End-of-Life Practices Among Tertiary Care PICUs in the United States: A Multicenter Study.
OBJECTIVE
To describe variability in end-of-life practices among tertiary care PICUs in the United States.


METHODS
Secondary analysis of data prospectively collected from a random sample of patients (n = 10,078) admitted to PICUs affiliated with the Collaborative Pediatric Critical Care Research Network between December 4, 2011, and April 7, 2013.


METHODS
Seven clinical centers affiliated with the Collaborative Pediatric Critical Care Research Network.


METHODS
Patients included in the primary study were less than 18 years old, admitted to a PICU, and not moribund on PICU admission. Patients included in the secondary analysis were those who died during their hospital stay.


METHODS
None.


RESULTS
Two hundred and seventy-five (2.7%; range across sites, 1.3-5.0%) patients died during their hospital stay; of these, 252 (92%; 76-100%) died in a PICU. Discussions with families about limitation or withdrawal of support occurred during the initial PICU stay for 173 patients (63%; 47-76%; p = 0.27) who died. Of these, palliative care was consulted for 67 (39%; 12-46%); pain service for 11 (6%; 10 of which were at a single site); and ethics committee for six (3%, from three sites). Mode of death was withdrawal of support for 141 (51%; 42-59%), failed cardiopulmonary resuscitation for 53 (19%; 12-28%), limitation of support for 46 (17%; 7-24%), and brain death for 35 (13%; 8-20%); mode of death did not differ across sites (p = 0.58). Organ donation was requested from 101 families (37%; 17-88%; p < 0.001). Of these, 20 donated (20%; 0-64%). Sixty-two deaths (23%; 10-53%; p < 0.001) were medical examiner cases. Of nonmedical examiner cases (n = 213), autopsy was requested for 79 (37%; 17-75%; p < 0.001). Of autopsies requested, 53 (67%; 50-100%) were performed.


CONCLUSIONS
Most deaths in Collaborative Pediatric Critical Care Research Network-affiliated PICUs occur after life support has been limited or withdrawn. Wide practice variation exists in requests for organ donation and autopsy.
1Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI. 2Department of Anesthesia and Critical Care Medicine, Valley Children's Hospital, Madera, CA. 3Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA. 4Department of Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ. 5Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA. 6Department of Pediatrics, Mattel Children's Hospital at University of California at Los Angeles, Los Angeles, CA. 7Department of Pediatrics, Children's National Medical Center, Washington, DC. 8Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, MI. 9Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 10Department of Pediatrics, University of Utah School of Medicine, University of Utah, Salt Lake City, UT. 11Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD. 12Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO.
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D000293:Adolescent; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007902:Length of Stay; D008297:Male; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D013727:Terminal Care / Q000379:methods* / Q000706:statistics & numerical data; D063128:Tertiary Health Care; D009927:Tissue and Organ Procurement / Q000706:statistics & numerical data; D014481:United States