title: End-of-life decisions and palliative care in a children's hospital.
abstract: OBJECTIVE
  To investigate clinical and demographic factors affecting the nature of end-of-life decisions and pediatric palliative care.
  
  
  METHODS
  Charts of 236 expired children were retrospectively reviewed for presence of endof- life care (EOLC) discussions and spiritual support, the nature of EOLC decisions, and the degree of opioid analgesics (OA) and sedatives (SDT) administration.
  
  
  RESULTS
  Approximately 60% of patients had EOLC discussion, of whom 87.4% obtained an EOLC decision, mostly opting for withholding therapy (68.8%). Presence of EOLC discussion was associated with a longer hospital stay (univariate analyses: odds ratio [OR] = 1.9; p < 0.029), higher number of failed organs (OR = 2.5; p < 0.003), chronic illnesses (OR = 2.4; p < 0.002), spiritual support (OR = 1.8; p < 0.028) and respiratory diseases (OR = 3.1; p < 0.0006). Younger patients and those with higher number of failed organs were more likely to have withdrawal of therapy (OR = 10.9 and 6.0; p < 0.0001 and <0.002, respectively), whereas patients with chronic illness opted for withholding of therapy (OR = 3.1; p < 0.006). Spiritual support was associated with higher use of both OA and SDT (OR = 1.9 and 2.3; p < 0.014 and p < 0.005, respectively). Younger patients received less OA and SDT (OR = 0.2 and 0.4, respectively; p < 0.0001). Multivariate analyses showed that EOLC discussion is associated with higher use of OA and SDT (OR = 4.4 and 4.2; p < 0.00001 and p < 0.0001, respectively), whereas younger age is associated with withdrawal of therapy (OR = 8.3; p < 0.0005) and lower use of SDT (OR = 0.23; p < 0.0001).
  
  
  CONCLUSIONS
  Patterns of care at the end of life vary in children with differing clinical and demographic characteristics. Because EOLC discussions are associated with greater focus on palliative care, strategies to enhance EOLC communications for pediatric patients should be further evaluated.
authors.affiliation: Division of Critical Care Medicine, Miami Children's Hospital, FL 33155, USA.
authors.forename: Gim H
authors.initials: GH
authors.lastname: Tan
authors.forename: Balagangadhar R
authors.initials: BR
authors.lastname: Totapally
authors.forename: Dan
authors.initials: D
authors.lastname: Torbati
authors.forename: Jack
authors.initials: J
authors.lastname: Wolfsdorf
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use; D003657:Decision Making; D006776:Hospitals, Pediatric; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D008485:Medical Audit; D010166:Palliative Care; D012189:Retrospective Studies; D019452:Terminally Ill
chemical_list: D000701:Analgesics, Opioid; D006993:Hypnotics and Sedatives