Racial and Ethnic Disparities in End-of-Life Care of Children Undergoing Terminal Extubation in ICU

Racial and Ethnic Disparities in End-of-Life Care of Children Undergoing Terminal Extubation in ICU

Burkiewicz K; Winter M; Tripathi S

Critical Care Medicine

2024

Child; child; adult; Caucasian; female; human; major clinical study; male; aged; terminal care; morphine; pediatric intensive care unit; ethnicity; positive pressure ventilation; ethnic group; Only Child; intensive care unit; intensive care; conference abstract; ventilator; electronic medical record; age distribution; Hispanic; secondary analysis; benzodiazepine; extubation; airway pressure; ethnic difference; hypertensive factor; positive end expiratory pressure ventilation; racial disparity

INTRODUCTION: Among elderly adults, significant racial disparities in hospice and end-of-life treatment intensity have been shown. This single-center secondary analysis was performed on data collected as part of the DONATE (Death One Hour After Terminal Extubation) study to identify racial and ethnic differences among children who had terminal extubation (TE) in the pediatric ICU. <br/>METHOD(S): Prespecified variables from patients (0-21 years) who died in the pediatric ICU after TE between 2010 and 2021 were extracted from the EMR by manual review and entered in the DONATE registry. For this analysis, we reviewed data from our center only for racial and ethnic differences. Race and ethnicity were combined into a derived variable of Hispanic, non-Hispanic Black, and non-Hispanic White for the analysis. <br/>RESULT(S): A total of 61 patients had TE (4 Hispanic, 12 non-Hispanic Black, 45 non-Hispanic White). There was no significant difference in the age distribution or primary diagnosis. Median time to death after TE was 14.5 (IQR 8.3, 62) minutes for Black, 19.5 (IQR 14.3, 930) minutes for Hispanic, and 24 (IQR 16, 58) minutes for White. Among patients (n=46) who died within one hour of TE, the maximum ventilator support in the last 24 hours before TE, including PEEP, mean airway pressure, and FiO2, trended higher in the White patients compared to Black patients. However, the difference was only significant for maximum FiO2 (65% for White compared to 40% for Black = 0.04). A similar proportion of the two groups required vasopressors (77% Black vs. 67% White) in the last 24 hours. An analysis of the medication administration at the end of life showed that there was a trend towards higher use of morphine or benzodiazepine within the last 24 hours in White patients compared to Black Patients (84% vs. 66%, p = 0.22 and 54% vs. 33%, p = 0.25 respectively) as well as within one hour (66% vs. 22%, P = 0.016 and 30% vs. 11%, p = 0.24, respectively) of TE. <br/>CONCLUSION(S): Single-center secondary analysis on previously collected data showed a trend toward discrepancies in end-of-life care between racial and ethnic groups. Most of the differences, however, were not statistically significant, and a larger adequately powered study is needed to better delineate the differences as well as identify potential contributing mechanisms.

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