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Practice in Pediatric Intensive Care: Death and Dying

Parshuram, Christopher, MBChB, DPhil1,,2; Dryden-Palmer, Karen, MSN, RN1,,2

Pediatric Critical Care Medicine: August 2018 - Volume 19 - Issue 8S - p S1–S3
doi: 10.1097/PCC.0000000000001595

1Critical Care Program, Hospital for Sick Children, Toronto, ON, Canada.

2Center for Safety Research, Child Health Evaluative Sciences, Research Institute, SickKids, Toronto, ON, Canada.

Dr. Parshuram disclosed other support from RDV Foundation and disclosed he is a named inventor of the patent of the Bedside Paediatric Early Warning System (the patent owner is the Hospital for Sick Children). He has received funding from holding shares in Bedside Clinical Systems, a clinical decision support company in part owned by the Hospital for Sick Children. The remaining author has disclosed that she does not have any potential conflict of interest. Ms. Dryden-Palmer has disclosed that she does not have any potential conflicts of interest.

The death of a child is a significant event. Quality end-of life care improves the quality of death for critically ill pediatric patients, the bereavement process for their families, and is an important skill for all working in the PICU. This is the raison d’etre of the “Death and Dying in the PICU” supplement. This internationally authored supplement provides a series of grounded and practical articles written for frontline providers in pediatric intensive care. Seventeen articles are presented in a sequence reflecting the various phases and aspects of care related to those children most likely to die during, or shortly after, their time in the ICU.

PICU was established to save the lives of critically ill children. Fortunately, death affects a small—and falling—proportion of critically ill children. Expectations of care in the PICU reflect this success and are further augmented by the availability and use of technology to support children with life-limiting conditions. Death can represent many things: therapeutic failure, respect of possible and reasonable limitations, acceptance and planning for the end of a wearying journey, and the outcome of a proud struggle—with refusal to acquiesce until the point of death. Thus, death in the contemporary PICU is complicated.

The goals of antemortem end-of-life care are to improve death and the dying process and to create a foundation for healthy bereavement after the death of the child. End-of-life care can be provided where goals of care are curative and children are receiving invasive ICU treatments, where there are therapeutic limitations, where the main goals are palliative, and where organ donation is intended. Each circumstance is described in the articles of the supplement.

The approach to and extent of end-of-life care provided to individual children and families is affected by the type and intensity of medical therapy provided, the willingness of the family, and ICU teams to accept the risk of death in the context of the primary goals of therapy—either palliative or curative (Fig. 1). Importantly, if stakeholders acknowledge and are willing to accept the high risk of death, meaningful and beneficial end-of-life care can be provided within the constraints of the child’s circumstance.

Figure 1

Figure 1

Few children in the PICU die, and a small number of children need to be treated as if they will die. In the first article, we describe considerations of the possibility of death and discussions with child, family, and healthcare team about the potential for death (1). In the second article, we review family and individual considerations leading up to decisions about goals of therapy and end of life (2).

Death continues to occur in the PICU; however, its relative infrequency presents opportunity for erosion of skills and confidence of individual providers and across PICU teams. In the next four articles, we consider common situations where death is the most likely outcome, specifically with planned withdrawal of life-sustaining therapies (3), continuation of active therapy without planned limitation (4), organ donation (5), and compassionate PICU discharge (6). Each of these end-of-life paths is distinct in context and process, and each path strives to achieve the same principled quality end-of-life care for child and family. Each presents opportunities for conflict and for service excellence and illustrates the intensity in which the experiences embedded within can influence the outcomes for those who are left behind.

Changes since the “early days” of pediatric critical care are described in a series of experiential articles that summarize the lived experiences of four ICU physicians from four culturally unique settings (7–10). Their personal journeys highlight the evolution of our speciality and the changing circumstances for childhood death over time and within and between cultures. An additional article describes the creation of a guideline for withdrawal of therapy illustrating the merits of local focus and incorporation of local culture to create meaningful guiding documents and to facilitate acceptance and uptake into practice (11).

Autopsy provides opportunity to reevaluate the presumption of accurate medical diagnosis in children for whom treatment has not been curative or lifesaving. The value of formal examination after death—in classical and new formats—and the integration of findings into clinical context in clinicopathologic case conferences are described in two articles (12, 13). Bereavement after ICU may be impacted by family experiences in ICU. Caring continues and is described in an article about the consequences and management of bereavement (14).

Articles describing the impact of providing end-of-life care on healthcare professionals describe and explore workplace stressors in PICU practice, and the strategies for facilitating high-quality end-of-life care practices are reviewed, and processes and approaches to improve healthcare professional resilience are discussed (15). We believe this is an important overarching role of the supplement and a key element to the success of our speciality as a vehicle for excellent care in all phases of critical illness.

