title: Use of the Natural Death Act in pediatric patients.
abstract: OBJECTIVE
  To review the use of Natural Death Act declarations (living will procedures) in pediatric patients. The implementation of such declarations for children is now possible in six states, including Texas, by specific statutory provisions.
  
  
  METHODS
  Retrospective study.
  
  
  METHODS
  Pediatric ICU in a university hospital.
  
  
  METHODS
  Records of patients who had a Texas Natural Death Act declaration, either discussed and signed or discussed only, were studied. Patients who had another vehicle of limiting care (e.g., a do-not-resuscitate order) were excluded from the study.
  
  
  RESULTS
  Reviewed characteristics included age, primary diagnosis, and concurrent complications. Also examined were who raised the issue of limiting care (parent or physician), the initial reaction of the other party, what support was withdrawn, what support was added, the final outcome (including the time from implementing limited care to death), and the description of witnesses. Discussions were held with parents of 17 patients, and 13 Natural Death Act declarations were actually implemented. In all but three instances, the patient died within 4 hrs from the time support was withdrawn. The main supports that were withdrawn were ventilators and catecholamines. In half of the cases, morphine sulfate was added for anticipated pain relief and sedation. All decisions were reached by close consultation between the family and the physicians, with the physicians raising the issue in 11 of the 17 cases and the family raising the issue in six cases. In 15 of the 17 patients, consultation with the Bioethics Committee was not necessary. The majority of difficulties involved resolving issues that beset patients with HIV infections, and finding appropriate witnesses as prescribed by the statute.
  
  
  CONCLUSIONS
  We conclude that the Natural Death Act works well in situations involving dying children and their parents.
authors.affiliation: Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030.
authors.forename: L S
authors.initials: LS
authors.lastname: Jefferson
authors.forename: B C
authors.initials: BC
authors.lastname: White
authors.forename: P T
authors.initials: PT
authors.lastname: Louis
authors.forename: B A
authors.initials: BA
authors.lastname: Brody
authors.forename: D D
authors.initials: DD
authors.lastname: King
authors.forename: C E
authors.initials: CE
authors.lastname: Roberts
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D003142:Communication; D003663:Decision Trees; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007258:Informed Consent; D016224:Living Wills / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D008499:Medical Records; D033282:Parental Consent; D010820:Physicians; D011368:Professional-Family Relations; D016414:Resuscitation Orders / Q000331:legislation & jurisprudence*; D012189:Retrospective Studies; D013781:Texas; D028761:Withholding Treatment