End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study

Furtado, Roiter de Albernaz; Tonial, Cristian Tedesco; Costa, Caroline Abud Drumond; Andrades, Gabriela Rupp Hanzen; Crestani, Francielly; Bruno, Francisco; Fiori, Humberto Holmer; Piva, Jefferson Pedro; Garcia, Pedro Celiny Ramos

doi:10.1016/j.jped.2020.10.017

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ORIGINAL ARTICLE • J. Pediatr. (Rio J.) 97 (05) • Sep-Oct 2021 • https://doi.org/10.1016/j.jped.2020.10.017 copy

End-of-life practices in patients admitted to pediatric intensive care units in Brazil: A retrospective study^☆ * Study conducted at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Faculdade de Medicina e Terapia Intensiva Pediátrica, Hospital São Lucas, Porto Alegre, RS, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To determine the prevalence of life support limitation (LSL) in patients who died after at least 24 h of a pediatric intensive care unit (PICU) stay, parent participation and to describe how this type of care is delivered.

Methods:

Retrospective cohort study in a tertiary PICU at a university hospital in Brazil. All patients aged 1 month to 18 years who died were eligible for inclusion. The exclusion criteria were those brain death and death within 24 h of admission.

Results:

53 patients were included in the study. The prevalence of a LSL report was 45.3%. Out of 24 patients with a report of LSL on their medical records only 1 did not have a donot-resuscitate order. Half of the patients with a report of LSL had life support withdrawn. The length of their PICU stay, age, presence of parents at the time of death, and severity on admission, calculated by the Pediatric Index of Mortality 2, were higher in patients with a report of LSL. Compared with other historical cohorts, there was a clear increase in the prevalence of LSL and, most importantly, a change in how limitations are carried out, with a high prevalence of parental participation and an increase in withdrawal of life support.

Conclusions:

LSLs were associated with older and more severely ill patients, with a high prevalence of family participation in this process. The historical comparison showed an increase in LSL and in the withdrawal of life support.

KEYWORDS
Intensive care units; pediatric; Palliative care; Terminal care; Death; Mortality; Child care

Characteristic	Without report of LSL (n = 29)	With report of LSL (n = 24)	p-Value
Male, n (%)	14 (48.3)	9 (37.5)	0.579
CCC, n (%)	17 (58.6)	15 (62.5)	1.00
NPO, n (%)	20 (69.0)	16 (66.7)	1.00
Psychological assessment, n (%)	17 (58.6)	17 (70.8)	0.401
Presence of parents at the time of death, n (%)^a a Medical record of the presence of the patient’s family at the time of death.	15 (53.6)	22 (91.7)	0.005
Maintained or increased sedatives and analgesics, n (%)	21 (72.4)	18 (75)	1.00
Maintained or increased vasoactive drugs, n (%)	27 (93.1)	7 (29.2)	<0.001
Age in months, md (IQR)	16.0	43.5	0.045
	(4.0−57.0)	(12.0−103.7)
Length of PICU stay, md (IQR)	4 (2−6)	9 (4.2−29)	0.017
Length of hospital stay, md (IQR)	6 (³3 Iglesias SB de O, de Oliveira NF, Neto AM, de Souza CR, Zoboli I, do Lago PM, et al. Cuidados Paliativos Pediátricos: O que são e qual sua importância? Cuidando da criança em todos os momentos. Sociedade Brasileira de Pediatria. 2017 [Internet]. [cited 2020 Oct 4]. Available from: https://www.sbp.com.br/fileadmin/user upload/2017/03/Medicina-da-DorCuidados-Paliativos.pdf https://www.sbp.com.br/fileadmin/user up... −30)	13 (4.2−36.2)	0.279
PIM2, md (IQR)	0.0275	0.0802	0.048
	(0.0101−0.0955)	(0.0300−0.3570)

Modes of death	N (%)
Received CPR, n (%)	1 (4.1)
DNR	23 (95.8)
WHLS	4 (16.6)
WDLS	12 (50)

Study Period (n)	Kipper et al.⁸8 Kipper DJ, Piva JP, Garcia PC, Einloft PR, Bruno F, Lago P, et al. Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil. Pediatr Crit Care Med. 2005;6:258–63.			Lago et al.²2 Lago PM, Piva J, Kipper D, Garcia PC, Pretto C, Giongo M, et al. Life support limitation at three pediatric intensive care units in southern Brazil. J Pediatr (Rio J). 2005;81:111–7.	Present study	p
Study Period (n)	1988 (129)	1998 (222)	1999−2000 (156)	2002 (150)	2015−2019 (61)	p
CPR (%)	89.1^a a,b Same superscript letters indicate no difference between the groups.	73.4^a a,b Same superscript letters indicate no difference between the groups.	60.8^b a,b Same superscript letters indicate no difference between the groups.	53.3^b a,b Same superscript letters indicate no difference between the groups.	49.1^b a,b Same superscript letters indicate no difference between the groups. ^,^c c Percentage considering n = 61 patients (53 patients eligible for the study + 8 patients with a diagnosis of brain death).	<0.001
LSL (%)	6.2^a a,b Same superscript letters indicate no difference between the groups.	15.8^a a,b Same superscript letters indicate no difference between the groups.	31.0^b a,b Same superscript letters indicate no difference between the groups.	35.9^b a,b Same superscript letters indicate no difference between the groups.	39.3^b a,b Same superscript letters indicate no difference between the groups. ^,^c c Percentage considering n = 61 patients (53 patients eligible for the study + 8 patients with a diagnosis of brain death).	<0.001
Brain death (%)	4.7	10.8	8.2	10.6	13.1^c c Percentage considering n = 61 patients (53 patients eligible for the study + 8 patients with a diagnosis of brain death).	0.244

Sociedade Brasileira de Pediatria Av. Carlos Gomes, 328 cj. 304, 90480-000 Porto Alegre RS Brazil, Tel.: +55 51 3328-9520 - Porto Alegre - RS - Brazil
E-mail: jped@jped.com.br

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[1] *
Study conducted at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Faculdade de Medicina e Terapia Intensiva Pediátrica, Hospital São Lucas, Porto Alegre, RS, Brazil.

Admissions during the study period, n	1671
Deaths, n (%)	53 (3.17)
Age in months, md (IQR)	21 (5.5−78.5)
Weight, md (IQR)	11.3 (5.7−19.2)
Male, n (%)	23 (46.4)
Main organ failures on admission, n (%)
Respiratory	26 (49.1)
Neurologic	16 (30.2)
Origin, n (%)
Emergency department	19 (35.8)
Ward	16 (30.2)
Transfer	15 (28.3)
Surgical unit	3 (5.7)
Length of hospital stay in days, md (IQR)	7 (3.5−33)
Length of PICU stay in days, md (IQR)	5 (3−19)
PIM2, md (IQR)	0.0439 (0.0174−0.1670)
Complex chronic condition, n (%)	32 (60.4)
Report of LSL, n (%)	24 (45.3)
Report of DNR, n (%)	23 (43.4)
Report of palliative care, n (%)	14 (26.4)
Palliative extubation, n (%)	3 (5.6)
Received CPR, n (%)	30 (56.6)
Presence of parents at the time of death, n (%)	37 (69.8)
Psychological counseling, n (%)	34 (64.2)
No nutritional support in the 24 h prior to death, n (%)	36 (67.9)