The last article is about incorporating palliative care within critical care practice, exploring the interrelationships, the complimentary characteristics, and the benefits of separating operational expertise from academic and consultative expertise (16).

We believe that the assembled wisdom, musings, and synthesis of available literature by the 39 authors contributing to the supplement are incomplete. This supplement places emphasis on broad principles and diversity of experiences. We did not address the nuances of navigating key discussions and decisions and chose to avoid articulating absolutes. The intent of the supplement is to promote local discourse, internal reflection, and reconsideration about practices at the time of death and during the dying process. There are many opportunities to explore variations in practice, perform local audits and quality reviews, and conduct the more classical research to compliment the vast experiential knowledge that has been drawn upon for the creation of this resource. We hope that this supplement can aid new and experienced clinicians alike to improve the care provided to children at the end of life and their families.

This supplement was funded by an unrestricted grant from the Robin DeVerteuil (RDV) Foundation. The RDV Foundation had no role in the decision to solicit the approval for this supplement, for content of any of the published articles, nor the decisions to submit or support publication. We see the 2018 Death and Dying Supplement as one step in the journey of pediatric critical care practice, as we continue to respect both life and death, the memories of those patients treated in the ICU, and those they left behind.

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1. Gilleland J, Parshuram C. Discussing Death as a Possible Outcome of ICU Care. Pediatr Crit Care Med 2018; 19 (Suppl 2):S4–S9
2. Kirsch R, Carnevale F, Larcher V, et al. Ethical, Cultural, Social, and Individual Considerations Prior to Transition to Limitation or Withdrawal of Life-Sustaining Therapies. Pediatr Crit Care Med 2018; 19 (Suppl 2):S10–S18
3. Dryden-Palmer K, Haut K, Murray C, et al. Logistics of Withdrawal of Life-Sustaining Therapies in the ICU. Pediatr Crit Care Med 2018; 19 (Suppl 2):S19–S25
4. Lewis-Newby M, Clark JD, Butt W, et al. When a Child Dies in the PICU Despite Ongoing Life Support. Pediatr Crit Care Med 2018; 19 (Suppl 2):S33–S40
5. Nakagawa T, Dryden-Palmer K, Parshuram CS, et al. Organ Donation Following Neurologic and Circulatory Determination of Death. Pediatr Crit Care Med 2018; 19 (Suppl 2):S26–S32
6. Kang T, Hynson J. Compassionate Discharges From the PICU. Pediatr Crit Care Med 2018; 19 (Suppl 2):S41–S47
7. Argent A. Death and Dying over 30 Years in the ICU: Personal Reflection. Pediatr Crit Care Med 2018; 19 (Suppl 2):S53–S54
8. Cox P. Death and Dying 1987–2017: The Destination is the Same, the Journey is Different. Pediatr Crit Care Med 2018; 19 (Suppl 2):S55–S56
9. Butt W. Death and Dying in the ICU: Personal Reflection of 30 Years’ Experience. Pediatr Crit Care Med 2018; 19 (Suppl 2):S57–S58
10. Piva J. Modes of Death and the Dying Process in Brazilian PICU Over the Last 30 years. Pediatr Crit Care Med 2018; 19 (Suppl 2):S59–S60
11. Grosek S, Orazem M, Groselj U. Notes on the Development of the Slovenian Ethical Recommendations for Decision-Making on Treatment and Palliative Care of Patients at the End of Life in Intensive Care Medicine. Pediatr Crit Care Med 2018; 19 (Suppl 2):S48–S52
12. Bohn D, Chiasson D, Huyer D. Investigations After Death in Children. Pediatr Crit Care Med 2018; 19 (Suppl 2):S69–S71
13. Griffiths B, Sebire N, Brierley J. Learning From Investigation After Death. Pediatr Crit Care Med 2018; 19 (Suppl 2):S72–S78
14. October T, Dryden-Palmer K, Meert K, et al. Caring for Parents After the Death of a Child. Pediatr Crit Care Med 2018; 19 (Suppl 2):S61–S68
15. Dryden-Palmer K, Garros D, Meyer E, et al. Care for Dying Children and Their Families in the PICU: Promoting Clinician Education, Support, and Resilience. Pediatr Crit Care Med 2018; 19 (Suppl 2):S79–S85
16. Morrison W, Gauvin F. Integrating Palliative Care into the ICU: From Core Competency to Consultative Expertise. Pediatr Crit Care Med 2018; 19 (Suppl 2):S86–S91

death; dying; education; end of life; organ donation; quality of care

©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies