50 - Do Not Resuscitate and the Terminally Ill Child

Abstract

Despite great advances in cancer treatments, cancer remains the leading cause of disease-related death in children in the United States. Decisions regarding life-prolonging interventions for children who reach the terminal phase of illness are legally left in the hands of their parents (or guardians). Frank and compassionate conversations with surrogate decision-makers regarding prognosis, patient and family values, and, ultimately, goals of care should begin early for children with poor prognoses. Advanced care planning, now routine in adults, can increase the likelihood that care at end of life is aligned with patient/family values and also leads to more peaceful death. Palliative surgical and interventional procedures can provide relief from distressing symptoms near end of life, and risks and benefits must be carefully considered. Patients with preoperative do not resuscitate (DNR) orders who are also candidates for invasive procedures will require some discussion regarding specific interventions to be given and/or withheld in the perioperative setting. In most centers, DNR orders are revoked in the perioperative setting. In this chapter, we will review the processes involved in identifying goals of care for pediatric patients with terminal cancer, common symptoms at end of life, and treatments and procedures that may be helpful, and discuss the inherent difficulty in maintaining a DNR order in the perioperative setting.