Limitation Of Life Support Research Articles

Constitutional and Legal Protection for Life Support Limitation in India.

Appropriate treatment limitations towards the end of life to reduce unwanted burdens require ethical clarity that is supported by appropriate legislation. The lack of knowledge of enabling legal provisions, physicians feel vulnerable to legal misinterpretation of treatment limiting decisions. In India the lack of societal awareness, inadequate exploration of the gray areas of bio-ethics and unambiguous legal position relating to terminal illness have resulted in poor quality end of life care. Much of the perceived vulnerability by the physician is attributable to insufficient knowledge and understanding of existing constitutional and legal position in India. While we await informed legal and legislative opinion, this paper highlights possible legal liabilities arising from treatment limitation decisions with available defense. It is hoped that such clarity would lead to more confident ethical decisions and improved end of life care for patients.

Nurses' autonomy in end-of-life situations in intensive care units.

The intensive care unit environment focuses on interventions and support therapies that prolong life. The exercise by nurses of their autonomy impacts on perception of the role they assume in the multidisciplinary team and on their function in the intensive care unit context. There is much international research relating to nurses' involvement in end-of-life situations; however, there is a paucity of research in this area in Brazil. In the Brazilian medical scenario, life support limitation generated a certain reluctance of a legal nature, which has now become unjustifiable with the publication of a resolution by the Federal Medical Council. In Brazil, the lack of medical commitments to end-of-life care is evident. To understand the process by which nurses exercise autonomy in making end-of-life decisions in intensive care units. Symbolic Interactionism and Corbin and Strauss theory methodology were used for this study. Data were collected through single audio-recorded qualitative interviews with 14 critical care nurses. The comparative analysis of the data has permitted the understanding of the meaning of nurse's experience in exercising autonomy relating to end-of-life decision-making. Institutional ethics approval was obtained for data collection. Participants gave informed consent. All data were anonymized. The results revealed that nurses experience the need to exercise autonomy in intensive care units on a daily basis. Their experience expressed by the process of increase opportunities to exercise autonomy is conditioned by the pressure of the intensive care unit environment, in which nurses can grow, feel empowered, and exercise their autonomy or else can continuously depend on the decisions made by other professionals. Nurses exercise their autonomy through care. They work to create new spaces at the same time that they acquire new knowledge and make decisions. Because of the complexity of the end-of-life situation, nurses must adopt a proactive attitude that inserts them into the decision-making process.

Beyond 30-day mortality: aligning surgical quality with outcomes that patients value.

Because of their strong sense of responsibility for the lives of patients, surgeons frequently struggle to withdraw postoperative life supporting treatments when patients or their families request it.1 Although surgeons experience this as therapeutic optimism or the emotional pull of error and responsibility, these forces are accentuated by the increasing emphasis on 30-day mortality reporting. Recent expansion of outcomes profiling imposes an unconscious bias in these critical decisions: surgeons who report concern about physician profiling are more likely to decline to operate on a patient who prefers to limit life support, or refuse to withdraw life support postoperatively, than surgeons who perceive less pressure from outcomes reporting.2,3 Public reporting of 30-day mortality may motivate surgeons and hospitals to improve outcomes and theoretically empowers patients to make informed choices.4 However, use of this single metric unintentionally fails to accommodate patients who might benefit from palliative surgery, or patients who would prefer death to prolonged postoperative treatment in the intensive care unit or long-term chronic care after a major complication. Surgeons should be able to offer informed patients a risky but potentially beneficial surgical option and then allow patients to refuse aggressive treatments if they have become overly burdensome or when patients’ goals for surgery are no longer possible. Reconciling the effects of an approach designed to ensure high quality surgical care with the needs of vulnerable patients is challenging, particularly for high-risk operations where hard outcomes like mortality are easily observed and other important outcomes are more difficult to assess. Strategies to mitigate the impact of 30-day mortality reporting through consideration of alternative quality metrics are required to protect the needs of surgical patients and the practices of surgeons who could make a valuable contribution to their patients’ quality of life.

Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit

IntroductionHeparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk.MethodsWe performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH.ResultsWe enrolled 1,935 patients (62.3 ± 16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1 ± 8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95% CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95% CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95% CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95% CI 0.05, 0.23).ConclusionsGuideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target.

Age and decisions to limit life support for patients with acute lung injury: a prospective cohort study.

IntroductionThe proportion of elderly Americans admitted to the intensive care unit (ICU) in the last month of life is rising. Hence, challenging decisions regarding the appropriate use of life support are increasingly common. The objective of this study was to estimate the association between patient age and the rate of new limitations in the use of life support, independent of daily organ dysfunction status, following acute lung injury (ALI) onset.MethodsThis was a prospective cohort study of 490 consecutive patients without any limitations in life support at the onset of ALI. Patients were recruited from 11 ICUs at three teaching hospitals in Baltimore, Maryland, USA, and monitored for the incidence of six pre-defined limitations in life support, with adjustment for baseline comorbidity and functional status, duration of hospitalization before ALI onset, ICU severity of illness, and daily ICU organ dysfunction score.ResultsThe median patient age was 52 (range: 18 to 96), with 192 (39%) having a new limitation in life support in the ICU. Of patients with a new limitation, 113 (59%) had life support withdrawn and died, 53 (28%) died without resuscitation, and 26 (14%) survived to ICU discharge. Each ten-year increase in patient age was independently associated with a 24% increase in the rate of limitations in life support (Relative Hazard 1.24; 95% CI 1.11 to 1.40) after adjusting for daily ICU organ dysfunction score and all other covariates.ConclusionsOlder critically ill patients are more likely to have new limitations in life support independent of their baseline status, ICU-related severity of illness, and daily organ dysfunction status. Future studies are required to determine whether this association is a result of differences in patient preferences by age, or differences in the treatment options discussed with the families of older versus younger patients.

Optimization of cardiopulmonary resuscitation using the iRCP/iCPR smartphone application

Objective: Analyze in hospital care provided to the patient in cardiac arrest (CA) prior to ALS Team arrival. This will be included in an improvement cycle in the context of commissioning a Cardiac Arrest management hospital plan. Material andmethods:Prospective observational study including CA alerts to the ALS Team (ICU of the University Hospital “Santa Lucia”, Cartagena, Spain) from January-2012 toMay-2013. It is done descriptive analysis of ward and emergencies personnel performance prior to the arrival of ALS team. Results: There were collected 73 patients. Mean age: 70.54 years (CI 95%: 67.25–73.83), Gender Male: 67.1%. Limitation of life support in 21.9%. Alert’s source: Internal Medicine ward (45.2%), followed by ER (36.9%). Basic life support was started at 45.2%. Delay CA team alert: 212.8′′ (CI 95%: 158.4–267.2′′), delay in cardiac rhythm acquisition: 381” (CI: 298.8–478.8). Delay in the onset of ALS manoeuvres: 325.26” (CI 340.0–410.5′′). The most common initial rhythm was Asystole (45.2%). Any kind of defibrillator was used by 8.33%. The teamperformed ALS in 79.5% of the alerts, 13.7% were falsearrests.Outcome:75.3%deadathospital discharge, 61.1% of the patients discharged alive had a Glasgow-Pittsburgh cerebral performance categories 1–2. Conclusions:

Pseudomonas aeruginosa Ventilator-associated Pneumonia. Predictive Factors of Treatment Failure

