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End-of-life care in the pediatric intensive care unit: Attitudes and practices of pediatric critical care physicians and nurses

Burns, Jeffrey P. MD, MPH; Mitchell, Christine RN; Griffith, John L. PhD; Truog, Robert D. MD

Special Article

Objective To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care.

Design Cross-sectional survey.

Setting A random sample of clinicians at 31 pediatric hospitals in the United States.

Measurements and Main Results  The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%;p < .003); that ethical issues are discussed well within the team (92% vs. 59%;p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%;p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care.

Conclusions Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.

From the Department of Anesthesia, Harvard Medical School (Drs. Burns and Truog) and Children’s Hospital (Drs. Burns and Truog); the Department of Patient Care Services (Ms. Mitchell) and the Biostatistics Research Center, New England Medical Center and Tufts University School of Medicine (Dr. Griffith), Boston, MA.

Although the medical and nursing leadership of intensive care units cannot change inadequacies in the ethics curriculum of medical and nursing education, unit-based educational programs for less-experienced clinicians can be initiated immediately.

Supported, in part, by the Deborah Munroe Noonan Memorial Fund and Fleet Investment Services.

© 2001 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins