Life-sustaining Treatment In Children Research Articles

Factors affecting nurses' attitude toward withdrawal of life-sustaining treatment for children

PurposeThe purpose of study was to investigate factors affecting nurses' attitudes toward withdrawal of life-sustaining treatment in children. Design and methodsThis descriptive survey study included 167 nurses working at children's hospitals or children's wards. Data were collected through a structured self-administered survey in November 2022. Data were analyzed using descriptive analysis, t-test, ANOVA, the Dunnett's T3 test, Pearson's correlation coefficient, and multiple linear regression. ResultsAttitude toward withdrawal of life-sustaining treatment in children showed a significant positive correlation with knowledge of life-sustaining treatment decision-making (r = 0.38, p < .001) and meaning as a subcategory of moral sensitivity (r = 0.21, p 0.008). The factors affecting attitude toward withdrawal of life-sustaining treatment in children were knowledge of life-sustaining treatment decision-making (β =0.31, p < .001) and meaning (β = 0.18, p = .015). This model showed a 21.0% explanation of attitude toward withdrawal of life-sustaining treatment in children. ConclusionsDeveloping an effective educational program designed to improve nurses' knowledge and attitude toward life-sustaining treatment decision-making is necessary. Practice implicationsIt may have a positive influence on attitudes toward withdrawal of life-sustaining treatment in children by improving child nurses' knowledge about life-sustaining treatment decision-making and moral sensitivity.

Withdrawal of Life-Sustaining Treatment for Pediatric Patients With Severe Traumatic Brain Injury

The decision to withdraw life-sustaining treatment for pediatric patients with severe traumatic brain injury (TBI) is challenging for clinicians and families with limited evidence quantifying existing practices. Given the lack of standardized clinical guidelines, variable practice patterns across trauma centers seem likely. To evaluate the factors influencing decisions to withdraw life-sustaining treatment across North American trauma centers for pediatric patients with severe TBI and to quantify any existing between-center variability in withdrawal of life-sustaining treatment practices. This retrospective cohort study used data collected from 515 trauma centers through the American College of Surgeons Trauma Quality Improvement Program between 2017 and 2020. Pediatric patients younger than 19 years with severe TBI and a documented decision for withdrawal of life-sustaining treatment were included. Data were analyzed from January to May 2023. A random intercept multilevel logistic regression model was used to quantify patient, injury, and hospital characteristics associated with the decision to withdraw life-sustaining treatment; the median odds ratio was used to characterize residual between-center variability. Centers were ranked by their conditional random intercepts and quartile-specific adjusted mortalities were computed. A total of 9803 children (mean [SD] age, 12.6 [5.7]; 2920 [29.8%] female) with severe TBI were identified, 1003 of whom (10.2%) had a documented decision to withdraw life-sustaining treatment. Patient-level factors associated with an increase in likelihood of withdrawal of life-sustaining treatment were young age (younger than 3 years), higher severity intracranial and extracranial injuries, and mechanism of injury related to firearms. Following adjustment for patient and hospital attributes, the median odds ratio was 1.54 (95% CI, 1.46-1.62), suggesting residual variation in withdrawal of life-sustaining treatment between centers. When centers were grouped into quartiles by their propensity for withdrawal of life-sustaining treatment, adjusted mortality was higher for fourth-quartile compared to first-quartile centers (odds ratio, 1.66; 95% CI, 1.45-1.88). Several patient and injury factors were associated with withdrawal of life-sustaining treatment decision-making for pediatric patients with severe TBI in this study. Variation in withdrawal of life-sustaining treatment practices between trauma centers was observed after adjustment for case mix; this variation was associated with differences in risk-adjusted mortality rates. Taken together, these findings highlight the presence of inconsistent approaches to withdrawal of life-sustaining treatment in children, which speaks to the need for guidelines to address this significant practice pattern variation.

Predicting Time to Death After Withdrawal of Life-Sustaining Treatment in Children.

OBJECTIVES:Accurately predicting time to death after withdrawal of life-sustaining treatment is valuable for family counseling and for identifying candidates for organ donation after cardiac death. This topic has been well studied in adults, but literature is scant in pediatrics. The purpose of this report is to assess the performance and clinical utility of the available tools for predicting time to death after treatment withdrawal in children.DATA SOURCES:Terms related to predicting time to death after treatment withdrawal were searched in PubMed and Embase from 1993 to November 2021.STUDY SELECTION:Studies endeavoring to predict time to death or describe factors related to time to death were included. Articles focusing on perceptions or practices of treatment withdrawal were excluded.DATA EXTRACTION:Titles, abstracts, and full text of articles were screened to determine eligibility. Data extraction was performed manually. Two-by-two tables were reconstructed with available data from each article to compare performance metrics head to head.DATA SYNTHESIS:Three hundred eighteen citations were identified from the initial search, resulting in 22 studies that were retained for full-text review. Among the pediatric studies, predictive models were developed using multiple logistic regression, Cox proportional hazards, and an advanced machine learning algorithm. In each of the original model derivation studies, the models demonstrated a classification accuracy ranging from 75% to 91% and positive predictive value ranging from 0.76 to 0.93.CONCLUSIONS:There are few tools to predict time to death after withdrawal of life-sustaining treatment in children. They are limited by small numbers and incomplete validation. Future work includes utilization of advanced machine learning models.

