title: End-of-life care in the pediatric intensive care unit after the forgoing of life-sustaining treatment.
abstract: OBJECTIVE
  To describe the attitudes and practice of clinicians in providing sedation and analgesia to dying patients as life-sustaining treatment is withdrawn.
  
  
  METHODS
  Prospective case series of 53 consecutive patients who died after the withdrawal of life-sustaining treatment in the pediatric intensive care unit at three teaching hospitals in Boston. Data on the reasons why medications were given were obtained from a self-administered anonymous questionnaire completed by the critical care physician and nurse for each case. Data on what medications were given were obtained from a review of the medical record.
  
  
  RESULTS
  Sedatives and/or analgesics were administered to 47 (89%) patients who died after the withdrawal of life-sustaining treatment. Patients who were comatose were less likely to receive these medications. Physicians and nurses cited treatment of pain, anxiety, and air hunger as the most common reasons, and hastening death as the least common reason, for administration of these medications. Hastening death was viewed as an "acceptable, unintended side effect" of terminal care by 91% of physician-nurse matched pairs. The mean dose of sedatives and analgesics administered nearly doubled as life-support was withdrawn, and the degree of escalation in dose did not correlate with clinician's views on hastening death.
  
  
  CONCLUSIONS
  Clinicians frequently escalate the dose of sedatives or analgesics to dying patients as life-sustaining treatment is withdrawn, citing patient-centered reasons as their principle justification. Hastening death is seen as an unintended consequence of appropriate care. A large majority of physicians and nurses agreed with patient management and were satisfied with the care provided. Care of the dying patient after the forgoing of life-sustaining treatment remains underanalyzed and needs more rigorous examination by the critical care community.
authors.affiliation: Department of Anesthesia, Harvard Medical School and Children's Hospital, Boston, MA, USA.
authors.forename: J P
authors.initials: JP
authors.lastname: Burns
authors.forename: C
authors.initials: C
authors.lastname: Mitchell
authors.forename: K M
authors.initials: KM
authors.lastname: Outwater
authors.forename: M
authors.initials: M
authors.lastname: Geller
authors.forename: J L
authors.initials: JL
authors.lastname: Griffith
authors.forename: I D
authors.initials: ID
authors.lastname: Todres
authors.forename: R D
authors.initials: RD
authors.lastname: Truog
mesh_terms: D000700:Analgesics / Q000008:administration & dosage; D001291:Attitude of Health Personnel; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007588:Job Satisfaction; D008020:Life Support Care; D011446:Prospective Studies; D013727:Terminal Care / Q000379:methods*; D015300:Ventilator Weaning
chemical_list: D000700:Analgesics; D006993:Hypnotics and Sedatives