Modos de morir en la Unidad de Cuidados Intensivos de niños del Hospital Pediátrico del Centro Hospitalario Pereira Rossell

Marta Alberti; Rosario Lores; Amanda Menchaca

Authors

Marta Alberti Universidad de la República, Facultad de Medicina, Cátedra de Pediatría Intensiva, Profesora Directora
Rosario Lores Universidad de la República, Facultad de Medicina, Cátedra de Pediatría Intensiva, Colaboradora Calificada, Licenciada en Psicología
Amanda Menchaca Universidad de la República, Facultad de Medicina, Cátedra de Pediatría Intensiva, Profesora Agregada

Keywords:

PEDIATRIC INTENSIVE CARE UNITS, WITHHOLDING TREATMENT, DECISSION MAKING, TERMINAL CARE, CAUSE OF DEATH, ETHICS, BIOETHICS

Abstract

Introduction: studying the modes of death in children hospitalized in the pediatric intensive care unit is essential for the ethical handling of application and limitation of technology.
Objective: to describe the modes of death and factors leading to withdrawal or limitation of life support in a pediatric intensive care unit and to contribute to the selection of a more humane end-of-life process.
Method: we conducted a prospective observational study which included infants dying from January 1, 2005 to June 30, 2007. Deaths were classified into four categories: ineffective cardiopulmonary resuscitation (CPR), no cardiopulmonary resuscitation (CPR), limitation or withdrawal of life support and brain death.
We applied a chi-square test of qualitative variables, analysis of variance of quantitative variables and polynomial logistics regression.
Results: 129 cases. The modes of death proportion was: CPR- 51%; no CPR - 12%; limitation or withdrawal of life support - 15.5% and brain death - 21%. Age, length of stay and chronic disease were significant factors that influenced the modes of death. Family members participated in 76% of the decisions made. As to the limitation of life support modality, in 75% of cases it was interrupted and in 20 % of cases it was not initiated.
Conclusions: Most patients received cardiopulmonary resuscitation. Age, length of stay and chronic disease had a significant influence on the modes of death. Upon the limitation of therapeutic efforts, the length of stay was longer, as well as in the case of chronic disease. Withdrawal of treatment prevailed over noninitiation of life support. The participation of family members in making a life or death decision was high.

