-sectional survey was carried out using a data collection form distributed by mail to the directors of all PICUs in the UK. Respondents were asked to give details of all patients on their unit on a specific day including age, reason for admission and any preexisting medical conditions. An assessment was made by respondents of whether the care being provided in each case was, in their opinion, appropriate, futile or inappropriate according to standard definitions. RESULTS We received responses from 21 units (68%) who reported the details of 111 patients. Care was felt to be appropriate in 88 of these cases (79%), futile in nine cases (8%) and inappropriate in 14 cases (13%). Futile cases were most commonly admitted with respiratory failure and all had preexisting medical conditions, most commonly developmental delay. Where care was felt to be inappropriate, respiratory failure was again the most common reason for admission and all had a preexisting medical condition, most commonly cardiovascular disease. CONCLUSIONS The care being provided in 21% of the PICU cases, described in this study, was felt to be either futile or inappropriate by the directors of those units. There is an urgent need to, accurately, establish the resource consumption associated with these patients and to establish a standard approach to futility and inappropriate care in PICU in the UK.
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Affiliation(s)
- Gopi Vemuri
- Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK
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18
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19
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Hopkins S. Withholding or withdrawing intensive care treatment in paediatric bone marrow transplant: A moral maze. Eur J Oncol Nurs 2005; 9:202-3. [PMID: 16048745 DOI: 10.1016/j.ejon.2005.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Briassoulis G, Filippou O, Natsi L, Mavrikiou M, Hatzis T. Acute and chronic paediatric intensive care patients: current trends and perspectives on resource utilization. QJM 2004; 97:507-18. [PMID: 15256608 DOI: 10.1093/qjmed/hch087] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Advances in paediatric critical care have resulted in increased survival of critically ill patients, many of whom require long-term ventilation as a means of life support. AIM To determine current trends in resource utilization, and problems in the care of acute and chronic paediatric intensive care patients. DESIGN Open observational study. METHODS We evaluated consecutive admissions (n = 1629) to a 10-bed paediatric intensive care unit (PICU) over a 5-year period. Three previously defined criteria for resource utilization were used: mean length of stay (LOS); length of mechanical ventilation (LOMV); and LOMV/LOS ratio. RESULTS A total of 10 310 patient bed days and 5223 ventilator days were used. Mean LOS increased from 5.3 +/- 12 days in 1998 to 8.7 +/- 27 days in 2001 (p < 0.05). Although LOMV/LOS ratio (50.7%) was significantly correlated with Paediatric Risk of Mortality score (p < 0.0001), there was no significant change in mortality rate (12.6% vs. 12%). Patients hospitalized for >2 weeks (n = 320, 20%) used 55% of LOS and 57% of LOMV, in contrast to the 1298 (80%) hospitalized for <7 days, who used only 29% of LOS and 20% of LOMV. Patients hospitalized for >3 months (11, 0.7%) consumed 17% of LOS and 23% of LOMV. Five of these (45%) were eventually discharged home, two on ventilators. CONCLUSION The increasing trend of occupation of PICU bed and ventilator days by critically ill children may be related to the increasing trend for hospitalization of chronic care patients. Severity scoring systems were predictive of resource consumption, but not of the overall trend in mortality rate.
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Affiliation(s)
- G Briassoulis
- Pediatric Intensive Care Unit, 'Aghia Sophia' Children's Hospital, Thivon & Levadias street, Goudi 11527, Athens, Greece.
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Tomlinson T, Michalski AJ, Pentz RD, Kuuppelomäki M. Futile care in oncology: when to stop trying. Lancet Oncol 2001; 2:759-64. [PMID: 11902519 DOI: 10.1016/s1470-2045(01)00592-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- T Tomlinson
- Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing, USA.
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