Goal-Concordance in Children with Complex Chronic Conditions
Hospice Care; Terminal Care; Child; Chronic Disease; Goals; Humans; Only Child; Resuscitation Orders
Abstract Objectives: To characterize delivery of goal-concordant end-of-life (EOL) care among children with complex chronic conditions and to determine factors associated with goal-concordance. Study design: This was a retrospective review of goals of care discussions for 272 children with at least 1 complex chronic condition who died at a tertiary care hospital between January 1, 2014, and December 31, 2017. Goals of care and code status were assessed before and within the last 72 hours of life. Goals of care discussions were coded as full interventions; considering withdrawal of interventions (palliation); planned transition to palliation; or actively transitioning/transitioned to palliation. Results: In total, 158 children had documented goals of care discussions before and within the last 72 hours of life, 18 had goals of care discussions only >72 hours before death, 54 only in the last 72 hours of life, and 42 had no documented goals of care. For children with goals of care, EOL care was goal-concordant for 82.2%, discordant in 7%, and unclear in 10.8%. Black children had a greater than 8-fold greater odds of discordant care compared with White children (OR 8.34, P = .007). Comparison of goals of care and code status before and within the last 72 hours of life revealed trends toward nonescalation of care. Specifically, rates of active palliation increased from 11.7% to 63.0%, and code status shifted from 32.6% do not resuscitate to 65.2% (P < .001). Conclusions: In this cohort, a majority of children had documented goals of care discussions and received goal-concordant EOL care. However, Black children had greater odds of receiving goal-discordant care. Goals of care and code status shifted toward palliation during the last 72 hours of life.
Harmon A; Jordan M; Platt A; Wilson J; Keith K; Chandrashekaran S; Schlichte L; Pendergast J; Ming D
The Journal of Pediatrics
2023
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.jpeds.2022.10.003" target="_blank" rel="noreferrer noopener">10.1016/j.jpeds.2022.10.003</a>
Polypharmacy among Pediatric Cancer Patients Dying In the Hospital
Child; Female; Humans; Male; Resuscitation Orders; Demography; Health Services Research; Hospitalization/statistics & numerical data; Neoplasm Staging; Antineoplastic Agents/therapeutic use; Neoplasms/drug therapy/mortality/pathology; Palliative Care/methods/statistics & numerical data; Polypharmacy; Terminal Care/methods/statistics & numerical data; Critical Pathways/statistics & numerical data; Israel/epidemiology; Steroids/therapeutic use
BACKGROUND: Decisions on medication treatment in children dying from cancer are often complex and may result in polypharmacy and increased medication burden. There is no information on medication burden in pediatric cancer patients at the end of life (EOL). OBJECTIVES: To characterize medication burden during the last hospitalization in children dying from cancer. METHODS: We performed a retrospective cohort study based on medical records of 90 children who died from cancer in hospital between 01 January 2010 and 30 December 2018. Demographic and clinical information were collected for the last hospitalization. We compared medication burden (number of medication orders) at hospitalization and at time of death and examined whether changes in medication burden were associated with clinical and demographic parameters. RESULTS: Median medication burden was higher in leukemia/lymphoma patients (6 orders) compared to solid (4 orders) or CNS tumor patients (4 orders, P = 0.006). Overall, the median number of prescriptions per patient did not change until death (P = 0.42), while there was a significant reduction for some medication subgroups (chemotherapy [P = 0.035], steroids [P = 0.010]).Patients dying in the ICU (n=15) had a higher medication burden at death (6 orders) than patients dying on wards (3 orders, P = 0.001). There was a trend for a reduction in medication burden in patients with "Do not resuscitate" (DNR) orders (P = 0.055). CONCLUSIONS: Polypharmacy is ubiquitous among pediatric oncology patients at EOL. Disease type and DNR status may affect medication burden and deprescribing during the last hospitalization.
Tamir S; Kurnik D; Weyl BAM; Postovsky S
The Israel Medical Association Journal
2021
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<a href="http://doi.org/" target="_blank" rel="noreferrer noopener"></a>
Values clarification: Eliciting the values that inform and influence parents' treatment decisions for periviable birth
Attitude to Health; Decision Making; Fetal Viability; Financial Stress; Parents; periviable delivery; Pilot Projects; Pregnancy; Premature Birth; Qualitative Research; Quality of Life; Religion; Resuscitation Orders; Second Trimester Pregnancy; shared decision making; Social Support; values clarification
BACKGROUND: Values clarification can assist families facing the threat of periviable delivery in navigating the complexity of competing values related to death, disability, and quality of life (QOL). OBJECTIVE: We piloted values clarification exercises to inform resuscitation decision making and qualitatively assess perceptions of QOL. METHODS: We conducted a mixed-method study of women with threatened periviable delivery (22 0/7-24 6/7 weeks) and their important others (IOs). Participants engaged in three values clarification activities as part of a semi-structured interview-(a) Card sorting nine conditions as an acceptable/unacceptable QOL for a child; (b) Rating/ranking seven common concerns in periviable decision making (scale 0-10, not at all to extremely important); and (c) "Agreed/disagreed" with six statements regarding end-of-life treatment, disability, and QOL. Participants were also asked to define "QOL" and describe their perceptions of a good and poor QOL for their child. Analysis was conducted using SAS version 9.4 and NVivo 12. RESULTS: All mild disabilities were an acceptable QOL, while two-thirds of participants considered long-term mechanical ventilation unacceptable. Although pregnant women rated "Impact on Your Physical/Mental Health" (average 5.6) and IOs rated "Financial Concerns" the highest (average 6.6), both groups ranked "Financial Concerns" as the most important concern (median 5.0 and 6.0, respectively). Most participants agreed that "Any amount of life is better than no life at all" (pregnant women 62.1%; IOs 75.0%) and disagreed that resuscitation would cause "Too much suffering" for their child (pregnant women 71.4%; IOs 80.0%). Half were familiar with the phrase "QOL". Although the majority described a good QOL in terms of emotional well-being (eg "loved", "happy", "supported"), a poor QOL was described in terms of functionality (eg "dependent" and "confined"). Additionally, financial stability emerged as a distinctive theme when IOs discussed poor QOL. CONCLUSION: The study offers important insights on parental perspectives in periviable decision making and potential values clarification tools for decision support.
Tucker EB; Hoffman SM; Laitano T; Bhamidipalli SS; Jeffries E; Fadel W; Kavanaugh K
Paediatric and Perinatal Epidemiology
2020
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<a href="http://doi.org/10.1111/ppe.12590" target="_blank" rel="noreferrer noopener">10.1111/ppe.12590</a>
Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations
Infant; Child; Palliative care; Pediatric critical care; Resuscitation orders; Treatment withdrawal; Treatment withholding
In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.
Cremer R; de Saint Blanquat L; Birsan S; Bordet F; Botte A; Brissaud O; Guilbert J; Le Roux B; Le Reun C; Michel F; Millasseau F; Sinet M; Hubert P
Archives of Pediatrics
2021
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<a href="http://doi.org/10.1016/j.arcped.2021.03.004" target="_blank" rel="noreferrer noopener">10.1016/j.arcped.2021.03.004</a>
End-of-Life Care: Consensus Statement by Indian Academy of Pediatrics
Family; Infant Newborn; Resuscitation Orders; Child; Humans; Child Preschool; Infant; Terminal Care; India; Academies and Institutes; Consensus; Pediatrics/methods/organization & administration/standards
Mishra S; Mukhopadhyay K; Tiwari S; Bangal R; Yadav BS; Sachdeva A; Kumar V
Indian Pediatrics
2017
Life-Sustaining Treatment Status at the Time of Death in a Japanese Pediatric Intensive Care Unit
decision making;Intensive Care Units;Life Support Care;Terminal Care sn [Statistics & Numerical Data];Adolescent;Artificial;Brain Death di [Diagnosis];Child;Female;Humans;Length of Stay;Life Support Care;Male;Pediatric sn [Statistics & Numerical Data];Preschool;Respiration;Resuscitation Orders;Retrospective Studies;Terminal Care px [Psychology];Time Factors;Withholding Treatment
BACKGROUND: Substantial variability exists among countries regarding the modes of death in pediatric intensive care units (PICUs). However, there is limited information on end-of-life care in Japanese PICUs. Thus, this study aimed to elucidate the characteristics of end-of-life care practice for children in a Japanese PICU. METHODS: We examined life-sustaining treatment (LST) status at the time of death based on medical chart reviews from 2010 to 2014. All deaths were classified into 3 groups: limitation of LST (limitation group, death after withholding or withdrawal of LST or a do not attempt resuscitation order), no limitation of LST (no-limitation group, death following failed resuscitation attempts), or brain death (brain death group). RESULTS: Of the 62 patients who died, 44 (71%) had limitation of LST, 18 (29%) had no limitation of LST, and none had brain death. In the limitation group, the length of PICU stay was longer than that in the no-limitation group (13.5 vs 2.5 days; P = .01). The median time to death after the decision to limit LST was 2 days (interquartile range: 1-5.5 days), and 94% of the patients were on mechanical ventilation at the time of death in the limitation group. CONCLUSIONS: Although limiting LST was a common practice in end-of-life care in a Japanese PICU, a severe limitation of LST such as withdrawal from the ventilator was hardly practiced, and a considerable LST was still provided at the time of death.
