Ethical aspects in the management of the terminally ill patient in the pediatric intensive care unit

OBJECTIVE: To identify the prevalence of management plans and decision-making processes for terminal care patients in pediatric intensive care units. METHODOLOGY: Evidence-based medicine was done by a systematic review using an electronic data base (LILACS, 1982 through 2000) and (MEDLINE, 1966 through 2000). The key words used are listed and age limits (0 to 18 years) were used. RESULTS: One hundred and eighty two articles were found and after selection according to the exclusion/inclusion criteria and objectives 17 relevant papers were identified. The most common decisions found were do-not-resuscitation orders and withdrawal or withholding life support care. The justifications for these were "imminent death" and "unsatisfatory quality of life". CONCLUSION: Care management was based on ethical principles aiming at improving benefits, avoiding harm, and when possible, respecting the autonomy of the terminally ill patient.

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Difficulties in Providing Intensive Care

PEDIATRICS ◽

10.1542/peds.64.1.10 ◽

1979 ◽

Vol 64 (1) ◽

pp. 10-16

Author(s):

Joel E. Frader

Keyword(s):

Intensive Care ◽

Life Support ◽

Medical Science ◽

Pediatric Intensive Care ◽

Pilot Project ◽

Functional Responses ◽

Ethical Implications ◽

Catastrophic Illness ◽

Decision Making Processes ◽

American Society

The results of a pilot project investigating the feelings, attitudes, and behavior of physicians working in a pediatric intensive care unit are presented. With recent technologic advances in our capacity to help patients suffering from catastrophic illness, various segments of American society have become concerned about the unrestricted use of medical science. Questions have arisen about the economic costs, long-term medical out-come, emotional costs to patients and families, legal problems, and ethical implications of "heroic" therapy. By contrast, we have asked relatively few questions about the social processes involved in providing intensive care. We know little about the emotional and functional responses of the physicians in critical care facilities, and their decision making processes remain obscure. This investigation evolved from the conviction that environments comprised of sophisticated medical technology and extensive life support systems pose pressing problems for those working and learning in them.

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Alterations in End-of-Life Support in the Pediatric Intensive Care Unit

PEDIATRICS ◽

10.1542/peds.2010-0420d ◽

2010 ◽

Vol 127 (2) ◽

pp. peds.2010-0420d-peds.2010-0420d

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

End Of Life ◽

Pediatric Intensive Care Unit ◽

Life Support ◽

Pediatric Intensive Care

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Code Blue Events in the Neonatal and Pediatric Intensive Care Units at a Tertiary Care Children's Hospital

American Journal of Perinatology ◽

10.1055/s-0040-1719116 ◽

2020 ◽

Author(s):

Catherine M. Groden ◽

Erwin T. Cabacungan ◽

Ruby Gupta

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Life Support ◽

Univariate Analysis ◽

Tertiary Care ◽

Neonatal Resuscitation ◽

Advanced Life Support ◽

Pediatric Intensive Care ◽

Code Blue ◽

Neonatal Resuscitation Program

Objective The authors aim to compare all code blue events, regardless of the need for chest compressions, in the neonatal intensive care unit (NICU) versus the pediatric intensive care unit (PICU). We hypothesize that code events in the two units differ, reflecting different disease processes. Study Design This is a retrospective analysis of 107 code events using the code narrator, which is an electronic medical record of real-time code documentation, from April 2018 to March 2019. Events were divided into two groups, NICU and PICU. Neonatal resuscitation program algorithm was used for NICU events and a pediatric advanced life-support algorithm was used for PICU events. Events and outcomes were compared using univariate analysis. The Mann–Whitney test and linear regressions were done to compare the total code duration, time from the start of code to airway insertion, and time from airway insertion to end of code event. Results In the PICU, there were almost four times more code blue events per month and more likely to involve patients with seizures and no chronic condition. NICU events more often involved ventilated patients and those under 2 months of age. The median code duration for NICU events was 2.5 times shorter than for PICU events (11.5 vs. 29 minutes), even when adjusted for patient characteristics. Survival to discharge was not different in the two groups. Conclusion Our study suggests that NICU code events as compared with PICU code events are more likely to be driven by airway problems, involve patients <2 months of age, and resolve quickly once airway is taken care of. This supports the use of a ventilation-focused neonatal resuscitation program for patients in the NICU. Key Points

