title: Modes of death in pediatrics: differences in the ethical approach in neonatal and pediatric patients.
abstract: OBJECTIVE
  To compare end-of-life decisions for neonatal and pediatric patients.
  
  
  METHODS
  This study involved a chart review of all pediatric deaths occurring over a 2-year period at a large maternal-child university hospital. Modes of death were compared.
  
  
  RESULTS
  Of the 220 deaths analyzed, 145 occurred in intensive care units (ICUs), including 77 in the neonatal ICU (NICU) and 68 in the pediatric ICU (PICU). Only 6% of deaths were preceded by cardiopulmonary resuscitation. Dying while on the respirator was the most common mode of death in the PICU (51%) and the least common in the NICU (5%; P<.05). Unstable physiology at time of death was much more common in the PICU (82% vs 47%; P<.05). Withdrawal of life-sustaining interventions (LSI) in stable patients for quality of life reasons was the most common cause of death in the NICU (53% vs 16%; P<.05). Seventy-five children died outside of an ICU because LSI were withheld; neonates died mainly of extreme prematurity, and older children died mainly from terminal illness.
  
  
  CONCLUSIONS
  The majority of pediatric deaths occur in ICUs. Modes of death in the NICU and the PICU are strikingly different. A greater proportion of deaths in the NICU occur in infants with stable physiology who might not have died had LSI not been withdrawn. Most deaths outside of ICUs are attributable to withholding of LSI. A significant proportion of neonates in whom LSI are withheld have a possibility of intact survival, unlike older patients.
authors: Neonatal and Pediatric Intensive Care Unit, Children's Hospital of Lucerne, Lucerne, Switzerland.
authors: Matteo S
authors: MS
authors: Fontana
authors: Catherine
authors: C
authors: Farrell
authors: France
authors: F
authors: Gauvin
authors: Jacques
authors: J
authors: Lacroix
authors: Annie
authors: A
authors: Janvier
mesh_terms: D000293:Adolescent; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D003657:Decision Making; D017052:Hospital Mortality; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000941:ethics*; D012189:Retrospective Studies