[Why teams in charge of children after a pediatric intensive care unit stay do not take into account the treatment limitation decisions previously made by intensivists]. / Pourquoi les décisions de limitation des traitements en réanimation ne sont-elles pas partagées avec les professionnels assurant les soins de l'enfant avant et après la réanimation?

UNLABELLED: The fact that some children may survive despite a limitation of treatment decision (LTD) made in the pediatric intensive care unit (PICU) is a recent concern. A previous study pointed out that the teams in charge of children after the PICU stay did not take previous PICU LTDs into account. PURPOSE: To identify the problems different units experience in cooperating with the PICU team, in order to increase the continuity of care for these children. STUDY DESIGN: Qualitative single-center study, using semi-structured interviews with physicians in charge of children who were discharged from the PICU even though a LTD was made. RESULTS: Nine pediatric subspecialists (hemato-oncologists, neurologists, and neurosurgeons) were interviewed, producing a corpus of approximately 80 pages of typed text. Three conflictual situations were identified by these physicians. The most frequently reported situation was being asked by the PICU team to give expert advice on a patient's prognosis, before a LTD was made. The 2 others had to defend a true care plan for children who were transferred to the PICU and designing a new care plan for children who were discharged from the PICU after a LTD was made. CONCLUSION: The medical reasoning model that is used for LTDs in the PICU generates conflictual situations when compared to the models that are used in other specialties. These models represent various expressions of subjectivity, as in any medical decision. Acknowledging this fact could facilitate its integration into clinical practice and should improve authentic debates that are necessary to ensure continuity of care for these children.

[What become the decisions of limitation of treatments after discharge from the paediatric intensive care unit?]. / Que deviennent les décisions de limitation ou d'arrêt des traitements actifs à la sortie de réanimation pédiatrique ?

UNLABELLED: The fact that some children may survive despite a decision of limitation of treatments (DLT) is taken in Paediatric Intensive Care Unit (PICU) is a recent data. Although the French-speaking Group of Paediatric Intensive and Emergency Care (GFRUP) has published guidelines for limitation of treatments in PICU, outcome of these surviving children has not yet been studied. PURPOSES: To evaluate transmission of data concerning DLT in PICU toward teams in charge of children after the PICU stay and to evaluate perennility of these decisions. METHOD: Cohort study in children for whom DLT was discussed and who were discharged from PICU between 2002 and 2006. The study included an analysis of the medical files and discussions with the physicians in charge of children at the time of the study, including their responses to standardised scenarios concerning the outcome of their patients. RESULTS: Among the 96 children for whom DLT was discussed in PICU, 37 were discharged toward another unit. Only 1 discharge letter mentioned the DLT. At the time of the study, the Pediatric Overall Performance Category (POPC) score had increased in 16 children and was stable in 12. All the 6 children with a worsening POPC score died, without PICU readmission. The physicians in charge of children after the PICU stay did not remember any DLT. For 18 children (including 8 with previous DLT) PICU readmission would be proposed in case of life-threatening event. Their median POPC score at the time of study was lower than that of other children (3 versus 4; p=0.001). CONCLUSION: This study shows a lack of DLT data transmission, which is in contradiction with the GFRUP's guidelines. Correction of this lack is essential to improve cooperation between units in charge of these children.