Logistics of Withdrawal of Life-Sustaining Therapies in PICU.

OBJECTIVES: To describe practical considerations and approaches to best practices for end-of-life care for critically ill children and families in the PICU. DATA SOURCES: Literature review, personal experience, and expert opinion. STUDY SELECTION: A sampling of the foundational and current evidence related to the withdrawal of life-sustaining therapies in the context of childhood critical illness and injury was accessed. DATA EXTRACTION: Moderated by the authors and supported by lived experience. DATA SYNTHESIS: Narrative review and experiential reflection. CONCLUSIONS: Consequences of childhood death in the PICU extend beyond the events of dying and death. In the context of withdrawal of life-sustaining therapies, achieving a quality death is impactful both in the immediate and in the longer term for family and for the team. An individualized approach to withdrawal of life-sustaining therapies that is informed by empiric and practical knowledge will ensure best care of the child and support the emotional well-being of child, family, and the team. Adherence to the principles of holistic and compassionate end-of-life care and an ongoing commitment to provide the best possible experience for withdrawal of life-sustaining therapies can achieve optimal end-of-life care in the most challenging of circumstances.

Nursing considerations to complement the Surviving Sepsis Campaign guidelines.

OBJECTIVES: To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis. DESIGN: Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus. METHODS: We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding. RESULTS: Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points. CONCLUSION: Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.

Pediatric sepsis: the infection unto death.

A significant percentage of pediatric patients admitted to an ICU have an infectious disease process. Many infants and children go on to develop sepsis, a major cause of death in the intensive care unit. Caring for these children presents a collaborative challenge because of the multifactorial etiology and the complicated pathophysiology. This article focuses on the specific implications of sepsis for infants and children.

Ethical issues in the neonatal intensive care unit.

The case of Baby Y presented a difficult and complex ethical dilemma for the family and the staff involved. The issues of religious beliefs and law, up-holding these beliefs in the center of a religious community, financial concerns, and health care workers disagreeing about carrying out treatments made this case one that few will forget. When asked after Baby Y died how they felt, many members of the staff answered that it should not have gone on as long as it did and that they learned a lot from the family and the experience. Palliative care has been well associated with the adult cancer population in the form of hospice care. It is the hope that this well-integrated aspect of care crosses over to the NICU population. Many of the patients in the types of cases mentioned previously stay in the NICU for extended periods of time until a decision is made clear or the infant expires on his own time. The hustle and bustle of a busy, open, and not-so-private NICU is not the place for this to take place. The NICU should have a designated place where these infants can be cared for better in a more family-centered and staff-friendly environment. Pain management is another important aspect of palliative care. Comfort of the infant is of utmost importance, as it helps the family believe the suffering is under control. During the last few days or weeks of life, the family should have time that is peaceful and restful, and, eventually, the infant should have a pain-free death.Lastly, a part of the palliative care philosophy and approach includes providing treatments that may ap-pear to prolong the inevitable but in fact help the process along to resolution. In the case of Baby Y, surgery to repair some of the defects may have allowed her to go home with her family and spend her short life with them. This was the wish of the mother,especially, and it never happened. It may well be the"what if" she continues to ask for the rest of her life.