Suzuki F;Takeuchi M;Tachibana K;Isaka K;Inata Y;Kinouchi K
American Journal of Hospice & Palliative Medicine
2018
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<a href="http://doi.org/10.1177/1049909117743474" target="_blank" rel="noreferrer noopener">10.1177/1049909117743474</a>
Association between religious and socio-economic background of parents of children with solid tumors and DNR orders
adolescent; Child; Female; Humans; infant; Male; retrospective studies; Survival Rate; Young Adult; Neoplasms; decision making; Adult; Parents; Education; Prognosis; Follow-Up Studies; Socioeconomic Factors; Resuscitation Orders; Religion; Medical Records; Preschool
BACKGROUND: The influence of socio-economic and religious background on decisions made by parents of children with incurable cancer regarding DNR orders is not fully understood. PROCEDURE: A retrospective analysis of medical charts of patients who died between January 2000 and January 2011 was performed. The following data were sought: written evidence of DNR discussion with parents, religious background, educational level, monthly income. RESULTS: There was evidence of a discussion on DNR in 73/90 charts. DNR consent was obtained in 14/17 (82.4%) cases where at least one parent had >15 years of education versus in only 24/45 (53.3%) cases where both parents had ≤15 years education as determined by univariate analysis (P = 0.03). DNR consent was also more likely to be obtained among parents of children with income >10,000 NIS (24/30, 80.0% vs. 20/38, 52.6%, P = 0.013). Parents of Jewish (22/30, 73.3%), Islamic (16/26, 61.5%), and Christian (8/9, 88.9%) background were equally likely to provide DNR consent. However, Druze families were less likely to do so (2/8, 25.0%, P = 0.036). CONCLUSIONS: The process of decision-making to a DNR request was associated with parents' educational level and monthly family income, and not by religious background, with the exception of Druze families.
2014-02
Hileli I; Weyl Ben Arush M; Hakim F; Postovsky S
Pediatric Blood & Cancer
2014
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Journal Article
<a href="http://doi.org/10.1002/pbc.24712" target="_blank" rel="noreferrer">10.1002/pbc.24712</a>
Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest
adolescent; Child; Humans; Resuscitation Orders; cardiopulmonary resuscitation; Wounds and Injuries; Out-of-Hospital Cardiac Arrest; Thoracotomy
This multiorganizational literature review was undertaken to provide an evidence base for determining whether or not recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care, because the evidence suggests that either death or a poor outcome is inevitable.
2014-04
American College of Surgeons Committee on Trauma; Pediatric Emergency Medicine Committee - American College of Emergency Physicians; National Association of EMS Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Fallat ME
Annals Of Emergency Medicine
2014
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Journal Article
<a href="http://doi.org/10.1016/j.annemergmed.2014.01.013" target="_blank" rel="noreferrer">10.1016/j.annemergmed.2014.01.013</a>
[French law related to patient's rights and end of life: pediatric intensive care unit's health professionals' opinions]
Child; Humans; Intensive Care Units; Palliative Care; patient care team; Terminal Care; Attitude of Health Personnel; Withholding Treatment; Resuscitation Orders; Double Effect Principle; Suicide; Patient Rights; Pediatric; Health Surveys; France; Assisted; Health Care; Quality Assurance
INTRODUCTION AND OBJECTIVES: To identify the knowledge of caregivers of pediatric intensive care units (PICUs) on the French law related to patients' rights and end of life, their views on withholding/withdrawing life-sustaining treatment (WWLST) decisions, and their feelings about how these decisions were made and implemented. MATERIALS AND METHODS: A multicenter survey in 24 French PICUs during the fourth trimester 2010. RESULTS: One thousand three hundred and thirty-nine professional healthcare workers (1005 paramedics and 334 physicians) responded. Over 85% of caregivers had good knowledge of the WWLST decision-making processes required by law. More than 80% of caregivers accepted mechanical ventilation, hemodiafiltration, or hemodynamic support withdrawal or withholding. Nevertheless, the withdrawal of artificial nutrition and hydration generated reluctance or opposition for the majority of respondents. While paramedics' participation in the decision-making process was deemed necessary by all caregivers, paramedics found more often than physicians that they were insufficiently involved. The quality of end-of-life care was judged very positively by caregivers. The answers on how WWLST was applied suggest very different interpretations of the law. Some caregivers respect the principles of palliative care as stated in the public health code and 40% of doctors and 64% of caregivers consider it "acceptable" to hasten death if resulting from a collaborative decision-making process. CONCLUSION: This study is the first to show that caregivers of French PICUs have good knowledge of the French law concerning the end of life. Yet, there is still confusion about the limits of practice during the end-of-life period.
2014-01
de Saint Blanquat L; Cremer R; Elie C; Lesage F; Dupic L; Hubert P; pour le Groupe francophone de réanimation et urgences pédiatriques (GFRUP)
Archives De Pediatrie
2014
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Journal Article
<a href="http://doi.org/10.1016/j.arcped.2013.10.018" target="_blank" rel="noreferrer">10.1016/j.arcped.2013.10.018</a>
Predictive factors for do-not-resuscitate designation among terminally ill cancer patients receiving care from a palliative care consultation service.
Female; Humans; Male; Prognosis; Aged; Middle Aged; Sex Factors; Multivariate Analysis; Time Factors; retrospective studies; DNAR; Taiwan; Resuscitation Orders; Palliative Care; Neoplasms/th [Therapy]; referral and consultation; Terminally Ill; Family/px [Psychology]; Liver Neoplasms/di [Diagnosis]; Liver Neoplasms/pp [Physiopathology]; Liver Neoplasms/px [Psychology]; Liver Neoplasms/th [Therapy]; Neoplasms/di [Diagnosis]; Neoplasms/pp [Physiopathology]; Neoplasms/px [Psychology]; Resuscitation Orders/px [Psychology]; Terminally Ill/px [Psychology]
CONTEXT: Since the development of palliative care in the 1980s, "do not resuscitate" (DNR) has been promoted worldwide to avoid unnecessary resuscitation in terminally ill cancer patients., OBJECTIVES: This study aimed to evaluate the effect of a palliative care consultation service (PCCS) on DNR designation and to identify a subgroup of patients who would potentially benefit from care by the PCCS with respect to DNR designation., METHODS: In total, 2995 terminally ill cancer patients (with a predicted life expectancy of less than six months by clinician estimate) who received care by the PCCS between January 2006 and December 2010 at a single medical center in Taiwan were selected. Among these, the characteristics of 2020 (67.4%) patients who were not designated as DNR at the beginning of care by the PCCS were retrospectively analyzed to identify variables pertinent to DNR designation., RESULTS: A total of 1301 (64%) of 2020 patients were designated as DNR at the end of care by the PCCS. Male gender and primary liver cancer were characteristics more predominantly found among DNR-designated patients who also had worse performance status, higher prevalence of physical distress, and shorter intervals from palliative care referral to death than did patients without DNR designation. On univariate analysis, a higher probability of DNR designation was associated with male gender, duration of care by the PCCS of more than 14 days, patients' prognostic awareness, family's diagnostic and prognostic awareness, and high Palliative Prognostic Index (PPI) scores. On multivariate analysis, duration of care by the PCCS, patients' prognostic awareness, family's diagnostic and prognostic awareness, and a high PPI score constituted independent variables predicting DNR-designated patients at the end of care by the PCCS., CONCLUSION: DNR designation was late in terminally ill cancer patients. DNR-designated cancer patient indicators were high PPI scores, patients' prognostic awareness, family's diagnostic and prognostic awareness, and longer durations of care by the PCCS.Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
2014
Kao Chen-Yi; Wang Hung-Ming; Tang Shu-Chuan; Huang K-G; Jaing T-H; Liu Chien-Ying; Liu Keng-Hao; Shen W-C; Wu Jin-Hou; Hung Y-S; Hsu H-C; Chen JS; Liau Chi-Ting; Lin Yung-Chang; Su Po-Jung; Hsieh C-H; Chou WC
Journal Of Pain And Symptom Management
2014
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Journal Article
<a href="http://doi.org/10.1016/j.jpainsymman.2013.03.020" target="_blank" rel="noreferrer">10.1016/j.jpainsymman.2013.03.020</a>
Was there a plan? End-of-life care for children with life-limiting conditions: a review of multi-service healthcare records
Child; Female; Humans; Male; Advance Directives; Physician-Patient Relations; Pediatrics; Practice Guidelines as Topic; Communication; Resuscitation Orders; Time Factors; quality of life; end of life; adolescent; Preschool; decision making; infant; retrospective studies; DNAR; Parents; documentation; Parents/px [Psychology]; Terminal Care; Patient Care Planning/og [Organization & Administration]; Terminal Care/og [Organization & Administration]; review; Medical Records; Neoplasms; advance planning; child and family wishes; Neoplasms/mo [Mortality]; Patient Care Planning/st [Standards]; Terminal Care/px [Psychology]
BACKGROUND: Planning for care at the end of life (EoL) is an essential component of support and care for families of children with life-limiting conditions. The purpose of this review was to compare documented EoL planning with published children's palliative care standards, across a range of children's healthcare services and to assess the impact on practice of written guidelines to support EoL care planning. METHOD: A manual retrospective review of healthcare records using a purpose-built form. Inclusion criteria were the records of children with a diagnosed life-limiting or life-threatening condition, who had died before the age of 18 years, between October 2008 and March 2010, within a defined geographical area served by one or more of the participating services. The sample was 114 sets of notes relating to a cohort of 48 children: 24 girls and 24 boys, the majority of whose deaths were cancer related. RESULTS: Examples of good practice were found in the records of individual services. Services had each developed their own systems and documents to support EoL care planning rather than using a unified documentation system. Where documented practice fell short, this was related to a lack of evidence that choice in location of death had been offered, delays in sharing of information between services, and information being buried in the narrative of the notes, making it difficult to find. CONCLUSIONS: Current documented EoL planning varies between services. Those who are infrequently involved in the provision of EoL care may benefit from support by those for whom this is part of their daily working life. These professionals can help prepare staff to engage families in these difficult but important conversations - and encourage them to document them in a way that can be easily and readily accessed and shared.
