 |
|
Limitations and Withdrawals of Medical Intervention in Pediatric Critical Care
Marcia Levetown, MD;
Murray M. Pollack, MD;
Timothy T. Cuerdon, PhD;
Urs E. Ruttimann, PhD;
Jacqueline J. Glover, PhD
JAMA. 1994;272(16):1271-1275.
Abstract
| |
Objective.
—To investigate the use and implementation in pediatric intensive care units (PICUs) of three levels of restriction of medical intervention: do not resuscitate (DNR), additional limitations of medical interventions beyond DNR, and withdrawal of care.
Design.
—Consecutive patients admitted between December 1989 and January 1992.
Setting.
—A total of 16 PICUs randomly selected to represent variability in size, teaching status, and presence or absence of a pediatric intensivist and unit coordination.
Main Outcome Measures.
—Profiles of children undergoing restrictions of medical interventions including the influence of chronic disease, the justifications for restrictions, and description of implementation practices.
Patients.
—All pediatric admissions undergoing restrictions (n=119) drawn from 5415 consecutive PICU admissions.
Results.
—A total of 94 (79%) of the restriction patients died during the PICU course, representing 38% of all deaths. A total of 73 restrictions (61%) resulted from acute disease, most involving the central nervous system or respiratory system. Restrictions were evenly divided between DNR (39%), additional limitations of medical intervention beyond DNR (27%), and withdrawals of medical intervention (34%). Survival decreased with increasing levels of restriction from 35% of DNR patients to 9% of patients with additional limitations and 2% of withdrawal patients. Imminent death was cited as the justification for restrictions in 70% of cases, no relational potential was cited in 22%, and excessive burden was cited in 8%.
Conclusions.
—Restrictions of medical intervention were used in all PICUs surveyed. Although severe chronic disease was common among restriction patients, acute disease was the predominant event precipitating placement of restrictions. Imminent death, not quality of life or excessive burden, was the most common justification.
(JAMA. 1994;272:1271-1275)
Author Affiliations
From the Department of Critical Care Medicine (Drs Levetown and Pollack), the Center for Health Services and Clinical Research, Children's Research Institute (Dr Pollack), and the Department of Pediatrics (Dr Cuerdon), Children's National Medical Center, Washington, DC; the Departments of Anesthesiology and Pediatrics (Drs Pollack and Cuerdon), Pediatrics (Dr Ruttimann), and Health Care Sciences (Dr Glover), The George Washington University School of Medicine, Washington, DC; and the National Institute on Alcohol Abuse and Alcoholism, the National Institutes of Health (Dr Ruttimann), Bethesda, Md. Dr Levetown is now with the Department of Pediatrics, University of Texas Medical Branch at Galveston. Dr Glover is a philosopher in residence with the Children's National Medical Center.
Footnotes
Reprint requests to Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010 (Dr Pollack).
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Parental Views on Withdrawing Life-Sustaining Therapies in Critically Ill Children
Michelson et al.
Arch Pediatr Adolesc Med 2009;163:986-992.
ABSTRACT
| FULL TEXT
Improving the Quality of End-of-Life Care in the Pediatric Intensive Care Unit: Parents' Priorities and Recommendations
Meyer et al.
Pediatrics 2006;117:649-657.
ABSTRACT
| FULL TEXT
Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit
Garros et al.
Pediatrics 2003;112:e371-371.
ABSTRACT
| FULL TEXT
Ethical debate: The distinction between withdrawing life sustaining treatment under the influence of paralysing agents and euthanasia Are we treading a fine line? Paralysing agents may be given up to but not at or beyond the point of extubation The parents' perspective on withdrawing treatment The doctrine of double effect is difficult but not impossible to apply
Street et al.
BMJ 2001;323:388-391.
FULL TEXT
The decision making process regarding the withdrawal or withholding of potential life-saving treatments in a children's hospital
Street et al.
J. Med. Ethics 2000;26:346-352.
ABSTRACT
| FULL TEXT
Ethical Issues Surrounding Limitation and Withdrawal of Support in the Pediatric Intensive Care Unit: Vose LA, Nelson RM Ethical issues surrounding limitation and withdrawal of support in the pediatric intensive care unit J Intensive Care Med 1999, 14 220-230
Vose and Nelson
J Intensive Care Med 1999;14:220-230.
Withdrawal and limitation of life support in paediatric intensive care
Goh et al.
Arch. Dis. Child. 1999;80:424-428.
ABSTRACT
| FULL TEXT
Advance Directives in a Pediatric Emergency Department
Walsh-Kelly et al.
Pediatrics 1999;103:826-830.
ABSTRACT
| FULL TEXT
Variability in Physician Opinion on Limiting Pediatric Life Support
Randolph et al.
Pediatrics 1999;103:46e-46.
ABSTRACT
| FULL TEXT
The Potential Benefits of the Pediatric Nonheartbeating Organ Donor
Koogler and Costarino Jr
Pediatrics 1998;101:1049-1052.
ABSTRACT
| FULL TEXT
Variability in Brain Death Determination Practices in Children
Mejia and Pollack
JAMA 1995;274:550-553.
ABSTRACT
|
