[Attitudes and needs of pediatric intensivists in relation to the death of their patients]

Quality of Care in Pediatric Palliative Care: A Scoping Review

Palliative care (PC) enhances the quality of life for patients and families facing life-threatening conditions. While PC is well-established for adults, not all practices apply to pediatrics. Consequently, specific quality indicators for Pediatric Palliative Care (PPC) must be identified. This scoping review aimed to identify the variables associated with the quality of care of PPC patients in Spain, focusing specifically on three areas: structure and process of care, psychological aspects of care, and care of patients approaching the end of life. The review was conducted following PRISMA-ScR guidelines. Searches were performed in the PubMed, Scopus, Web of Science, Embase, ProQuest, and Dialnet databases covering the period extending from January 2000 to May 2023. Finally, 35 studies were identified for the complete review. A total of 30 studies include variables associated with the structure and process of care, 20 include variables associated with psychological aspects of care, and 23 studies integrate variables related to patient care at the end of life. Analysis suggests that enhancing professional training in aspects such as communication with patients and families, creating intimate spaces with flexible visiting hours, increasing emotional support, promoting frequent contact with healthcare teams, and transparently communicating about illness and imminent death to both families and minors could improve the quality of PPC.

How Do Children Die in PICUs Nowadays? A Multicenter Study From Spain

OBJECTIVES

To describe how children currently die in Spanish PICUs, their epidemiologic characteristics and clinical diagnoses.

DESIGN

Prospective multicenter observational study.

SETTING

Eighteen PICUs participating in the MOdos de Morir en UCI Pediátrica-2 (MOMUCI-2) study in Spain.

PATIENTS

Children 1 to 16 years old who died in PICU during 2017 and 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the 2-year study period, 250 deaths were recorded. Seventy-three children (29.3%) were younger than 1 year, 131 (52.6%) were between 1 and 12 years old, and 45 (18.1%) were older than 12. One-hundred eighty patients (72%) suffered from an underlying chronic disease, 54 (21.6%) had been admitted to PICU in the past 6 months, and 71 (28.4%) were severely disabled upon admission. Deaths occurred more frequently on the afternoon-night shift (62%) after a median PICU length of stay of 3 days (1-12 d). Nearly half of the patients died (48.8%) after life-sustaining treatment limitation, 71 died (28.4%) despite receiving life-sustaining therapies and cardiopulmonary resuscitation, and 57 (22.8%) were declared brain dead. The most frequent type of life-sustaining treatment limitation was the withdrawal of mechanical ventilation (20.8%), followed by noninitiation of cardiopulmonary resuscitation (18%) and withdrawal of vasoactive drugs (13.7%). Life-sustaining treatment limitation was significantly more frequent in patients with an underlying neurologic-neuromuscular disease, respiratory disease as the cause of admission, a previous admission to PICU in the past 6 months, and severe disability. Multivariate analyses indicated that life-sustaining treatment limitation, chronicity, and poor Pediatric Cerebral Performance Category score were closely related.

CONCLUSIONS

Currently, nearly half of the deaths in Spanish PICUs occur after the withdrawal of life-sustaining treatments. These children are more likely to have had previous admissions to the PICU, be severely disabled or to suffer from chronic diseases. Healthcare professionals who treat critically ill children ought to be aware of this situation and should therefore be prepared and trained to provide the best end-of-life care possible.

Suitability of therapeutic effort in paediatric intensive care units: Opinion and attitude of professionals

OBJECTIVE

To determine the opinion and describe the attitude of different health professionals on suitability of therapeutic effort.

METHOD

Multi-centre, cross-sectional observational study carried out with nurses and doctors who work in the paediatric intensive care units of four hospitals in the Madrid region. A self-administered questionnaire, previously piloted to assess its viability, was used and a sealed box was set up at the nursing station to hand it in. The analysis was performed using SPSS 21.0 software.

RESULTS

The 98.9% of the respondents were in favour of suitability of therapeutic effort. Doctors consider that the decision is made with the agreement of the multidisciplinary staff and the child's parents (48.8%). Of the nurses, 51.1% believe that the decision is made by agreement with the doctors and parents. Of the nurses, 65.5% state that they are never asked about decision-making for their patients. Of the doctors, 75% are always or almost always asked. Fifty-seven percent of the nurses and 83% of the doctors feel capable of making decisions about suitability of therapeutic effort. Of the professionals, 77.2% believe that suitability is used less often than required.

CONCLUSIONS

There are differences between doctors and nurses both in the perception of the decision-making model and in the way to proceed. Professionals seem not to follow any protocols or circuits in the decision-making process.

Dignified death: Concept development involving nurses and doctors in Pediatric Intensive Care Units

The aim of this study was to develop the concept of the dignified death of children in Brazilian pediatric intensive care units (PICUs). The Hybrid Model for Concept Development was used to develop a conceptual structure of dignified death in PICUs in an attempt to define the concept. The fieldwork study was carried out by means of in-depth interviews with nine nurses and seven physicians working in PICUs. Not unexpectedly, the concept of dignified death was found to be a complex phenomenon involving aspects related to decisions made by the multidisciplinary team as well as those related to care of the child and the family. Knowledge of the concept’s dimensions can promote reflection on the part of healthcare professionals regarding the values and beliefs underlying their conduct in end-of-life situations. Our hope is that this study may contribute to theoretic and methodological development in the area of end-of-life care.

[Anxiety of nursing staff in the face of death in critical care units and its relationship with the patients' age]

INTRODUCTION

Death is a biological and psychosocial process, in which many of the vital events extinguish in a gradual and silent sequence, this escaping simple observation. People live with the fear of death, however health care professionals are constantly faced with the death of other people and in continuous contact with this. This may negatively or positively affect their attitudes.

OBJECTIVE

To assess anxiety levels of the intensive care unit nurses in the face of death.

MATERIAL AND METHOD

This is an observational, descriptive cross-sectional study conduced in the Pediatric and Adult Intensive Care Unit (ICU) of the University Hospital General Gregorio Marañón. A Death Anxiety Inventory (DAI) was used for the assessment of anxiety in the presence of death.

RESULTS

The response rate was 86.9%. Mean age of participants was 38±9.25 years (range, 22-63). Mean working experience was 13±7.2 years (range, 35 years-7 months). The item having the highest level of anxiety was number 14-"I would like to live to an advanced age" (n=113; mean, 3.35±1.2). Statistically significant correlations (p=0.01) were found in the levels of anxiety between nurses of pediatric ICU and adult ICU in factor 1-"External generators of anxiety", this being higher in the pediatric ICU. A total of 77% of the professionals consider they are trained for the subject of death compared to 18.6% who do not.

CONCLUSIONS

The ICU professionals who attend to children have higher levels of anxiety and of considering that they are not trained for this than those attending adults.