title: [Development, implementation, and analysis of a "collaborative decision-making for reasonable care" document in pediatric palliative care].
abstract: BACKGROUND
  In France, a legal framework and guidelines state that decisions to limit treatments (DLT) require a collaborative decision meeting and a transcription of decisions in the patient's file. The do-not-attempt-resuscitation order involves the same decision-making process for children in palliative care. To fulfill the law's requirements and encourage communication within the teams, the Resource Team in Pediatric Palliative Care in Aquitaine created a document shared by all children's hospital units, tracing the decision-making process. This study analyzed the decision-making process, quality of information transmission, and most particularly the relevance of this new "collaborative decision-making for reasonable care" card.
  
  
  METHODS
  Retrospective study evaluating the implementation of a traceable document relating the DLT process. All the data sheets collected between January and December 2013 were analyzed.
  
  
  RESULTS
  A total of 58 data sheets were completed between January and December 2013. We chose to collect the most relevant data to evaluate the relevance of the items to be completed and the transmission of the document, to draw up the patients' profile, and the contents of discussions with families. Of the 58 children for whom DLT was discussed, 41 data sheets were drawn up in the pediatric intensive care unit, seven in the oncology and hematology unit, five in the neonatology unit, four in the neurology unit, and one in the pneumology unit. For 30 children, one sheet was created, for 11 children, two sheets and for two children, three sheets were filled out. Thirty-nine decisions were made for withholding lifesaving treatment, 11 withdrawing treatment, and for five children, no limitation was set. Nine children survived after DLT. Of the 58 data sheets, only 31 discussions with families were related to the content of the data sheet. Of the 14 children transferred out of the unit with a completed data sheet, it was transmitted to the new unit for 11 children (79%).
  
  
  CONCLUSIONS
  The number of data sheets collected in 1 year shows the value of this document. The participation of several pediatric specialities' referents in its creation, then its progressive presentation in the children's hospital units, were essential steps in introducing and establishing its use. Items describing the situation, management proposals, and adaptation of the children's supportive care were completed in the majority of cases. They correspond to a clinical description, the object of the discussion, and the daily caregiver's practices, respectively. On the other hand, discussions with families were related to the card's contents in only 53% of the cases. This can be explained by the time required to complete the DLT process. It is difficult for referring doctors to systematically, faithfully, and objectively transcribe discussions with parents. Although this process has been used for a long time in intensive care units, this document made possible an indispensable formalisation in the decision-making process. In other pediatric specialities, the sheet allowed introducing the palliative approach and was a starter and a tool for reflection on the do-not-attempt-resuscitation order, thus suggesting the need for anticipation in these situations.
  
  
  CONCLUSIONS
  With the implementation of this new document, the DLT, data transmission, and continuity of care conditions were improved in the children's hospital units. Sharing this sheet with all professionals in charge of these children would support homogeneity and quality of management and care for children and their parents.
authors.affiliation: Équipe ressource régionale de soins palliatifs pédiatriques aquitaine, groupe hospitalier Pellegrin, hôpital des enfants, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France. Electronic address: marianne.paoletti@chu-bordeaux.fr.
authors.forename: M
authors.initials: M
authors.lastname: Paoletti
authors.affiliation: Équipe ressource régionale de soins palliatifs pédiatriques aquitaine, groupe hospitalier Pellegrin, hôpital des enfants, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France.
authors.forename: M-N
authors.initials: MN
authors.lastname: Litnhouvongs
authors.affiliation: Équipe ressource régionale de soins palliatifs pédiatriques aquitaine, groupe hospitalier Pellegrin, hôpital des enfants, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France.
authors.forename: J
authors.initials: J
authors.lastname: Tandonnet
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D000066491:Clinical Decision-Making; D003299:Cooperative Behavior; D004282:Documentation / Q000379:methods*; D005602:France; D006284:Health Plan Implementation / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D033183:Interdisciplinary Communication; D010166:Palliative Care / Q000458:organization & administration*; D012189:Retrospective Studies; D028761:Withholding Treatment