Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil.
OBJECTIVE
To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil.


METHODS
A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000).


METHODS
Three PICUs in Porto Alegre, southern Brazilian region.


METHODS
Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000.


RESULTS
The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000.


CONCLUSIONS
We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.
Kipper
Délio José
DJ
Pediatric Intensive Care Unit, Hospital São Lucas, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Brazil.
Piva
Jefferson Pedro
JP
Garcia
Pedro Celiny Ramos
PC
Einloft
Paulo Roberto
PR
Bruno
Francisco
F
Lago
Patrícia
P
Rocha
Taís
T
Schein
Alaor Ernst
AE
Fontela
Patrícia Scolari
PS
Gava
Débora Hendler
DH
Guerra
Luciano
L
Chemello
Keli
K
Bittencourt
Roney
R
Sudbrack
Simone
S
Mulinari
Evandro Freddy
EF
Morais
João Feliz Duarte
JF
D001938:Brazil / Q000453:epidemiology; D016887:Cardiopulmonary Resuscitation; D002675:Child, Preschool; D016638:Critical Illness / Q000401:mortality*; D003430:Cross-Sectional Studies; D003657:Decision Making; D005260:Female; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric / Q000458:organization & administration* / Q000639:trends; D007902:Length of Stay; D008020:Life Support Care / Q000639:trends; D008297:Male; D010347:Patient Care Planning / Q000639:trends; D010818:Practice Patterns, Physicians' / Q000639:trends*; D016414:Resuscitation Orders; D013727:Terminal Care / Q000639:trends*; D028761:Withholding Treatment / Q000639:trends