End-of-life practices in seven Brazilian pediatric intensive care units.
OBJECTIVE
To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs).


METHODS
Cross-sectional multicenter retrospective study based on medical chart review.


METHODS
Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in São Paulo (southeastern region), and three in Salvador (northeastern region).


METHODS
Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded.


METHODS
Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (kappa = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student's t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data.


RESULTS
Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p = .0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders.


CONCLUSIONS
The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.
Lago
Patricia M
PM
Hospital de Clínicas de Porto Alegre (Brazil) and Pediatric and Child Health Post Graduation Program, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil. lagopatricia@terra.com.br
Piva
Jefferson
J
Garcia
Pedro Celiny
PC
Troster
Eduardo
E
Bousso
Albert
A
Sarno
Maria Olivia
MO
Torreão
Lara
L
Sapolnik
Roberto
R
D001938:Brazil / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D008020:Life Support Care / Q000706:statistics & numerical data*; D008297:Male; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods*