Variability in physician opinion on limiting pediatric life support.

OBJECTIVE: We conducted this study to investigate how physicians in a pediatric intensive care unit (ICU) currently make decisions to withdraw and withhold life support. Consultation with the patient's primary caregiver often precedes decisions about withdrawal and limitation of life support in chronically ill patients. In these scenarios, the patient's primary caregiver was the pediatric oncologist. To evaluate the influence of subspecialty training, we compared the attitudes of the pediatric intensivists and the oncologists using scenarios describing critically ill oncology patients. DESIGN: Cross-sectional survey. Each physician was randomly assigned 4 of 8 potential case scenarios. SETTING: A total of 29 American pediatric ICUs. PARTICIPANTS: Pediatric intensive care and oncology attendings and fellows. INTERVENTION: Systematic manipulation of patient characteristics in two hypothetical case scenarios describing 6-year-old female oncology patients presenting to the ICU after the institution of mechanical ventilator support for acute respiratory failure. Cases 1 through 4 described a patient who, before admission, had a 99% projected 1-year probability of survival from her underlying cancer and suffered from severe neurologic disabilities. Cases 5 through 8 described a patient who was neurologically normal before admission and had a <1% chance of surviving longer than 1 year because of her underlying cancer. Each physician was randomly assigned 2 cases from cases 1 through 4 and 2 cases from cases 5 through 8. Within each of these case scenarios, parental preferences (withdraw or advance support or look for guidance from the caregivers) and probability of survival (5% vs 40%) were manipulated. Before distribution, the survey instrument was pilot-tested and underwent a rigorous assessment for clinical sensibility. PRIMARY OUTCOME MEASURES: Physicians ratings of the importance of 10 factors considered in the decision to withdraw life support, and their decisions about the appropriate level of care to provide. Respondents were offered five management options representing five levels of care: 1) discontinue inotropes and mechanical ventilation but continue comfort measures; 2) discontinue inotropes and other maintenance therapy but continue mechanical ventilation and comfort measures; 3) continue with current management but add no new therapeutic intervention; 4) continue with current management, add additional inotropes, change antibiotics and the like as needed, but do not start dialysis; and 5) continue with full aggressive management and plan for dialysis if necessary. Respondents also were asked whether they would obtain an ethics consultation. RESULTS: A total of 270 physicians responded to our survey (165 of 198 potentially eligible pediatric intensivists and 105 of 178 pediatric oncologists for response rates of 83% and 59%, respectively). The respondents considered the probability of ICU survival and the wishes of the parents regarding the aggressiveness of care most important in the decision to limit life-support interventions. No clinically important differences were found when the responses of oncologists were compared with those of intensivists. In six of eight possible scenarios, the same level of intensity of care was chosen by less than half of all respondents. In three scenarios, >/=10% of respondents chose full aggressive management as the most appropriate level of care, whereas another >/=10% chose comfort measures only when viewing the same scenario. The most significant respondent factors affecting choices were professional status (attending vs fellow) and the self-rated importance of functional neurologic status. The majority of respondents (83%) believed that the intensive care and the oncology staff were usually in agreement at their institution about the level of intervention to recommend to the parents. (ABSTRACT TRUNCATED)

Skin breakdown in children and high-frequency oscillatory ventilation.

OBJECTIVE: To investigate the relationship of high-frequency oscillatory ventilation (HFOV) to skin breakdown on the scalp and ears in mechanically ventilated children. STUDY DESIGN: Retrospective cohort study of 32 patients supported with HFOV paired with 32 patients supported with conventional mechanical ventilation (CV) in a pediatric intensive care unit (PICU). RESULTS: By univariate analysis, more HFOV patients had skin breakdown than did the CV patients (53% vs 12.5%, p=.001); HFOV patients also had greater severity of illness (Pediatric Risk of Mortality scores), higher mortality, and longer durations of neuromuscular blockade, low systolic blood pressure, and time exposed to risk. Life table analysis demonstrated no difference in the rate of skin breakdown between HFOV and CV patients. Multifactorial analysis showed that only PICU time at risk was a risk factor for skin breakdown. CONCLUSIONS: HFOV was not an independent risk factor for the development of skin breakdown. PICU time at risk was the sole risk factor for the development of skin breakdown in all mechanically ventilated patients in the PICU.

Factors explaining variability among caregivers in the intent to restrict life-support interventions in a pediatric intensive care unit.

OBJECTIVE: To explore patient-related factors which influence the decisions of pediatric intensive care unit (ICU) caregivers to restrict life-support interventions. DESIGN: Cross-sectional survey. SETTING: A university-affiliated pediatric ICU. SUBJECTS: All physicians and nurses caring for oncology or cardiology ICU patients. INTERVENTIONS: Seven patient characteristics were systematically presented in 16 theoretical case scenarios. MEASUREMENTS AND MAIN RESULTS: Individual linear regression models were constructed for each participant by calculating the importance caregivers placed on seven patient characteristics when deciding about starting intravenous vasopressors, performing chest compressions, and withdrawing life support. We compared the numerical and descriptive (very low, low, moderate, high) probability of survival. We surveyed 86 caregivers and 56 (65%) responded. The most important factors influencing decisions were family preferences (76% of decisions), followed by probability of survival (50%), and functional status (47%). There was marked variability among respondents in 38 (79%)/48 of the questions; 20% to 50% of caregivers chose opposing directions of patient management when they were asked to indicate the likelihood that they would perform a specific life-support intervention. The same term was never used by all respondents to describe the probability of survival for a scenario. CONCLUSION: Critically ill children and their families could face markedly different attitudes about the restriction of life-support interventions, depending on which nurses and physicians are involved in their care.

Altered skin integrity in children admitted to a pediatric intensive care unit.

As part of a quality improvement study, the incidence and severity of altered skin integrity in a tertiary pediatric intensive care unit (PICU) were investigated in an attempt to identify contributing risk factors. Demographic, severity of illness, and practice variables were collected on 271 of 357 admissions during an 18-week period. Data were analyzed from the date of PICU admission until a change in skin integrity occurred or until PICU discharge. Altered skin integrity occurred in 26 percent of admissions; 7 percent of the cases had skin breakdown. By multivariate analysis, only the Pediatric Risk of Mortality Score and white race were associated with altered skin integrity.

Knowing the score: using predictive scoring systems in clinical practice.

Outcome scores have been promoted as adjuncts to clinical decision making, especially when further care is thought to be futile. The Pediatric Risk of Mortality score is used to calculate the risk of mortality for patients admitted to pediatric intensive care units. In this article the Pediatric Risk of Mortality score in evaluated for its ability to contribute to individual patient care decisions in the context of clinical practice. Through analysis several features of the Pediatric Risk of Mortality score were identified that require discretion if the score is to be used in decisions involving individual patients. These features include variability and bias introduced in data collection and data presentation. Also, outcome scores do not allow for the incorporation of patient and family values into the decision process. Outcome scores can provide some adjunctive information to clinicians, but they should be used with caution when making patient care decisions. Use of Pediatric Risk of Mortality scores in clinical practice must be tempered with a knowledge of the limitations of the scores, individual patient variability, the conditions under which the scores have been validated and collected and, most importantly, an awareness that outcome scores do not take into account the caregiver and patient values that are inherent in any treatment decision.