2014-03
Beringer AJ; Heckford EJ
Child: Care, Health And Development
2014
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Journal Article
<a href="http://doi.org/10.1111/cch.12020" target="_blank" rel="noreferrer">10.1111/cch.12020</a>
Withdrawal of ventilatory support outside the intensive care unit: guidance for practice
adolescent; Child; Female; Humans; infant; Male; retrospective studies; Intensive Care Units; Palliative Care; Practice Guidelines as Topic; Resuscitation Orders; Pediatric; Preschool; Newborn; Mechanical; Ventilators; Place of Death; Guildlines; Paediatric Intensive Care (PICU)
OBJECTIVE: To review the work of one tertiary paediatric palliative care service in facilitating planned withdrawal of ventilatory support outside the intensive care setting, with the purpose of developing local guidance for practice. METHODS: Retrospective 10-year (2003-2012) case note review of intensive care patients whose parents elected to withdraw ventilation in another setting. Demographic and clinical data revealed common themes and specific incidents relevant to local guideline development. RESULTS: 18 children (aged 2 weeks to 16 years) were considered. Three died prior to transfer. Transfer locations included home (5), hospice (8) and other (2). Primary pathologies included malignant, neurological, renal and respiratory diseases. Collaborative working was evidenced in the review including multidisciplinary team meetings with the palliative care team prior to discharge. Planning included development of symptom management plans and emergency care plans in the event of longer than anticipated survival. Transfer of children and management of extubations demonstrated the benefits of planning and recognition that unexpected events occur despite detailed planning. We identified the need for local written guidance supporting healthcare professionals planning and undertaking extubation outside the intensive care setting, addressing the following phases: (i) introduction of withdrawal, (ii) preparation pretransfer, (iii) extubation, (iv) care postextubation and (v) care postdeath. CONCLUSIONS: Planned withdrawal of ventilatory support outside the intensive care setting is challenging and resource intensive. The development of local collaborations and guidance can enable parents of children dependent on intensive care to consider a preferred place of death for their child, which may be outside the intensive care unit.
2014-09
Laddie J; Craig F; Brierley J; Kelly P; Bluebond-Langner M
Archives Of Disease In Childhood
2014
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Journal Article
<a href="http://doi.org/10.1136/archdischild-2013-305492" target="_blank" rel="noreferrer">10.1136/archdischild-2013-305492</a>
Impact of a palliative care initiative on end-of-life care in the general wards: A before-and-after study._
Female; Humans; Male; retrospective studies; Palliative Care; Logistic Models; Aged; Comorbidity; cardiopulmonary resuscitation; Program Evaluation; Social Class; retrospective studies; DNAR; cardiopulmonary resuscitation; Resuscitation Orders; Chronic Disease/therapy; Palliative Care; DNAR Outcomes; Life Support Care/statistics & numerical data; Withholding Treatment/statistics & numerical data; Chronic Disease/epidemiology; Patient Admission/statistics & numerical data; Palliative Care; Hospital Mortality/trends; Advance Care Planning/st [Standards]; Forms and Records Control; Life Support Care/mt [Methods]; Advance Care Planning/standards; Asian; Chronic Disease/ep [Epidemiology]; Chronic Disease/th [Therapy]; Clinical Audit; Do-not-resuscitate orders; Forms and Records Control; general wards; Hospital Mortality/td [Trends]; Life Support Care/methods; Life Support Care/sn [Statistics & Numerical Data]; Patient Admission/statistics & numerical data; Patient Admission/td [Trends]; Patient Admission/trends; Resuscitation Orders; Singapore/ep [Epidemiology]; Singapore/epidemiology; Withholding Treatment/sn [Statistics & Numerical Data]
BACKGROUND: Data on deaths in the general wards of our hospital in 2007 revealed infrequent discussions on end-of-life care and excessive burdensome interventions., AIM: A physician order form to withhold inappropriate life-sustaining interventions was initiated in 2009. The use of the form was facilitated by staff educational sessions and a palliative care consult service. This study aims to evaluate the impact of these interventions in 2010., DESIGN: Retrospective medical chart review with comparisons was made for the following: baseline patient characteristics, orders concerning life-sustaining therapies, treatment provided in last 24 h of life, and discussion of specific life-sustaining therapies with patients and families., SETTINGS/PARTICIPANTS: This study included all adult patients who died in our hospital's general wards in 2007 (N = 683) versus 2010 (N = 714)., RESULTS: There was an increase in orders to withhold life-sustaining therapies, such as cardiopulmonary resuscitation (66.2%-80.0%). There was a decrease in burdensome interventions such as antibiotics (44.9%-24.9%) and a small increase in palliative treatments such as analgesia (29.1%-36.7%). There were more discussions on the role of cardiopulmonary resuscitation with conversant patients (4.6%-10.2%) and families (56.5%-79.8%) (p-value all < 0.05). On multivariate analysis, the physician order form independently predicted orders to withhold cardiopulmonary resuscitation., CONCLUSIONS: A multifaceted intervention of a physician order form, educational sessions, and palliative care consult service led to an improvement in documentation of end-of-life discussions and was associated with an increase in such discussions and less burdensome treatments. There were small improvements in the proportion of palliative treatments administered.
2014
Tan A; Seah A; Chua G; Lim Tow K; Phua J
Palliative Medicine
2014
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Journal Article
<a href="http://doi.org/10.1177/0269216313484379" target="_blank" rel="noreferrer">10.1177/0269216313484379</a>
Pediatric palliative care and pediatric medical ethics: opportunities and challenges
adolescent; Child; Humans; infant; Pediatrics; Withholding Treatment; Communication; Resuscitation Orders; Ethics; Medical; Palliative Care; 20th Century; History
The fields of pediatric palliative care (PPC) and pediatric medical ethics (PME) overlap substantially, owing to a variety of historical, cultural, and social factors. This entwined relationship provides opportunities for leveraging the strong communication skills of both sets of providers, as well as the potential for resource sharing and research collaboration. At the same time, the personal and professional relationships between PPC and PME present challenges, including potential conflict with colleagues, perceived or actual bias toward a palliative care perspective in resolving ethical problems, potential delay or underuse of PME services, and a potential undervaluing of the medical expertise required for PPC consultation. We recommend that these challenges be managed by: (1) clearly defining and communicating clinical roles of PPC and PME staff, (2) developing questions that may prompt PPC and PME teams to request consultation from the other service, (3) developing explicit recusal criteria for PPC providers who also provide PME consultation, (4) ensuring that PPC and PME services remain organizationally distinct, and (5) developing well-defined and broad scopes of practice. Overall, the rich relationship between PPC and PME offers substantial opportunities to better serve patients and families facing difficult decisions.
2014-02
Feudtner C; Nathanson PG
Pediatrics
2014
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Journal Article
<a href="http://doi.org/10.1542/peds.2013-3608B" target="_blank" rel="noreferrer">10.1542/peds.2013-3608B</a>
Unilateral pediatric "do not attempt resuscitation" orders: the pros, the cons, and a proposed approach
Child; Female; Humans; infant; Male; Parental Consent; Pediatrics; Prognosis; Resuscitation Orders; Ethics; Medical; quality of life; Newborn; Extremely Premature
A unilateral do not attempt resuscitation (DNAR) order is written by a physician without permission or assent from the patient or the patient's surrogate decision-maker. Potential justifications for the use of DNAR orders in pediatrics include the belief that attempted resuscitation offers no benefit to the patient or that the burdens would far outweigh the potential benefits. Another consideration is the patient's right to mercy, not to be made to undergo potentially painful interventions very unlikely to benefit the patient, and the physician's parallel obligation not to perform such interventions. Unilateral DNAR orders might be motivated in part by the moral distress caregivers sometimes experience when feeling forced by parents to participate in interventions that they believe are useless or cruel. Furthermore, some physicians believe that making these decisions without parental approval could spare parents needless additional emotional pain or a sense of guilt from making such a decision, particularly when imminent death is unavoidable. There are, however, several risks inherent in unilateral DNAR orders, such as overestimating one's ability to prognosticate or giving undue weight to the physician's values over those of parents, particularly with regard to predicted disability and quality of life. The law on the question of unilateral DNAR varies among states, and readers are encouraged to learn the law where they practice. Arguments in favor of, and opposed to, the use of unilateral DNAR orders are presented. In some settings, particularly when death is imminent regardless of whether resuscitation is attempted, unilateral DNAR orders should be viewed as an ethically permissible approach.
2014-02
Mercurio MR; Murray PD; Gross I
Pediatrics
2014
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Journal Article
<a href="http://doi.org/10.1542/peds.2013-3608G" target="_blank" rel="noreferrer">10.1542/peds.2013-3608G</a>
Clinician perspectives regarding the do-not-resuscitate order
Female; Humans; Male; decision making; Critical Illness; Data Collection; Attitude of Health Personnel; Physicians; Boston; Resuscitation Orders; Nurses; Heart Arrest; advance care planning
IMPORTANCE: While data exist regarding the frequency and timing of the do-not-resuscitate (DNR) order in children, little is known about clinician attitudes and behaviors regarding this order. OBJECTIVE: To identify clinician attitudes regarding the meaning, implication, and timing of the DNR order for pediatric patients. DESIGN: Physicians and nurses from practice settings where advance care planning typically takes place were surveyed regarding their attitudes and behaviors about DNR orders. RESULTS: In total, 107 physicians and 159 nurses responded to the survey (N = 266). There was substantial variability in the interpretation of the DNR order. Most clinicians (66.9%) believe that a DNR order indicates limitation of resuscitative measures only on cardiopulmonary arrest. In reality, however, more than 85% believe that care changes beyond response to cardiopulmonary arrest, varying from increased attention to comfort to less clinician attentiveness. In addition, most clinicians reported that resuscitation status discussions take place later in the illness course than is ideal. CONCLUSIONS AND RELEVANCE: Clinicians use the DNR order not only as a guide for therapeutic decisions during a cardiopulmonary arrest but also as a surrogate for broader treatment directives. Most clinicians believe that DNR discussions should take place earlier than they actually do. Interventions aimed at improving clinician knowledge and skills in advance care discussions as well as the development of orders that address overall goals of care may improve care for children with serious illness.
2013-10
Sanderson A; Zurakowski D; Wolfe J
Jama Pediatrics
2013
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Journal Article
<a href="http://doi.org/10.1001/jamapediatrics.2013.2204" target="_blank" rel="noreferrer">10.1001/jamapediatrics.2013.2204</a>
Ethnicity, race, and advance directives in an inpatient palliative care consultation service.
Female; Humans; Male; Adult; Aged; Middle Aged; Cross-Cultural Comparison; Program Evaluation; Spirituality; 80 and over; decision making; DNAR; Resuscitation Orders; Advance Directives/eh [Ethnology]; Attitude to Death/eh [Ethnology]; Palliative Care/og [Organization & Administration]; Referral and Consultation/og [Organization & Administration]; Terminal Care/og [Organization & Administration]; African Americans/statistics & numerical data; Asian Continental Ancestry Group/sn [Statistics & Numerical Data]; European Continental Ancestry Group/sn [Statistics & Numerical Data]; Hispanic Americans/sn [Statistics & Numerical Data]; New York/ep [Epidemiology]
OBJECTIVE: Although race and ethnic background are known to be important factors in the completion of advance directives, there is a dearth of literature specifically investigating the effect of race and ethnicity on advance directive completion rate after palliative care consultation (PCC)., METHOD: A chart review of all patients seen by the PCC service in an academic hospital over a 9-month period was performed. Data were compiled using gender, race, ethnicity, religion, and primary diagnosis. For this study, advance directives were defined as: "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI)., RESULTS: Of the 400 medical records reviewed, 57% of patients were female and 71.3% documented their religion as Christian. The most common documented diagnosis was cancer (39.5%). Forty-seven percent reported their race as white. White patients completed more advance directives than did nonwhite patients both before (25.67% vs. 12.68%) and after (59.36% vs. 40.84%) PCC. There was a significantly higher proportion of whites who signed an advance directive after a PCC than of nonwhites (p = 0.021); of the 139 whites who did not have an advance directive at admission, 63 signed an advance directive after a PCC compared with 186/60 nonwhites (45% vs. 32%, respectively, p = 0.021). Further analysis revealed that African Americans differed from whites in the likelihood of advance directive execution rates pre-PCC, but not post-PCC., SIGNIFICANCE OF RESULTS: This study demonstrates the impact of a PCC on the completion of advance directives, on both whites and nonwhites. The PCC Intervention significantly reduced differences between whites and African Americans in completing advance directives, which have been consistently documented in the end-of-life literature.
2013
Zaide GB; Pekmezaris R; Nouryan CN; Mir Tanveer P; Sison CP; Liberman T; Lesser ML; Cooper LB; Wolf-Klein GP
Palliative & Supportive Care
2013
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Journal Article
<a href="http://doi.org/10.1017/s1478951512000417" target="_blank" rel="noreferrer">10.1017/s1478951512000417</a>
The attitudes of neonatal professionals towards end-of-life decision-making for dying infants in Taiwan
Cross-Sectional Studies; Female; Humans; infant; Male; Intensive Care Units; Terminal Care; decision making; referral and consultation; Adult; Attitude of Health Personnel; Education; Medical Staff; Withholding Treatment; Questionnaires; Middle Aged; Attitude to Death; Resuscitation Orders; Self Report; Neonatology; Medical; Neonatal; Nursing Staff; Newborn; Clinical; Ethics Committees; Taiwan; Hospital; continuing
The purposes of research were to describe the neonatal clinicians' personal views and attitudes on neonatal ethical decision-making, to identify factors that might affect these attitudes and to compare the attitudes between neonatal physicians and neonatal nurses in Taiwan. Research was a cross-sectional design and a questionnaire was used to reach different research purposes. A convenient sample was used to recruit 24 physicians and 80 neonatal nurses from four neonatal intensive care units in Taiwan. Most participants agreed with suggesting a do not resuscitate (DNR) order to parents for dying neonates (86.5%). However, the majority agreed with talking to patients about DNR orders is difficult (76.9%). Most participants agree that review by the clinical ethics committee is needed before the recommendation of 'DNR' to parents (94.23%) and nurses were significantly more likely than physicians to agree to this (p=0.043). During the end-of-life care, most clinicians accepted to continue current treatment without adding others (70%) and withholding of emergency treatments (75%); however, active euthanasia, the administration of drug to end-of-life, was not considered acceptable by both physicians and nurses in this research (96%). Based on our research results, providing continuing educational training and a formal consulting service in moral courage for neonatal clinicians are needed. In Taiwan, neonatal physicians and nurses hold similar values and attitudes towards end-of-life decisions for neonates. In order to improve the clinicians' communication skills with parents about DNR options and to change clinicians' attitudes for providing enough pain-relief medicine to dying neonates, providing continuing educational training and a formal consulting service in moral courage are needed.
2013-06
Huang L-C; Chen CH; Liu Hsin-Li; Lee Ho-Yu; Peng Niang-Huei; Wang Teh-Ming; Chang YC
Journal Of Medical Ethics
2013
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Journal Article
<a href="http://doi.org/10.1136/medethics-2011-100428" target="_blank" rel="noreferrer">10.1136/medethics-2011-100428</a>
End-of-life decision making in Taiwan: healthcare practice is rooted in local culture and laws that should be adjusted to patients' best interests
Female; Humans; Male; Terminal Care; decision making; Attitude of Health Personnel; Medical Staff; Attitude to Death; Resuscitation Orders; Neonatology; Nursing Staff; Hospital
The observed Taiwanese neonatal professionals' more conservative attitudes than their worldwide colleagues towards end-of-life (EOL) decision making may stem from cultural attitudes toward death in children and concerns about medicolegal liability. Healthcare practice is rooted in local culture and laws; however that should be adjusted to patients' best interests. Improving Taiwanese neonatal professionals' knowledge and competence in EOL care may minimize ethical dilemmas, allow appropriate EOL care decision making, avoid infants' suffering, and ease parents' bereavement grief.
2013-06
Tang Siew Tzuh
Journal Of Medical Ethics
2013
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Journal Article
<a href="http://doi.org/10.1136/medethics-2012-100760" target="_blank" rel="noreferrer">10.1136/medethics-2012-100760</a>
The effects of the Palliative Medicine Consultation on the DNR status of African Americans in a safety-net hospital.
Female; Humans; Male; Critical Illness; Prognosis; Aged; Middle Aged; Communication; Poverty Areas; Attitudes; retrospective studies; Health Knowledge; DNAR; Resuscitation Orders; Palliative Care/mt [Methods]; Advance Directives/eh [Ethnology]; Palliative Care/og [Organization & Administration]; New York City; Advance Directives/sn [Statistics & Numerical Data]; African Americans/statistics & numerical data; Hispanic Americans/sn [Statistics & Numerical Data]; Palliative Care/sn [Statistics & Numerical Data]; Practice/eh [Ethnology]; Referral and Consultation/statistics & numerical data
OBJECTIVE: To examine the effectiveness of palliative medicine consultation on completion of advance directives/do-not-resuscitate (DNR) orders by racial/ethnic minorities., METHOD: A sample of 1999 seriously ill African American and Hispanic inpatients was obtained from the Palliative Medicine Consultation database (n = 2972). Associations between race/ethnicity and diagnosis and documentation of DNR status on admission and discharge were examined., RESULTS: Cancer was the primary diagnosis, 34.5%. Among patients with a consultation, 98% agreed to discuss advance directives; 65% of African Americans and 70% of Hispanics elected DNR status. Inpatient deaths were 46%; 74% of decedents agreed to DNR orders. Discharged patients referred to hospice were 29%., CONCLUSION: Palliative medicine consultations resulted in timely completion of DNR orders and were positively associated with DNR election and hospice enrollment.
2013
Sacco J; Deravin Carr DR; Viola D
The American Journal Of Hospice & Palliative Care
2013
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Journal Article
<a href="http://doi.org/10.1177/1049909112450941" target="_blank" rel="noreferrer">10.1177/1049909112450941</a>
Characteristics of patients who refuse do-not-resuscitate orders upon admission to an acute palliative care unit in a comprehensive cancer center.
Female; Humans; Male; Palliative Care; Adult; Middle Aged; Patient Acceptance of Health Care; Survival Analysis; Case-Control Studies; African Americans; retrospective studies; DNAR; Cancer Care Facilities; Neoplasms/di [Diagnosis]; Neoplasms/mo [Mortality]; Resuscitation Orders; Nausea/co [Complications]; Pain/co [Complications]
BACKGROUND: Refusal of appropriately indicated do-not-resuscitate (DNR) orders may cause harm and distress for patients, families, and the medical team. We conducted a retrospective study to determine the frequency and predictors of refusals of DNR in advanced cancer patients admitted to an acute palliative care unit., METHODS: A total of 2538 consecutive admissions were reviewed. Demographic and clinical characteristics from 200 consecutive patients with DNR orders and 100 consecutive patients who refused DNR were collected, and differences between the groups were determined by multivariate regression and recursive partitioning analysis., RESULTS: Of 2538 admissions, 2530 (99%) were appropriate for DNR discussion. Of the 2530 admissions, 2374 were unique patients, and 100 (4%) of 2374 refused DNR. Refusers had median (interquartile range, IQR) pain of 7 (4-9) versus 5 (3-8, P = .0005), nausea of 2 (0-7) versus 1 (0-4, P = .05), and dyspnea of 1 (0-5) versus 4 (0-7, P = .002) as compared with DNR nonrefusers, respectively. Patients with hematological malignancies and advance directives had a lower DNR refusal risk (odds ratio [OR], 0.38; P = .02, and OR, 0.36; P < .0001, respectively). Multivariate regression analysis revealed that patients with moderate-severe pain (OR, 3.19; P = .002) and with no advance directives (OR, 2.94; P < or = .001) had higher DNR refusal risk. There were more inpatient deaths among DNR nonrefusers (87 of 200 vs 1 of 100, P < .0001). Median (IQR) time from discharge to death was 18 (8-35) days for those with DNR orders and 85 (25-206) days for DNR refusers (P < or = .0001)., CONCLUSIONS: DNR refusal in patients admitted to the acute palliative care unit is low, more frequent in patients with more pain and nausea and no advance directives, and associated with longer survival. This study demonstrates possible predictors of complicated DNR discussions.
2010
Parsons HA; de la Cruz MJ; Zhukovsky DS; Hui D; Delgado-Guay MO; Akitoye AE; El Osta B; Palmer JL; Palla SL; Bruera E
Cancer
2010
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Journal Article
<a href="http://doi.org/10.1002/cncr.25045" target="_blank" rel="noreferrer">10.1002/cncr.25045</a>
Pediatric palliative care.
Child; Humans; Professional-Family Relations; Interdisciplinary Communication; Resuscitation Orders; Adaptation; Psychological; patient care team; Psychological; Stress; DNAR; Child welfare; hospice care; Analgesics/tu [Therapeutic Use]; Palliative Care/px [Psychology]; decision making; Pain/dt [Drug Therapy]; Pediatrics/td [Trends]; Quality of Life/px [Psychology]; Analgesics/ae [Adverse Effects]; Constipation/ci [Chemically Induced]; Nausea/ci [Chemically Induced]; Vomiting/ci [Chemically Induced]
Palliative care has always been a part of the care of children. It includes any intervention that focuses on relieving suffering, slowing the progression of disease, and improving quality of life at any stage of disease. In addition, for even the child with the most unpredictable disease, there are predictable times in this child's life when the child, family, and care team will be suffering in ways that can be mitigated by specific interventions. Rather than defining pediatric palliative care in terms of a patient base, severity of disease, or even a general philosophy of care, palliative care can best be understood as a specific set of tasks directed at mitigating suffering. By understanding these tasks; learning to identify predictable times and settings of suffering; and learning to collaborate with multidisciplinary specialists, use communication skills, and identify clinical resources, the pediatrician can more effectively support children with life-threatening illnesses and their families. In this article, we define palliative care as a focus of care integrated in all phases of life and as a set of interventions aimed at easing suffering associated with life-threatening conditions. We detail an approach to these interventions and discuss how they can be implemented by the pediatrician with the support of specialists in hospice and palliative medicine. We discuss common and predictable times of suffering when these interventions become effective ways to treat suffering and improve quality of life. Finally, we discuss those situations that pediatricians most commonly and intensely interface with palliative care-the care of the child with complex, chronic conditions and severe neurologic impairment (SNI).Copyright 2010 Mosby, Inc. All rights reserved.
2010
Klick JC; Hauer JM
Current Problems In Pediatric And Adolescent Health Care
2010
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Journal Article
<a href="http://doi.org/10.1016/j.cppeds.2010.05.001" target="_blank" rel="noreferrer">10.1016/j.cppeds.2010.05.001</a>
Determinants of do-not-resuscitate orders in palliative home care.
Female; Humans; Male; Pain Measurement; Adult; Canada; Aged; Middle Aged; Activities of Daily Living; Demography; Case Management; adolescent; 80 and over; retrospective studies; DNAR; Resuscitation Orders; Neuropsychological Tests; Pain/di [Diagnosis]; Advance Directives/sn [Statistics & Numerical Data]; Critical Illness/mo [Mortality]; Critical Illness/th [Therapy]; Palliative Care/sn [Statistics & Numerical Data]; Cognition Disorders/di [Diagnosis]; Cognition Disorders/ep [Epidemiology]; Palliative Care/lj [Legislation & Jurisprudence]
OVERVIEW: Do-not-resuscitate (DNR) orders allow home care clients to communicate their own wishes over medical treatment decisions, helping to preserve their dignity and autonomy. To date, little is known about DNR orders in palliative home care. Basic research to identify rates of completion and determinants of DNR orders has yet to be examined in palliative home care., PURPOSE: The purpose of this exploratory study was to determine who in palliative home care has a DNR order as part of their advance directive., METHODS: Information on health was collected using the interRAI instrument for palliative care (interRAI PC). The sample included 470 home care clients from one community care access centre in Ontario., RESULTS: This study indicated that a preference to die at home (odds ratio [OR]: 8.29, confidence interval [CI]: 4.55-15.11); close proximity to death (OR: 0.99, CI: 0.99-1.00); daily incontinence (OR: 2.74, CI: 1.05-7.16); and sleep problems (OR: 1.85, CI: 1.02-3.37) are associated with DNR orders. In addition, clients who are more accepting of their situation are 5.67 times (CI: 1.67-19.27) more likely to have a DNR in place., CONCLUSION: This study represents an important first step to identifying issues related to DNR orders. In addition to proximity to death, incontinence, and sleep problems, acceptance of one's own situation and a preference to die at home are important determinants of DNR completion. The results imply that these discussions might often depend not only on the health of the clients but also on the clients' acceptance of their current situation and where they wish to die.
2008
Brink P; Smith TF; Kitson M
Journal Of Palliative Medicine
2008
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Journal Article
<a href="http://doi.org/10.1089/jpm.2007.0105" target="_blank" rel="noreferrer">10.1089/jpm.2007.0105</a>
Impact of writing "comfort measures only" orders in a community teaching hospital.
Female; Humans; Male; Terminal Care; Adult; Medical Audit; Aged; Middle Aged; Teaching; Community; 80 and over; retrospective studies; DNAR; Resuscitation Orders; Palliative Care/og [Organization & Administration]; Hospitals; Baltimore
OBJECTIVES: We compared end-of-life care for patients with and without orders for "comfort measures only" (CMO) and evaluated whether standards for palliative medicine were met., DESIGN: We retrospectively reviewed the charts of 40 patients, 20 with and 20 without a CMO order, who died in our community teaching hospital from October 2003 through September 2004. Appropriate use of medications and interventions and documentation of symptoms and family consultation were examined., RESULTS: There were no significant demographic differences between the groups. Family meeting (18/20 versus 7/20, p < 0.001) and do-not-resuscitate/do-not-intubate (DNR/DNI) code status (20/20 versus 8/20; p < 0.001) occurred significantly more frequently in the CMO group. There were no other significant differences in prescribing medications or treatments. Notation of symptoms common at the end of life did not differ between the groups except for nausea/vomiting, which was more common in the non-CMO group. In the CMO group, opioids were significantly more available and antibiotics and routine laboratory work were significantly less common after the CMO order, but no other differences were observed., CONCLUSION: CMO orders alone were insufficient for redirecting changes in care at the end-of-life.
2010
Walker KA; Peltier H; Mayo RL; Kearney CD
Journal Of Palliative Medicine
2010
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Journal Article
<a href="http://doi.org/10.1089/jpm.2009.0257" target="_blank" rel="noreferrer">10.1089/jpm.2009.0257</a>
Finding the right words: using the terms allow natural death (AND) and do not resuscitate (DNR) in pediatric palliative care.
Humans; Intensive Care Units; Terminal Care; Health Care Surveys; Education; Medical; Pediatric; DNAR; Resuscitation Orders; Palliative Care; Communication; Hospitals; Terminology as Topic
When children are dying in a hospital setting, healthcare providers need to help families make important end-of-life care decisions. Most providers use the term do not resuscitate (DNR) when suggesting a course of action that involves not using extraordinary lifesaving measures. Some healthcare providers use the term allow natural death (AND) to discuss this same approach. This study investigated pediatric healthcare providers' beliefs about using AND as opposed to DNR. Results revealed that providers believe the term AND is somewhat ambiguous but may be more family centered.
2008
Jones BL; Parker-Raley J; Higgerson RA; Christie LA; Legett S; Greathouse J
Journal For Healthcare Quality
2008
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Journal Article
<a href="http://doi.org/10.1111/j.1945-1474.2008.tb01162.x" target="_blank" rel="noreferrer">10.1111/j.1945-1474.2008.tb01162.x</a>
Cardiopulmonary resuscitation in patients with cancer.
Humans; Resuscitation Orders; quality of life; DNAR; Palliative Care; Neoplasms/th [Therapy]; decision making; cardiopulmonary resuscitation
Cancer is the second leading cause of death in the United States, with most of these deaths taking place in the hospital setting. Discussions on end-of-life care and on cardiopulmonary resuscitation in particular are an important component in the management of patients with cancer. Clinical decision making and respect for patient autonomy dictate that health care providers provide their patients with accurate information on the expected outcomes of cardiopulmonary resuscitation. This article reviews those factors that affect the outcome of cardiopulmonary resuscitation in patients with cancer and provides recommendations on obtaining do-not-resuscitate orders in these patients.
2007
Varon J; Marik PE
The American Journal Of Hospice & Palliative Care
2007
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Journal Article
<a href="http://doi.org/10.1177/1049909107301485" target="_blank" rel="noreferrer">10.1177/1049909107301485</a>
Easing of suffering in children with cancer at the end of life: is care changing?.
Child; Humans; Cohort Studies; Resuscitation Orders; Psychological; Stress; DNAR; Oncology at EOL; Neoplasms/th [Therapy]; Palliative Care/mt [Methods]; Palliative Care/td [Trends]
PURPOSE: In the past decade studies have documented substantial suffering among children dying of cancer, prompting national attention on the quality of end-of-life care and the development of a palliative care service in our institutions. We sought to determine whether national and local efforts have led to changes in patterns of care, advanced care planning, and symptom control among children with cancer at the end of life., METHODS: Retrospective cohort study from a US tertiary level pediatric institution. Parent survey and chart review data from 119 children who died between 1997 and 2004 (follow-up cohort) were compared with 102 children who died between 1990 and 1997 (baseline cohort)., RESULTS: In the follow-up cohort, hospice discussions occurred more often (76% v 54%; adjusted risk difference [RD], 22%; P < .001) and earlier (adjusted geometric mean 52 days v 28 days before death; P = .002) compared with the baseline cohort. Do-not-resuscitate orders were also documented earlier (18 v 12 days; P = .031). Deaths in the intensive care unit or other hospitals decreased significantly (RD, 16%; P = .024). Parents reported less child suffering from pain (RD, 19%; P = .018) and dyspnea (RD, 21%; P = .020). A larger proportion of parents felt more prepared during the child's last month of life (RD, 29%; P < .001) and at the time of death (RD, 24%; P = .002)., CONCLUSION: Children dying of cancer are currently receiving care that is more consistent with optimal palliative care and according to parents, are experiencing less suffering. With ongoing growth of the field of hospice and palliative medicine, further advancements are likely.
2008
Wolfe J; Hammel JF; Edwards KE; Duncan J; Comeau M; Breyer J; Aldridge SA; Grier HE; Berde C; Dussel V; Weeks JC
Journal Of Clinical Oncology
2008
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Journal Article
<a href="http://doi.org/10.1200/jco.2007.14.0277" target="_blank" rel="noreferrer">10.1200/jco.2007.14.0277</a>
Alterations in end-of-life support in the pediatric intensive care unit.
Child; Humans; Advance Directives; Withholding Treatment; Life Support Care; Resuscitation Orders; Brain Death; Pediatric; DNAR; Intensive Care Units; Terminal Care
OBJECTIVE: Our purpose was to examine alterations in end-of-life support in a multiinstitutional sample of PICUs., METHODS: This was a retrospective, descriptive study. Variables collected included end-of-life support category, race, length of stay, operative status, reason for admission, and Pediatric Index of Mortality 2 score, as well as the number of ICU beds and the presence of trainees., RESULTS: There were 1745 deaths at 35 institutions between January 1, 2004, and September 30, 2005. Of those, 1263 had complete data and were analyzed. The end-of-life support category distribution was as follows: brain death, 296 (23%); do not resuscitate, 205 (16%); limitation of support, 36 (3%); withdrawal of support, 579 (46%); no limitation, 124 (10%); no advance directives, 23 (2%). For further analyses, end-of-life support categories were grouped as limitation (ie, do not resuscitate, limitation of support, or withdrawal of support) versus no limitation (ie, no limitation or no advance directive). Brain death was not included in further analyses. The majority of deaths were in the limitation group (n=820 [85%]), and 12 (40%) of 30 institutions had 100% of deaths in this group. There were significant differences between institutions (P<.001). Decisions for limitation were seen less frequently in the black race (112 [76%] of 147 deaths; P=.037) and in institutions with no trainees (56 [69%] of 81 deaths; P<.001)., CONCLUSIONS: Decisions to limit support are common. Black race and an absence of trainees are associated with decreased frequency of limitation decisions.
2010
Lee KJ; Tieves K; Scanlon MC
Pediatrics
2010
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Journal Article
<a href="http://doi.org/10.1542/peds.2010-0420" target="_blank" rel="noreferrer">10.1542/peds.2010-0420</a>
Documenting end of life decisions in residential aged care facilities in South Australia.
Female; Humans; Male; Health Services Research; Sensitivity and Specificity; advance care planning; DNAR; Resuscitation Orders; Attitude to Death; documentation; South Australia; Palliative Care/ut [Utilization]; Advance Directives/td [Trends]; Homes for the Aged; Life Support Care/st [Standards]; Skilled Nursing Facilities; Life Support Care/td [Trends]
OBJECTIVE: This research examined the provision of palliative care for residents with a non-cancer diagnosis including the use of advance directives and advance care planning as part of palliative care policies in residential aged care facilities in South Australia. There are no guidelines for recording residents' wishes if they are no longer competent., METHODS: Stage 1 involved a survey of 90 randomly selected aged care facilities. Stage 2 involved case studies of 69 residents, appropriate for palliative care, from 17 facilities and interviews with 15 directors of care., RESULTS: Most residential aged care facilities used forms to record residents' wishes about end of life care, but there was little consistency. Some had no palliative care policy and few facilities required a formal advance directive. Not all residents had formally appointed a proxy., CONCLUSIONS: Residential aged care facilities should be required to develop and implement a palliative care policy acknowledging the Accreditation Standards and State legislation and including a simple tool for advance care planning. Case conferencing could assist in discussing and documenting the resident's wishes. Public education is essential to increase community and professional awareness in order to promote empowerment for the increasing number of older people who will die in residential aged care facilities.
2005
Brown M; Grbich C; Maddocks I; Parker D; Connellan PR; Willis E
Australian And New Zealand Journal Of Public Health
2005
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Journal Article
<a href="http://doi.org/10.1111/j.1467-842x.2005.tb00754.x" target="_blank" rel="noreferrer">10.1111/j.1467-842x.2005.tb00754.x</a>
Simple changes can improve conduct of end-of-life care in the intensive care unit.