Embracing Asymmetry and Humility in the Face of Disability.

In "The Relational Potential Standard," in this issue of the Hastings Center Report, Aaron Wightman and colleagues propose "relational potential" as an addition to existing standards that are employed in making difficult decisions regarding life-sustaining treatment for children with profound cognitive disabilities. They offer compelling explanations for why the expanded standard is important and why an approach grounded in an ethics of care is both necessary and justified. In what follows, I would like to explore asymmetries that emerge from their account: between clinician and parent and between child and parent. "Asymmetry" is a term invoked in the context of disability, often as a marker of something undesirable, abnormal, pathological. Yet asymmetry may also be generative and worthy of attention, and in some cases, something to be embraced. My aim here is to argue that an important dimension of humility in the face of disability lies in recognizing these asymmetrical relationships and responding to them with care.

Capacity and Relationship.

In the lead article in the May-June 2019 issue of the Hastings Center Report, Aaron Wightman and coauthors consider the guiding principles for making decisions about life-sustaining treatment for children who have profound cognitive impairments. They argue that the usual standard, which asks decision-makers to consider what will be in the child's best interests, cannot provide sufficient guidance. Discussing this problem in HCR thirty-five years ago, the philosopher John Arras proposed addressing it by means of a "relational potential standard," according to which decisions about providing life-sustaining treatment to a child should depend in part on whether the child has the capacity to form human relationships. Wightman et al. build on Arras's work, but where Arras had suggested that the capacity to form relationships could be gauged by examining the child's cognitive capabilities, the authors suggest that the medical team should lean heavily on the parents' views.

Medical indication regarding life-sustaining treatment for children: Focus groups with clinicians

Background: Decisions about medical indication are a relevant problem in pediatrics. Difficulties arise from the high prognostic uncertainty, the decisional incapacity of many children, the importance of the family, and conflicts with parents. The objectivity of judgments about medical indication has been questioned. Yet, little is known about the factors pediatricians actually include in their decisions. Aim: Our aims were to investigate which factors pediatricians apply in deciding about medical indication, and how they manage conflicts with parents. Design: We performed a qualitative focus group study with experienced pediatricians. The transcripts were subjected to qualitative content analysis. Setting/participants: We conducted three focus groups with pediatricians from different specialties caring for severely ill children/adolescents. They discussed life-sustaining treatment in two case scenarios that varied according to diagnosis, age, and gender. Results: The decisions about medical indication were based on considerations relating to the individual patient, to the family, and to other patients. Individual patient factors included clinical aspects and benefit–burden considerations. Physicians’ individual views and feelings influenced their decision-making. Different factors were applied or weighed differently in the two cases. In case of conflict with parents, physicians preferred solutions aimed at establishing consensus. Conclusion: The pediatricians defined medical indication on a case-by-case basis and were influenced by emotional reasoning. In contrast to prevailing ethico-legal principles, they included the interests of other persons in their decisions. Decision-making strategies should incorporate explicit discussions of social aspects and physicians’ feelings to improve the transparency of the decision-making process and reduce bias.

When is the right time? Complex issues around withdrawing life-sustaining treatment in children

When should one withdraw treatment in children? The challenge is to recognise when a decision needs to be made. Parents may be in denial, and deciding which questions to ask may be difficult. Ethically, the guiding principle should be the child's best interests. May the parents or primary caregiver decide what the child's best interests are? Legislation in South Africa prevents a parent or caregiver from refusing treatment that professionals deem to be in the child's best interests. This article discusses the ethical and legal aspects around the decision to palliate in children.

Managing palliation in the neonatal unit

Professionals working in neonatology have a duty to act in the best interests of the infant. Normally, the goal of care is to sustain life and restore health. However, there...

Balancing obligations: should written information about life-sustaining treatment be neutral?

Parents who are facing decisions about life-sustaining treatment for their seriously ill or dying child are supported by their child's doctors and nurses. They also frequently seek other information sources...

Czy rodzice powinni mieć prawo do decydowania o życiu i śmierci krytycznie chorych noworodków

The article is a follow-up to an online debate, “On Rational Decision Making in Neonatal Care”, which was held within between 15th September and 15th October 2012 on the website of the Polish Bioethics Society. In it I provide justifications for the following three proposals: (I) the creation of a category for critically ill infants as patients in whose case withholding or withdrawing life-sustaining treatment would be a morally justified action, (II) that this category subsume all the five cases mentioned in the document of the Royal College of Pediatrics and Child Health, entitled Withholding or Withdrawing Life-Sustaining Treatment in Children. A Framework for Practice (2004), and (III) that parents of critically ill infants be provided not only the moral, but also the legal possibility of refusing life-sustaining treatment.