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Resuscitation and Withdrawal of Therapy in Pediatric Intensive Care

PEDIATRICS ◽

10.1542/peds.89.5.961 ◽

1992 ◽

Vol 89 (5) ◽

pp. 961-963

Author(s):

RICHARD B. MINK ◽

MURRAY M. POLLACK

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Neonatal Intensive Care ◽

Life Support ◽

Pediatric Intensive Care ◽

New Haven ◽

Hammersmith Hospital ◽

Hospital Deaths ◽

Withdrawal Of Therapy ◽

Haven Hospital

Although issues concerning withdrawal and limitation of life support are commonly discussed,1-6 actual practices in pediatrics are largely unknown and are limited to neonatal intensive care unit (ICU) studies. In the neonatal ICUs at Yale-New Haven Hospital and at Hammersmith Hospital, 14% and 30%, respectively, of all deaths followed withdrawal of care.7,8 In adult ICUs, limitation and/or withdrawal of therapy is common,9 and in one investigation, resuscitation was not attempted immediately before ICU death in nearly two-thirds of cases.10 Nonetheless, many physicians believe that most hospital deaths occur only after all resuscitative attempts have failed,6,11,12 and others believe that resuscitative efforts neither are indicated nor desirable in many cases.1,13

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Extracorporeal Membrane Oxygenation: The First 10 Years Experience of a Portuguese Pediatric Intensive Care Unit

Acta Médica Portuguesa ◽

10.20344/amp.15227 ◽

2021 ◽

Vol 34 (6) ◽

pp. 435

Author(s):

Daniel Meireles ◽

Francisco Abecasis ◽

Leonor Boto ◽

Cristina Camilo ◽

Miguel Abecasis ◽

...

Keyword(s):

Intensive Care Unit ◽

Overall Survival ◽

Intensive Care ◽

Pediatric Intensive Care Unit ◽

Pediatric Patients ◽

Life Support ◽

Extracorporeal Life Support ◽

Pediatric Intensive Care ◽

Overall Survival Rate ◽

Clinical Complications

Introduction: In Portugal, extracorporeal membrane oxygenation (ECMO) is used in pediatric patients since 2010. The aim of this study was to describe the clinical characteristics of patients, indications, complications and mortality associated with the use of ECMO during the first 10-years of experience in the Pediatric Intensive Care Unit located in Centro Hospitalar Universitário Lisboa Norte.Material and Methods: Retrospective observational cohort study of all patients supported with ECMO in a Pediatric Intensive Care Unit, from the 1st of May 2010 up to 31st December 2019.Results: Sixty-five patients were included: 37 neonatal (≤ 28 days of age) and 28 pediatric patients (> 28 days). In neonatal cases, congenital diaphragmatic hernia was the main reason for ECMO (40% of neonatal patients and 23% of total). Among pediatric patients, respiratory distress was the leading indication for ECMO (47% of total). The median length of ECMO support was 12 days. Clinical complications were more frequent than mechanical complications (65% vs 35%). Among clinical complications, access site bleeding was the most prevalent with 38% of cases. The overall patient survival was 68% at the time of discharge (65% for neonatal and 71% for pediatric cases), while the overall survival rate in Extracorporeal Life Support Organization registry was 61%. The number of ECMO runs has been increasing since 2011, even though in a non-linear way (three cases in 2010 to 11 cases in 2019).Discussion: In the first 10 years we received patients from all over the country. Despite continuous technological developments, circuitrelated complications have a significant impact. The overall survival rate in the Pediatric Intensive Care Unit was not inferior to the one reported by the Extracorporeal Life Support Organization.Conclusion: The overall survival of our Pediatric Intensive Care Unit is not inferior to one reported by other international centers. Our experience showed the efficacy of the ECMO technique in a Portuguese centre.

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