The predictive factors of treatment failure for ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa (PA) remain uncertain. To describe PA-VAP recurrence prognosis and to identify associated risk factors in a large cohort of intensive care unit patients with PA-VAP. From the multicenter OUTCOMEREA database (1997-2011), PA-VAP onset and recurrence were recorded. All suspected cases of VAP were confirmed by a positive quantitative culture of a respiratory sample. Multidrug-resistant PA strains were defined by the resistance to two antibiotics among piperacillin, ceftazidime, imipenem, colistine, and fluoroquinolones (FQ). An extensively resistant PA was defined by resistance to piperacillin, ceftazidime, imipenem, and FQ. A treatment failure was defined as a PA-VAP recurrence or by the death occurrence. A total of 314 patients presented 393 PA-VAP. Failure occurred for 112 of them, including 79 recurrences. Susceptible, multidrug resistant, and extensively resistant PA represented 53.7%, 32%, and 14.3% of the samples, respectively. Factors associated with treatment failure were age (P = 0.02); presence of at least one chronic illness (P = 0.02); limitation of life support (P = 0.0004); a high Sepsis-Related Organ Failure Assessment score (P < 0.0001); PA bacteremia (P = 0.003); and previous use of FQ before the first PA-VAP (P = 0.0007). The failure risk was not influenced by the strain resistance profile or by the biantibiotic treatment, but decreased in case of VAP treatment that includes FQ (subdistribution hazard ratio, 0.5 [0.3-0.7]; P = 0.0006). However, the strain resistance profile slowed down the intensive care unit discharge hazard (subdistribution hazard ratio, 0.6 [0.4-1.0]; P = 0.048). Neither resistance profile nor biantibiotic therapy decreased the risk of PA-VAP treatment failure. However, the profile of PA resistance prolonged the length of stay. Better evaluation of the potential benefit of an initial treatment containing FQ requires further randomized trials.

Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study

Our aim was to explore reasons for physician variability in decisions to limit life support in the intensive care unit (ICU) utilizing qualitative methodology. Single center study consisting of semi-structured interviews with experienced physicians and nurses. Seventeen intensivists from medical (n = 7), surgical (n = 5), and anesthesia (n = 5) critical care backgrounds, and ten nurses from medical (n = 5) and surgical (n = 5) ICU backgrounds were interviewed. Principles of grounded theory were used to analyze the interview transcripts. Eleven factors within four categories were identified that influenced physician variability in decisions to limit life support: (1) physician work environment-workload and competing priorities, shift changes and handoffs, and incorporation of nursing input; (2) physician experiences-of unexpected patient survival, and of limiting life support in physician's family; (3) physician attitudes-investment in a good surgical outcome, specialty perspective, values and beliefs; and (4) physician relationship with patient and family-hearing the patient's wishes firsthand, engagement in family communication, and family negotiation. We identified several factors which physicians and nurses perceived were important sources of physician variability in decisions to limit life support. Ways to raise awareness and ameliorate the potentially adverse effects of factors such as workload, competing priorities, shift changes, and handoffs should be explored. Exposing intensivists to long term patient outcomes, formalizing nursing input, providing additional training, and emphasizing firsthand knowledge of patient wishes may improve decision making.

Cranioplasty with bandaging: New forms of limitation of life support and organ donation

Abstract Most of the transplanted organs are obtained from brain death (BD) donors. In neurocritical patients with catastrophic injuries and decompressive craniectomy (DC), which show a dreadful development in spite of this treatment, DC could be a futile tool to avoid natural progress to BD. We propose whether cranial compressive bandage (cranioplasty with bandage) could be an ethically correct practice, similar to other life-sustaining treatment limitation (LSTL) common methods. Based on a clinical case, we had contacted the Assistance Ethics Committee and some of the bioethics professionals and asked them two questions: 1) Is ethically correct to perform a cranioplasty with bandage in those patients with LSTL indication? 2) Thinking in organ donation possibility, is this option preferable? Conclusions (1) Cranioplasty with bandage could be considered an ethically acceptable LSTL practice, similar to other procedures. (2) It facilitates organ donation for transplant, which provides for value-added proposition because of its own social good. (3) In these cases, it is necessary to know previous patient's will or, in absentia, to obtain family consent after a detailed procedure report.

