Discussing withholding and withdrawing of life-sustaining medical treatment in paediatric inpatients: audit of current practice.
OBJECTIVE
To understand the circumstances of inpatient deaths at a tertiary paediatric hospital and current practices regarding the timing and documentation of discussions concerning the withholding and withdrawing of life-sustaining medical treatment (WWLSMT).


METHODS
Retrospective review of the medical records of 50 consecutive inpatient deaths.


RESULTS
In total, 84% of inpatient deaths occurred in an intensive care setting. In all, 74% of patients had an underlying life-limiting or life-threatening condition and death was documented as having been expected in the short term in 88% of patients. Life-sustaining treatment was either withdrawn or limited prior to death in 84% of cases. There was documented family involvement in the decision-making process in 98% of cases. A total of 83% of discussions first took place on the day of death itself or in the week leading up to the child's death. Although medical staff frequently documented the outcome of these discussions, the content, clarity and accessibility of documentation varied widely.


CONCLUSIONS
The majority of inpatient deaths at The Royal Children's Hospital occur in acute circumstances and involve patients with chronic conditions. In most cases, death follows WWLSMT. Discussions with families are documented as first occurring relatively late in the course of the final admission although opportunities for earlier discussions may exist. Further research is needed to understand more about how and when discussions actually take place, what the barriers to communication are and to what extent opportunities exist for discussions to be initiated earlier in the illness course.
Stark
Zornitza
Z
Department of Clinical Quality and Safety, Royal Children's Hospital, Melbourne, Victoria, Australia.
Hynson
Jenny
J
Forrester
Mike
M
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003657:Decision Making; D005190:Family; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008485:Medical Audit; D018447:Medical Futility; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D013727:Terminal Care; D014739:Victoria; D028761:Withholding Treatment