Female; Humans; Male; Attitude of Health Personnel; Aged; Middle Aged; Resuscitation Orders; Intervention Studies; Patient Admission; Pastoral Care; retrospective studies; cause of death; DNAR; cardiopulmonary resuscitation; Intensive Care Units; Life Support Care; Palliative Care; Withholding Treatment; Analgesics/tu [Therapeutic Use]; Diazepam/tu [Therapeutic Use]; DNAR Outcomes; Hypnotics and Sedatives/tu [Therapeutic Use]; Nurses/px [Psychology]; Physicians/px [Psychology]
PURPOSE: To describe changes to the conduct of withdrawal of life support (WOLS) in two teaching hospital tertiary care medical surgical intensive care units (ICUs) in a single centre over two distinct time periods., METHODS: We used a retrospective chart review with a before and after comparison. We assessed aspects of end-of-life care for ICU patients dying after a WOLS before and after we introduced instruments to clarify do not resuscitate (DNR) orders and to standardize the WOLS process, sought family input into the conduct of end-of-life care, and modified physicians' orders regarding use of analgesia and sedation., RESULTS: One hundred thirty-eight patients died following life support withdrawal in the ICUs between July 1996 and June 1997 (PRE) and 168 patients died after a WOLS between May 1998 and April 1999 (POST). Time from ICU admission to WOLS (mean +/- SD) was shorter in the POST period (191 +/- 260 hr PRE vs 135 +/- 205 hr POST, P = 0.05). Fewer patients in the POST group received cardiopulmonary resuscitation in the 12-hr interval prior to death (PRE = 7; POST = 0: P < 0.05). Fewer comfort medications were used (PRE: 1.7 +/- 1.0 vs POST: 1.4 +/- 1.0; P < 0.05). Median cumulative dose of diazepam (PRE: 20.0 vs POST: 10.0 mg; P < 0.05) decreased. Documented involvement of physicians in WOLS discussions was unchanged but increased for pastoral care (PRE: 10/138 vs POST: 120/168 cases; P < 0.05). The majority of nurses (80%) felt that the DNR and WOLS checklists led to improved process around WOLS., CONCLUSION: Simple changes to the process of WOLS can improve conduct of end-of-life care in the ICU.
2004
Hall RI; Rocker GM; Murray D
Canadian Journal Of Anaesthesia
2004
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Journal Article
<a href="http://doi.org/10.1007/bf03018408" target="_blank" rel="noreferrer">10.1007/bf03018408</a>
One-year survival and neurological outcome after pediatric cardiopulmonary resuscitation
Child; Female; Humans; Male; Logistic Models; Resuscitation Orders; Survival Analysis; Predictive Value of Tests; Disability Evaluation; adolescent; Preschool; infant; retrospective studies; Outcomes; cardiopulmonary resuscitation; mortality
OBJECTIVE: Reported survival after cardiopulmonary resuscitation (CPR) in children varies considerably. We aimed to identify predictors of 1-year survival and to assess long-term neurological status after in- or outpatient CPR. DESIGN: Retrospective review of the medical records and prospective follow-up of CPR survivors. SETTING: Tertiary care pediatric university hospital. PATIENTS AND METHODS: During a 30-month period, 89 in- and outpatients received advanced CPR. Survivors of CPR were prospectively followed-up for 1 year. Neurological outcome was assessed by the Pediatric Cerebral Performance Category scale (PCPC). Variables predicting 1-year survival were identified by multivariable logistic regression analysis. INTERVENTIONS: None. RESULTS: Seventy-one of the 89 patients were successfully resuscitated. During subsequent hospitalization do-not-resuscitate orders were issued in 25 patients. At 1 year, 48 (54%) were alive, including two of the 25 patients with out-of-hospital CPR. All patients died, who required CPR after trauma or near drowning, when CPR began >10 min after arrest or with CPR duration >60 min. Prolonged CPR (21-60 min) was compatible with survival (five of 19). At 1 year, 77% of the survivors had the same PCPC score as prior to CPR. Predictors of survival were location of resuscitation, CPR during peri- or postoperative care, and duration of resuscitation. A clinical score (0-15 points) based on these three items yielded an area under the ROC of 0.93. CONCLUSIONS: Independent determinants of long-term survival of pediatric resuscitation are location of arrest, underlying cause, and duration of CPR. Long-term survivors have little or no change in neurological status.
2002
Horisberger T; Fischer E; Fanconi S
Intensive Care Medicine
2002
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Journal Article
<a href="http://doi.org/10.1007/s00134-001-1188-z" target="_blank" rel="noreferrer">10.1007/s00134-001-1188-z</a>
Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death
Female; Humans; Male; Hospital Mortality; Prospective Studies; Aged; Middle Aged; Comorbidity; Resuscitation Orders; Severity of Illness Index; Survival Analysis; Risk Factors; Hospitals; Analysis of Variance; Predictive Value of Tests; Proportional Hazards Models; Teaching; 80 and over; Empirical Approach; Death and Euthanasia; decision making; ICU Decision Making; Intensive Care Units/statistics & numerical data; APACHE; Critical Care/statistics & numerical data; Life Support Care/statistics & numerical data; Paris/epidemiology; Withholding Treatment/statistics & numerical data
OBJECTIVE: More than one-half the deaths of patients admitted to intensive care units (ICUs) occur after a decision to forgo life-sustaining therapy (DFLST). Although DFLSTs typically occur in patients with severe comorbidities and intractable acute medical disorders, other factors may influence the likelihood of DFLSTs. The objectives of this study were to describe the factors and mortality associated with DFLSTs and to evaluate the potential independent impact of DFLSTs on hospital mortality. DESIGN AND SETTING: Prospective multicenter 2-year study in six ICUs in France. PATIENTS: The 1,698 patients admitted to the participating ICUs during the study period, including 295 (17.4%) with DFLSTs. MEASUREMENTS AND RESULTS: The impact of DFLSTs on hospital mortality was evaluated using a model that incorporates changes in daily logistic organ dysfunction scores during the first ICU week. Univariate predictors of death included demographic factors (age, gender), comorbidities, reasons for ICU admission, severity scores at ICU admission, and DFLSTs. In a stepwise Cox model five variables independently predicted mortality: good chronic health status (hazard ratio, 0.479), SAPS II score higher than 39 (2.05), chronic liver disease (1.463), daily logistic organ dysfunction score (1.357 per point), and DFLSTs (1.887). CONCLUSIONS: DFLSTs remain independently associated with death after adjusting on comorbidities and severity at ICU admission and within the first ICU week. This highlights the need for further clarifying the many determinants of DFLSTs and for routinely collecting DFLSTs in studies with survival as the outcome variable of interest.
2003
Azoulay E; Pochard F; Garrouste-Orgeas M; Moreau D; Montesino L; Adrie C; deLassence A; Cohen Y; Timsit JF; Outcomerea Study Group
Intensive Care Medicine
2003
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Journal Article
<a href="http://doi.org/10.1007/s00134-003-1989-3" target="_blank" rel="noreferrer">10.1007/s00134-003-1989-3</a>
The impact of a palliative medicine consultation service in medical oncology.
Female; Humans; Male; Adult; Prognosis; Eligibility Determination; Prospective Studies; Aged; Middle Aged; Resuscitation Orders; Health Status; adolescent; 80 and over; social support; DNAR; hospice care; Pain/dt [Drug Therapy]; Medical Oncology; Neoplasms/th [Therapy]; Palliative Care/ut [Utilization]; referral and consultation; Pain/et [Etiology]; Palliative Care/og [Organization & Administration]
This prospective study of consecutive patients describes the palliative medicine consult service in a tertiary level cancer center and its impact on patient care. All inpatients/outpatients referred to the Palliative Medicine Program in a 4-month period were enrolled. Data were collected at the initial consultation using standardized forms with spaces for: reason for the consultation, referring service, demographics and history, ECOG performance status, symptoms, prognosis and diagnostic tests, treatment, and care plan. In all, 240 patients were seen: 79% were referred for symptom management; 53% were referred from medical oncology; and 50% were women. Median patient age was 67 years (range 18-96). Median performance status was 2 (1-4). Most (84%) of the patients had cancer. The cancer sites were: lung in 26% of cases, colorectal in 8%, and breast in 7%. Inpatients accounted for 53% and outpatients, for 47% of the study population. The median number of symptoms per patient was 13 (2-30). The estimated survival was <2 weeks in 15%, 2-8 weeks in 38%, 2-6 months in 37%, and >6 months in 10%. The patients' goals were: improve symptoms for 84%, return home for 55%, and no further admissions for 5%. The support systems named by patients were: family in 89%, friends in 13%, and the community in 5%. Hospice care was discussed at the consultation with 38% of the patients, would have been inappropriate for 31%, was not discussed with 22%, and had been discussed before with 9%. In response to questions about psychosocial care, a caregiver was identified by 78%, a spokesperson by 75%, and durable power of attorney was referred to by 21%. The DNR status was discussed on consult by 57%, had already been discussed with 30%, and was not discussed with 13%. Plan of care foresaw outpatient follow-up for 40%, inpatient follow-up for 32%, and transfer to palliative medicine for 27%. In 39% of cases the consults were considered late referrals. New medications suggested were opioids for 46% of patients, antiemetics for 28%, a bowel regimen for 24%, steroids for 15%, and others for 51%. (1) Palliative medicine consultation involves common complex medical, psychological, and social problems. (2) Complex symptomatology in this population is confirmed. (3) Multiple interventions were suggested even at the initial consultation. (4) Important issues such as DNR (do not resuscitate) status, support system, treatment goals, and eligibility for hospice care had often not been addressed.
2002
Homsi J; Walsh D; Nelson KA; LeGrand SB; Davis M; Khawam E; Nouneh C
Supportive Care In Cancer : Official Journal Of The Multinational Association Of Supportive Care In Cancer
2002
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Journal Article
<a href="http://doi.org/10.1007/s00520-002-0341-8" target="_blank" rel="noreferrer">10.1007/s00520-002-0341-8</a>
Circumstances surrounding end of life in a pediatric intensive care unit
Child; Female; Humans; infant; Male; Intensive Care Units; Adult; Parent-Child Relations; Withholding Treatment; Attitude to Death; Resuscitation Orders; Ontario; Analgesia; Treatment Failure; Pediatric; adolescent; Preschool; patient care team; decision making; infant; Newborn; ICU Decision Making; cause of death; Parents/psychology; Physicians/psychology; Terminal Care/psychology
OBJECTIVE: Approximately 60% of deaths in pediatric intensive care units follow limitation or withdrawal of life-sustaining treatment (LST). We aimed to describe the circumstances surrounding decision making and end-of-life care in this setting. METHODS: We conducted a prospective, descriptive study based on a survey with the intensivist after every consecutive death during an 8-month period in a single multidisciplinary pediatric intensive care unit. Summary statistics are presented as percentage, mean +/- standard deviation, or median and range; data are compared using the Mantel-Haenszel test and shown as survival curves. RESULTS: Of the 99 observed deaths, 27 involved failed cardiopulmonary resuscitation; of the remaining 72, 39 followed withdrawal/limitation (W/LT) of LST, 20 were do not resuscitate (DNR), and 13 were brain deaths (BDs). Families initiated discussions about forgoing LST in 24% (17 of 72) of cases. Consensus between caregivers and staff about forgoing LST as the best approach was reached after the first meeting with 51% (35 of 68) of families; 46% (31 of 68) required >or=2 meetings (4 not reported). In the DNR group, the median time to death after consensus was 24 hours and for W/LT was 3 hours. LST was later withdrawn in 11 of 20 DNR cases. The family was present in 76% (45 of 59) of cases when LST was forgone. The dying patient was held by the family in 78% (35 of 45) of these occasions. CONCLUSIONS: More than 1 formal meeting was required to reach consensus with families about forgoing LST in almost half of the patients. Families often held their child at the time of death. The majority of children died quickly after the end-of-life decision was made.
2003
Garros D; Rosychuk RJ; Cox PN
Pediatrics
2003
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Journal Article
<a href="http://doi.org/10.1542/peds.112.5.e371" target="_blank" rel="noreferrer">10.1542/peds.112.5.e371</a>
Discussing do-not-resuscitate orders in the hospital setting: Part 1
Hospitalization; Communication; decision making; Human; Resuscitation Orders; Terminal Care; Patient Education; Patient Participation
2002
von Gunten CF; Weissman DE
Journal Of Palliative Medicine
2002
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Journal Article
Discussing do-not-resuscitate orders in the hospital setting: Part 2
Medical Futility; Human; Resuscitation Orders; Emotions
2002
von Gunten CF; Weissman DE
Journal Of Palliative Medicine
2002
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Journal Article
Limitations and withdrawals of medical intervention in pediatric critical care
Child; Female; Humans; Male; Survival Rate; United States; Intensive Care Units; Withholding Treatment; Hospital Mortality; Resuscitation Orders; Patient Selection; Analysis of Variance; Outcome and Process Assessment (Health Care); Preschool; Empirical Approach; Death and Euthanasia; infant; ICU Decision Making; Intervention; Interventions; Life Support Care/utilization; Pediatric/standards/statistics & numerical data
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.
1994
Levetown M; Pollack MM; Cuerdon TT; Ruttimann UE; Glover JJ
Jama
1994
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Journal Article
<a href="http://doi.org/10.1001/jama.272.16.1271" target="_blank" rel="noreferrer">10.1001/jama.272.16.1271</a>
How children die in hospital.
Child; Humans; Death; Palliative Care; symptoms; Euthanasia; Communication; Death; Resuscitation Orders; Longitudinal Studies; Critical Care; Children; Children; Preschool; infant; DNAR; Human; Pediatric intensive care unit; Passive; Hospital Mortality; Infant Mortality; Canuck Place 15 year chart review; dying; Infants; Pediatric intensive care unit
A retrospective analysis was performed to describe the course of terminal care provided to dying hospitalized children in terms of symptom assessment and management, and communication and decision-making, at the end of life. Seventy-seven of 236 infants and children who died after hospital admission in Edmonton, Canada between January 1996 and June 1998 met entry criteria. Only children who died after a minimum hospitalization of 24 hours in the case of chronic illness or after a minimum hospitalization of 7 days following an acute event were included. Unanticipated deaths were excluded. Eighty-three percent of children died in intensive care settings (64/77), and 78 % (60/77) were intubated prior to their death. Symptoms were recorded in narrative progress notes. Five of 77 (6%) charts contained specific pain assessment and treatment records. Opioid analgesia was provided in 84 % of all cases (65/77). Six (8 %) patients had do not resuscitate (DNNR) orders preceding final hospital admission and 56/71 (79%) remaining patients had documented discussion resulting in DNR decision during final hospital admission. Median time from DNR to death was < 1 day. Mode of death was withdrawal of therapy in 33/77 (43 %), no cardiopulmonary resuscitation (CPR) in 26/77 (34 %), andfailed CPR in 13/77 (17%). Five children were declared brain dead. In only one case was there evidence in the medical record of the possibility of death being discussed explicitly with the patient. Decision-making regarding end-of-life issues in this pediatric population was deferred very close to the time of death, and only after no remaining curative therapy was available. Acuity of care was very high prior to death. Children are rarely told that they are dying.
2000
McCallum DE; Byrne P; Bruera E
Journal Of Pain And Symptom Management
2000
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Journal Article
<a href="http://doi.org/10.1016/s0885-3924(00)00212-8" target="_blank" rel="noreferrer">10.1016/s0885-3924(00)00212-8</a>
Variables influencing end-of-life care in children and adolescents with cancer
Child; Female; Humans; Male; Adult; Withholding Treatment; Resuscitation Orders; adolescent; Preschool; Empirical Approach; Death and Euthanasia; decision making; infant; cause of death; Neoplasms/complications/therapy; location of death; hospice care; home care services; Terminal Care/trends
BACKGROUND: The purpose of this study was to describe the variables influencing end-of-life care in children and adolescents dying of cancer. MATERIALS AND METHODS: Records of 146 children with cancer who died at Children's Hospital were reviewed for demographics, diagnosis, location of death, withdrawal of life support, use of "do not resuscitate" (DNR) orders, and the length of time that those orders were in effect. RESULTS: Ninety-five patients were evaluated. Fifty-nine died of progressive disease and 36 deaths were therapy-related. Sixty-four percent of disease-related deaths occurred at home with support from home care or hospice. Only 10% of all patients died while receiving maximal aggressive support in the intensive care unit. Age, diagnosis (solid tumor vs. leukemia), cause of death, length of last hospital admission, and the duration of DNR orders had a significant correlation with the place of death and referral to and use of hospice. Thirty-five percent of all patients had hospice support. CONCLUSIONS: Most children who die of cancer die because of progressive disease at home with hospice support. Do not resuscitate orders were written for most patients who died. End-of-life decisions are influenced by patient diagnosis, cause of death, and age.
Klopfenstein KJ; Hutchison C; Clark C; Young D; Ruymann FB
Journal Of Pediatric Hematology/oncology
2001
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Journal Article
<a href="http://doi.org/10.1097/00043426-200111000-00004" target="_blank" rel="noreferrer">10.1097/00043426-200111000-00004</a>
Assessing preferences about the DNR order: does it depend on how you ask?
Female; Humans; Male; Attitude to Health; Treatment Outcome; Choice Behavior; Resuscitation Orders; Quality-Adjusted Life Years; Research Design; Probability; Reproducibility of Results; Non-U.S. Gov't; Research Support; Students; Questionnaires/standards; Effect Modifiers (Epidemiology); Nursing/psychology; Resuscitation/adverse effects
Despite increasing emphasis on advance directives, there has been little methodologic work to assess preferences about the "do not resuscitate" (DNR) order. This developmental work assessed, in a non-patient group, the performance of a probability-trade-off task designed to assess DNR attitudes, in terms of framing effects and stability of preferences. 105 female nursing students each completed one of two versions of the task. In version I (n = 58), the trade-off moved to increasingly negative descriptions of the outcomes of resuscitation (decreasing chance of survival and increasing risk of brain death), whereas in version II (n = 47), the trade-off moved to increasingly positive descriptions. One week later, repeat assessments were obtained for versions I (n = 35) and II (n = 28). The DNR preference scores were lower and more stable when the task moved to increasingly positive descriptions; perhaps this version of the task tends to weaken risk aversion. These results imply that care should be used in applying a probability trade-off task to the assessment of DNR preferences, since artefactual effects could be induced.
1995
Percy ME; Llewellyn-Thomas HA
Medical Decision Making
1995
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Journal Article
<a href="http://doi.org/10.1177/0272989x9501500303" target="_blank" rel="noreferrer">10.1177/0272989x9501500303</a>