Changes in end of life care 5 years after the introduction of a rapid response team: A multicentre retrospective study

RationaleRapid response teams (RRTs) are intended to stabilize deteriorating patients on the ward, but recent studies suggest that RRTs may also improve end-of-life care (EOLC). We sought to study the effect of introducing an RRT on EOLC at our institutions, and compare the EOLC care received by patients who were consulted by the RRT with that of patients who were not consulted by the RRT. MethodsRetrospective review of 450 consecutive deaths at 3 institutions. We compared demographic factors and EOLC received before (2005) and 5 years after (2010) the introduction of an RRT. We also compared these same factors for patients who died in 2010 with and without RRT consultation. ResultsThere were no differences in the proportion of patients who had Patient/Family Conferences or orders to limit life support on the ward between 2005 and 2010. Although the RRT was consulted for 30% of patients eligible to be seen by the RRT, the RRT was involved in only 11.1% of Patient/Family Conferences that took place on the ward. The prevalence of palliative care consultation and orders for opioids as needed was higher in 2010 than 2005, but those seen by the RRT were less likely to receive a palliative care consultation (30.2% vs. 55.9%), spiritual care consultation (25.4% vs. 41.3%) or an order for sedatives as needed (44.4% vs. 65.0%) than those who were not seen by the RRT. There was no change in the proportion of patients admitted to the ICU in 2010 compared with 2005, and multivariable logistic regression showed that the year of death did not influence the likelihood of ICU admission based on any comorbid or demographic factors. ConclusionsThe introduction of an RRT was not associated with significant improvements in EOLC at our institutions. However, almost 1/3 of dying patients were consulted by the RRT, suggesting that the RRT could play a role in facilitating improved EOLC for some inpatients.

Physician Staffing Models Impact the Timing of Decisions to Limit Life Support in the ICU

A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making. A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record. The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death ( P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days ( P = .09), time to decision to limit any life support was shortened by 1 day ( P = .08), time to death was shortened by 2 days ( P = .08), and intubations against patient wishes decreased (from three to none; P = .12). The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.

Surgeons Expect Patients to Buy-In to Postoperative Life Support Preoperatively

Evidence suggests that surgeons implicitly negotiate with their patients preoperatively about the use of life supporting treatments postoperatively as a condition for performing surgery. We sought to examine whether this surgical buy-in behavior is present among a large, nationally representative sample of surgeons who routinely perform high-risk operations. Using findings from a qualitative study, we designed a survey to determine the prevalence of surgical buy-in and its consequences. Respondents were asked to consider their response to a patient at moderate risk for prolonged mechanical ventilation or dialysis who has a preoperative request to limit postoperative life- supporting treatment. We used bivariate and multivariate analysis to identify surgeon characteristics associated with 1) preoperatively creating an informal contract with the patient defining agreed upon limitations of postoperative life support and 2) declining to operate on such patients. U.S. mail-based survey of 2,100 cardiothoracic, vascular, and neurosurgeons. None. The adjusted response rate was 56%. Nearly two thirds of respondents (62%) reported they would create an informal contract with the patient describing agreed upon limitations of aggressive therapy and a similar number (60%) endorsed sometimes or always refusing to operate on a patient with preferences to limit life support. After adjusting for potentially confounding covariates, the odds of preoperatively contracting about life-supporting treatment were more than two-fold greater among surgeons who felt it was acceptable to withdraw life support on postoperative day 14 compared with those who believed it was not acceptable to withdraw life support on postoperative day 14 (odds ratio 2.1, 95% confidence intervals 1.3-3.2). Many surgeons will report contracting informally with patients preoperatively about the use of postoperative life support. Recognition of this process and its limitations may help to inform postoperative decision making.

Clinical review: Ethics and end-of-life care for critically ill patients in China

Critical care medicine in China has made great advances in recent decades. This has led to an unavoidable issue: end-of-life ethics. With advances in medical technology and therapeutics allowing the seemingly limitless maintenance of life, the exact time of death of an individual patient is often determined by the decision to limit life support. How to care for patients at the end of life is not only a medical problem but also a social, ethical, and legal issue. A lot of factors, besides culture, come into play in determining a person’s ethical attitudes or behaviors, such as experience, education, religion, individual attributes, and economic considerations. Chinese doctors face ethical problems similar to those of their Western counterparts; however, since Chinese society is different from that of Western countries in cultural traditions, customs, religious beliefs, and ethnic backgrounds, there is a great difference between China and the Western world in regard to ethics at the end of life, and there is also a huge controversy within China.

Deaths in a paediatric intensive care unit: A review over three years

Background: Deaths in paediatric intensive care units (PICUs) are sometimes unavoidable. The decision to withdraw or withhold treatment is important especially in places where there are limited resources. Objective : To evaluate the modes of death and underlying diseases of patients’ deaths in a PICU. Method : We retrospectively reviewed the clinical features and management of consecutive non-survivors in the PICU at a tertiary care University Hospital in a developing country over a three-year period. Results : Of 1,389 admissions, 110 (8%) patients died. The median age of the deaths was 4.1 years. Most (86%) patients had underlying diseases including congenital heart diseases (27%) and malignancies (23%). Forty-seven patients died with active treatment (AT), 60 died with life support limitation (LSL), and 3 had brain death (BD). The median length of stay (LOS) in AT group was 3 days and this was not significantly different ( p =0.056) from the median LOS in LSL group which was 5 days. LOS less than 3 days, postoperative cases and underlying diseases of the cardiovascular system were factors associated with the AT group. The three common complications leading to death were multi-organ failure, septicaemia with septic shock and respiratory failure. Conclusions : Congenital heart diseases and malignancies were the two common underlying diseases found in non-survivors. LSL was the common mode of death in PICU. (Key words: paediatric intensive care unit; mode of death; life support limitation; active treatment; brain death) DOI: http://dx.doi.org/10.4038/sljch.v41i4.4977

Physician Staffing Models Impact the Timing of Decisions to Limit Life Support in the ICU

SESSION TYPE: Hot Topics in Respiratory & Critical Care

Recommendations to limit life support: a national survey of critical care physicians.

There is debate about whether physicians should routinely provide patient surrogates with recommendations about limiting life support. To explore physicians' self-reported practices and attitudes. A cross-sectional, stratified survey of 1,000 randomly selected US critical care physicians was mailed. We included a vignette to experimentally examine how surrogate desire for a recommendation and physician agreement with the surrogate modified whether physicians would provide a recommendation. Proportion of respondents reporting they routinely provide surrogates with a recommendation and how responses varied based on vignette characteristics. A total of 608 (66%) of 922 eligible physicians participated. Approximately one (22%) in five reported always providing surrogates with a recommendation, whereas 1 (11%) in 10 reported rarely or never doing so. Almost all respondents reported comfort making recommendations (92%) and viewed them as appropriate (93%). Most also viewed recommendations as a critical care physician's duty (87%) and did not view them as unduly influential (80%). Approximately two-fifths (41%) believed recommendations were only appropriate if sought by surrogates. In response to the vignettes, nearly all respondents (91%) provided a recommendation when the surrogate requested a recommendation and the physician agreed with the surrogate's likely decision. Physicians were less likely to provide an unwanted recommendation, both when physicians agreed (29%) and disagreed with the surrogate's likely decision (44%). There is substantial variation among physicians' self-reported use of recommendations to surrogates of critically ill adults. Surrogates' desires for recommendations and physicians' agreement with surrogates' likely decisions may have important influence on whether recommendations are provided.

