title: Withdrawal of ventilatory support outside the intensive care unit: guidance for practice.
abstract: OBJECTIVE
  To review the work of one tertiary paediatric palliative care service in facilitating planned withdrawal of ventilatory support outside the intensive care setting, with the purpose of developing local guidance for practice.
  
  
  METHODS
  Retrospective 10-year (2003-2012) case note review of intensive care patients whose parents elected to withdraw ventilation in another setting. Demographic and clinical data revealed common themes and specific incidents relevant to local guideline development.
  
  
  RESULTS
  18 children (aged 2 weeks to 16 years) were considered. Three died prior to transfer. Transfer locations included home (5), hospice (8) and other (2). Primary pathologies included malignant, neurological, renal and respiratory diseases. Collaborative working was evidenced in the review including multidisciplinary team meetings with the palliative care team prior to discharge. Planning included development of symptom management plans and emergency care plans in the event of longer than anticipated survival. Transfer of children and management of extubations demonstrated the benefits of planning and recognition that unexpected events occur despite detailed planning. We identified the need for local written guidance supporting healthcare professionals planning and undertaking extubation outside the intensive care setting, addressing the following phases: (i) introduction of withdrawal, (ii) preparation pretransfer, (iii) extubation, (iv) care postextubation and (v) care postdeath.
  
  
  CONCLUSIONS
  Planned withdrawal of ventilatory support outside the intensive care setting is challenging and resource intensive. The development of local collaborations and guidance can enable parents of children dependent on intensive care to consider a preferred place of death for their child, which may be outside the intensive care unit.
authors.affiliation: Evelina London Children's Hospital, Guys and St Thomas's NHS Foundation Trust, London, UK.
authors.forename: Joanna
authors.initials: J
authors.lastname: Laddie
authors.affiliation: The Louis Dundas Centre for Children's Palliative Care, Great Ormond Street Children's Hospital NHS Foundation Trust, London, UK.
authors.forename: Finella
authors.initials: F
authors.lastname: Craig
authors.affiliation: Great Ormond Street Children's Hospital NHS Foundation Trust, London, UK.
authors.forename: Joe
authors.identifier: http://orcid.org/0000-0003-0919-6882
authors.initials: J
authors.lastname: Brierley
authors.affiliation: The Louis Dundas Centre for Children's Palliative Care, University College London, Institute of Child Health and Lecturer in Child and Adolescent Nursing, Kings College London, London, UK.
authors.forename: Paula
authors.initials: P
authors.lastname: Kelly
authors.affiliation: The Louis Dundas Centre for Children's Palliative Care, University College London, Institute of Child Health, London, UK Rutgers University, Camden, New Jersey, USA.
authors.forename: Myra
authors.initials: M
authors.lastname: Bluebond-Langner
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric / Q000706:statistics & numerical data*; D008297:Male; D010166:Palliative Care / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D016414:Resuscitation Orders; D012189:Retrospective Studies; D012122:Ventilators, Mechanical / Q000706:statistics & numerical data*
keywords: Guildlines; Paediatric Intensive Care (PICU); Palliative Care; Place of Death