References

(1) Aarons E, Beeching N. Survey of "do not resuscitate" orders in a district general hospital. BMJ 1991; 303: 1504-6.
(2) Faber-Langendoen K, Bartels D. Process of forgoing life-sustaining treatment in a university hospital: an empirical study. Crit Care Med 1992; 20: 570-7.
(3) Prendergast TC, Luce JM. Increasing incidente of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Med 1997; 155: 15-20.
(4) Ryan C, Byrne P, Kuhn S, Tyebkhan J. No resuscitation and withdrawal of therapy in a neonatal and a pediatric intensive care unit in Canada. J Pediatr 1993; 123: 534-8.
(5) Mink R, Pollack M. Resuscitation and withdrawal of therapy in pediatric intensive care. Pediatrics 1992; 89: 961-3.
(6) Vernon DD, Dean JM, Timmons OD, Banner W Jr, Allen-Webb EM. Modes of death in the pediatric intensive care: withdrawal and limitation of supportive care. Crit Care Med 1993; 21: 1798-802.
(7) Lantos J, Berger A, Zucker A. Do not resuscitate orders in a children’s hospital. Cit Care Med 1993; 21: 52-5.
(8) Levetown M, Pollak MM, Cuerdon TT, Ruttimann UE, Glover JJ. Limitations and withdrawals of medical intervention in pediatric critical care. JAMA 1994; 272: 1271-5.
(9) Martinot A, Lejeune C, Hue V, Fourier C, Beyaert C, Diependaele JF, et al. Modalités et causes de 259 decées dans un service de réanimation pédiatrique. Arch Pediatr 1995; 2: 735-41.
(10) Martinot A, Grandbastien B, Leteutre S, Duhamel A, Leclerc F. et al. No resucitation orders in withdrawal of therapy in French pediatric intensive care units. Acta Paedriatr 1998; 87: 769-73.
(11) Devictor DJ, Nguyen DT, Groupe Francophone de Réanimation et d´Urgences Pédiatriques. Forgoing live-sustaining treatments: how decision is made in French pediatric intensive care units. Crit Care Med 2001; 29: 1356-9.
(12) Devictor D, Nguyen D. Forgoing live-sustaining treatments in children: a comparison between Northern and Southern European pediatric intensive care units. Pediatr Crit Care Med 2004; 5: 211-5.
(13) Althabe M, Cardigni G, Vasallo J, Allende D, Berrueta M, Codermatz M, et al. Dying in the intensive care unit: collaborative multicenter study about forgoing life-sustaining treatment in Argentine pediatric intensive care units. Pediatr Crit Care Med 2003; 4: 164-9.
(14) Carvalho P, Rocha T, Santo A, Lago P. Modos de morrer na UTI pediátrica de um hospital terciario. Rev Assoc Med Brasil 2001; 47: 325-31.
(15) Kipper D, Martin L, Fabbro L. Decisões médicas envolvendo o fim da vida – o desafio de adequar as leis às exigências éticas. J Pediatr (Rio J) 2000; 76: 403-6.
(16) Lago PM, Piva J, Kipper D, Garcia PC, Pretto C, Giongo M, et al. Limitação de suporte de vida em três unidades terapia intensiva pediátrica do sul do Brasil. J Pediatr (Rio J) 2005; 81: 111-7.
(17) Kipper DJ. Final de vida em crianças: aspectos técnicos e bioéticos. Porto Alegre: EDIPUCRS 2007.
(18) Agresti A. Categorical data analysis. 2ed. New Jersey: John Wiley & Sons, 2002: 710 p.
(19) Zar JH. Biostatistical analysis. New Jersey: Prentice Hall, 1996.
(20) Hosmer DW, Lemeshow S. Applied logistic regression. New York: John Wiley & Sons, 1989: 307 p.
(21) Trenchs Sáinz de la Maza V, Cambra Lasaosa FJ, Palomeque Rico A, Balcells Ramírez J, Seriñá Ramírez C, Hermana Tezanos MT, et al. Limitación terapéutica en cuidados intensivos. An Esp Pediatr 2002; 57: 511-7.
(22) Kipper D, Piva J, García P, Einloft P, Bruno F, Lago P, et al. Evolution of the medical practices en mode of death on pediatric intensive care unit in southern Brazil. Pediatr Crit Care Med 2005; 6: 258-63.
(23) Garros D. A "good" death in a pediatric ICU: is it possible? J Pediatr (Rio J) 2003; 79 (Suppl 2): S243-54.
(24) Cantegrel S, Ducrocq S, Chedeville G, Marchand S. Mortalité dans un hôpital pédiatrique. Étude rétrospective sur six ans. Arch Pediatr 2000; 7: 725-31.
(25) Lago PM, Devictor D, Piva JP, Bergounioux J. End-of-life care in children: the Brazilian and the international perspectives. J Pediatr (Rio J) 2007; 83(2 Suppl): S110-16.
(26) Garros D, Rosychuck R, Cox P. Circumstances surrounding end of life in a pediatric intensive care unit. Pediatrics 2003; 112: 371-9.
(27) Zawistowski C, De Vita M. A descriptive study of children in the pediatric intensive care unit after withdrawal of life-sustaining treatment. Pediatr Crit Care Med 2004; 5: 216-23.
(28) Meyer E, Burns J, Griffith J, Troug R. Parenteral perspectives on end-of-life care in the pediatric intensive care unit. Crit Care Med 2002; 30: 226-31.
(29) American Academy of Pediatrics Committee on Bioethics. Guidelines on foregoing life-sustaining medical treatment. Pediatrics 1994; 93: 532-6.
(30) Ethics and the care of critically ill infants and children. American Academy of Pediatrics Committee on Bioethics. Pediatrics 1996; 98: 149-52.
(31) Burns J, Mitchell C, Outwater K, Geller M, Griffith JL, Todres ID, et al. End-of-life in the pediatric intensive care unit after the forgoing of life-sustaining treatment. Crit Care Med 2000; 28: 3060-6.