Faculty Bibliography

OBJECTIVE: To examine physiologic and therapeutic changes following withdrawal of life-sustaining treatment in children. DESIGN: Retrospective chart review. SETTING: University-affiliated tertiary care pediatric hospital. PATIENTS: All patients who had life-sustaining treatment withdrawn over a 5-yr period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 125 charts were examined to obtain 50 in which the terminal event preceding death was withdrawal of life-sustaining treatment. Data are expressed as median (1st, 3rd quartiles). Median hospital stay before death was 20 days (1st and 3rd quartiles, 8 and 30). Median time from decision to withdraw life-sustaining treatment to actual withdrawal was 30 mins (1st and 3rd quartiles, 10 and 180). All interventions were simultaneously discontinued in 80% of patients with mechanical ventilation followed by vasopressors being most common. No patients had stepwise reduction in ventilator rate before discontinuing the mechanical ventilation. Devices were rarely removed from patients including endotracheal tubes. Time from withdrawal of life-sustaining treatment to death was 15 mins (5, 30); only seven patients took >60 mins to die. Multivariable analysis (Kruskal-Wallis test) of various factors revealed simultaneous withdrawal of life-sustaining treatment, female gender, and not having received renal therapy as hastening death. CONCLUSIONS: Forgoing life-sustaining treatment in a small cohort of children at a single institution follows a pattern: Most cases occur after prolonged intensive care unit stays, withdrawal of treatment occurs almost immediately after the decision to withdraw, most treatments are withdrawn simultaneously rather than sequentially, and most patients die within minutes of life-sustaining treatment cessation. This is the first pediatric study to report the time to death after withdrawal of life-sustaining treatment and factors associated with shorter time to death in children

Informed consent constitutes one of the important considerations included in the myriad ethical dilemmas in the pediatric intensive care unit. Traditionally, the law has viewed children as incompetent to make medical decisions, and society has authorized parents or guardians to act on behalf of children. Empirical evidence has revealed that children may be more capable of participating in their medical decisions than previously thought. Some scholars now think that parents have the right to give informed permission and that professionals should seek the child's assent in many circumstances. Physicians in the intensive care unit should seriously consider consulting adolescent patients about the direction of their care and may wish to seek the input of younger patients in appropriate circumstances

Organ transplantation is one of the groundbreaking achievements in medicine in the 20th century. In the early days of transplantation, organs were obtained from non-heartbeating (NHB) cadavers. With time, better options for organ sources became available (for example, living-related and 'brain dead' donors), and the practice of obtaining organs from NHB cadavers fell out of favor. Improvements in the field of transplantation have led to an increased demand for organs. Various strategies have been employed recently to increase the supply, one of them being non-heartbeating organ donation (NHBOD). NHBOD can take place in controlled or uncontrolled circumstances. Recently, national organizations have supported and proposed guidelines for NHBOD and to aid clinicians in identifying potential donors. Outcomes of organs obtained from NHB cadavers are comparable to those obtained from heartbeating donors. The practice of NHBOD is increasing and has proven that it can contribute to increasing organ availability