Withholding and withdrawing life‐sustaining treatment in children

Modern medicine gives us the ability to prolong life even in situations where it may not be right to do so. This article discusses some of the complex ethical and legal issues surrounding withholding and withdrawing life-sustaining treatment in children, including the concepts of futility, best interests and intolerability. We advocate the use of a structured framework to help guide decision-making, particularly in the more difficult situations. The lack of a morally or legally significant difference between withholding and withdrawing treatment is discussed, as is the role of the doctrine of double effect (particularly in relation to the use of neuromuscular blocking agents during withdrawal of ventilatory support).

Attitudes Towards End-of-life Issues Amongst Pediatricians in a Tertiary Hospital in a Developing Country

To describe the perspectives of pediatricians from a tertiary care center from India on end-of-life (EOL) care issues, a standardized anonymous questionnaire was administered, which included questions regarding attitudes towards withdrawal/withholding of life-sustaining treatment in children and neonates at the EOL, and responses to an EOL case scenario. The questionnaire was administered to 40 pediatricians, of whom 31 (22 males, mean age 34.5 +/- 7.7 years) responded. None of the participants had ever instructed withdrawal of support. The most common modes of life-support limitation practiced were withholding new treatments (17/31; 54.8%) and 'do-not-resuscitate orders' (14/31; 45.2%). 51.6% respondents believed that withholding treatment and withdrawal of support were ethically the same. There is wide variation in responses and there were significant differences from findings of similar studies from the developed countries, the most important being the complete lack of use of withdrawal of support.

A descriptive study of children dying in the pediatric intensive care unit after withdrawal of life-sustaining treatment.

To examine physiologic and therapeutic changes following withdrawal of life-sustaining treatment in children. Retrospective chart review. University-affiliated tertiary care pediatric hospital. All patients who had life-sustaining treatment withdrawn over a 5-yr period. None. A total of 125 charts were examined to obtain 50 in which the terminal event preceding death was withdrawal of life-sustaining treatment. Data are expressed as median (1st, 3rd quartiles). Median hospital stay before death was 20 days (1st and 3rd quartiles, 8 and 30). Median time from decision to withdraw life-sustaining treatment to actual withdrawal was 30 mins (1st and 3rd quartiles, 10 and 180). All interventions were simultaneously discontinued in 80% of patients with mechanical ventilation followed by vasopressors being most common. No patients had stepwise reduction in ventilator rate before discontinuing the mechanical ventilation. Devices were rarely removed from patients including endotracheal tubes. Time from withdrawal of life-sustaining treatment to death was 15 mins (5, 30); only seven patients took >60 mins to die. Multivariable analysis (Kruskal-Wallis test) of various factors revealed simultaneous withdrawal of life-sustaining treatment, female gender, and not having received renal therapy as hastening death. Forgoing life-sustaining treatment in a small cohort of children at a single institution follows a pattern: Most cases occur after prolonged intensive care unit stays, withdrawal of treatment occurs almost immediately after the decision to withdraw, most treatments are withdrawn simultaneously rather than sequentially, and most patients die within minutes of life-sustaining treatment cessation. This is the first pediatric study to report the time to death after withdrawal of life-sustaining treatment and factors associated with shorter time to death in children.

Ethical attitudes of Japanese physicians regarding life-sustaining treatment for children with severe neurological disabilities.

Ethical attitudes of Japanese physicians regarding life-sustaining treatment for children with severe neurological disabilities (SND) were investigated by mailing a translated questionnaire which the Child Neurology Society (CNS) of the United States used for their survey. The questionnaire was sent to 202 council members of the Japanese Society of Child Neurology (JSCN), and the answers of 147 respondents (72.8%) were analyzed. It was found that the majority (85. 0%) of respondents believed that the same level of care should be provided to children with SND as those without it. However, fewer respondents (15.6%) believed that cardiopulmonary resuscitation was indicated for children with progressive or degenerative brain disorders. With respect to the authoritative role of medical indications and family/guardian's wishes in clinical decision-making for children with SND, about 30% of respondents believed that medical indications should override family/guardian's wishes. However, almost as many respondents (29.9%) chose an ambivalent answer. If compared with the results of the preceding CNS survey, considerably more respondents gave ambivalent answers (average 26. 6%) than in the CNS survey (5.8%). About half of the respondents (49. 0%) acknowledged the need for ethical guidelines to help physicians make ethically difficult decisions. Although statistical comparison was not possible, there were considerable differences between the results of the current study and those of the CNS survey.