Short profile for the human spacecraft Soyuz-TMA rendezvous mission to the ISS

Reduction of flight duration after insertion till docking to the ISS is considered. In the beginning of the human flight era both the USSR and the USA used short mission profiles due to limited life support resources. A rendezvous during these missions was usually achieved in 1–5 revolutions. The short-term rendezvous were made possible by the coordinated launch profiles of both rendezvousing spacecraft, which provided specific relative position of the spacecraft or phase angle conditions. After the beginning of regular flights to the orbital stations these requirements became difficult to fulfill. That is why it was decided to transfer to 1- or 2-day rendezvous profile. The long stay of a crew in a limited habitation volume of the Soyuz-TMA spacecraft before docking to the ISS is one of the most strained parts of the flight and naturally cosmonauts wish to dock to the ISS as soon as possible. As a result of previous studies the short four-burn rendezvous mission profile with docking in a few orbits was developed. It is shown that the current capabilities of the Soyuz-FG launch vehicle and the Soyuz-TMA spacecraft are sufficient to provide for that. The first test of the short rendezvous mission during Progress cargo vehicle flight to the ISS is planned for 2012. Possible contingencies pertinent to this profile are described. In particular, in the majority of the emergency cases there is a possibility of an urgent transfer to the present 2-day rendezvous profile. Thus, the short mission will be very flexible and will not influence the ISS mission plan. Fuel consumption for the nominal and emergency cases is defined by statistical simulation of the rendezvous mission. The qualitative analysis of the short-term and current 2-day rendezvous missions is performed.

Therapiebegrenzung in der Intensivmedizin - Was ist in der Praxis zu beachten?

End-of-life decisions (EOLD) are frequently used in patients who die in the intensive care unit. The decision to limit life support and the extent of limitation depends on the nature of the disease, its progress and the presumed prognosis and, equally important, the patient's preferences. These preferences should be stated by the patient if he or she is able to do so. If not, the patient's assumed will can be elicited by using written advance directives or with the help of surrogate decision makers.Primarily withholding life-sustaining treatment is reasonable in patients who present with an endstage, irreversibly progressive disease or if the patient explicitly rejects intensive care treatment.Limiting the extent of intensive care medicine by withholding specific procedures (e.g. resuscitation) should be discussed in critically ill patients whose prognosis would become futile with an additional serious medical problem.Withdrawing life-sustaining treatment and changing to palliative care should be considered if intensive care medicine is futile because of the severity of the patient's condition.It is vital to find an interdisciplinary consensus about EOLD within the medical team as well as with the patient/surrogate decision maker. The agreement is documented in the patient's chart.

Providing Recommendations to Patient Surrogates About Limiting Life Support

Increasingly, patients' final days are experienced on life support in intensive care units (ICUs). Decisions about continuing or terminating aggressive interventions often fall to patient surrogates. To understand intensivists' perspectives on their role in this shared decision making, investigators surveyed a nationally representative sample of 1000 critical …

Nurses’ participation in the end-of-life — process in two paediatric intensive care units in Brazil

The aim of this study was to evaluate the medical and nursing care provided to children in the last 24 hours of life in two Brazilian paediatric intensive care units and analyse the nurses' participation in the decision-making process for life support limitation (LSL). The study was based on an analysis of the patients' medical charts, looking at the medical and nursing care provided in the last 24 hours of life during a 6-month period in the two units, and on semi-structured interviews with 20 nurses to evaluate their participation in LSL decisions. The children were classified into two groups: those who were to receive full cardiopulmonary resuscitation (CPR) and a non-CPR group. A total of 34 deaths occurred during the study period. Of these, 17 (50%) were children that had been in the non-CPR group; there were only 10 recorded LSL plans in their medical charts. In the interviews, only 30% of the nurses mentioned active participation in LSL decisions. In conclusion, the paediatric intensive care nurses in these two Brazilian units did not participate much in LSL decisions, and the care offered in the last hours of life to children with terminal and irreversible illness was not primarily directed toward comfort and alleviating suffering.