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October 26, 1994, Vol 272, No. 16 >
ARTICLE | October 26, 1994

Limitations and Withdrawals of Medical Intervention in Pediatric Critical Care FREE

Marcia Levetown, MD; Murray M. Pollack, MD; Timothy T. Cuerdon, PhD; Urs E. Ruttimann, PhD; Jacqueline J. Glover, PhD
[+] Author Affiliations

Reprint requests to Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010 (Dr Pollack).


JAMA. 1994;272(16):1271-1275. doi:10.1001/jama.1994.03520160055043
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References

Objective.  —To investigate the use and implementation in pediatric intensive care units (PICUs) of three levels of restriction of medical intervention: do not resuscitate (DNR), additional limitations of medical interventions beyond DNR, and withdrawal of care.

Design.  —Consecutive patients admitted between December 1989 and January 1992.

Setting.  —A total of 16 PICUs randomly selected to represent variability in size, teaching status, and presence or absence of a pediatric intensivist and unit coordination.

Main Outcome Measures.  —Profiles of children undergoing restrictions of medical interventions including the influence of chronic disease, the justifications for restrictions, and description of implementation practices.

Patients.  —All pediatric admissions undergoing restrictions (n=119) drawn from 5415 consecutive PICU admissions.

Results.  —A total of 94 (79%) of the restriction patients died during the PICU course, representing 38% of all deaths. A total of 73 restrictions (61%) resulted from acute disease, most involving the central nervous system or respiratory system. Restrictions were evenly divided between DNR (39%), additional limitations of medical intervention beyond DNR (27%), and withdrawals of medical intervention (34%). Survival decreased with increasing levels of restriction from 35% of DNR patients to 9% of patients with additional limitations and 2% of withdrawal patients. Imminent death was cited as the justification for restrictions in 70% of cases, no relational potential was cited in 22%, and excessive burden was cited in 8%.

Conclusions.  —Restrictions of medical intervention were used in all PICUs surveyed. Although severe chronic disease was common among restriction patients, acute disease was the predominant event precipitating placement of restrictions. Imminent death, not quality of life or excessive burden, was the most common justification.(JAMA. 1994;272:1271-1275)

REFERENCES

1 +
Duff RS, Campbell AGM.  Moral and ethical dilemmas in the special care nursery. N Engl J Med . 1973;;289:890-894.
2 +
Faber-Langendoen K, Bartels DM.  Process of forgoing life-sustaining treatment in a university hospital. Crit Care Med . 1992;;20:570-577.
3 +
Mink RB, Pollack MM.  Resuscitation and withdrawal of therapy in pediatric intensive care. Pediatrics . 1992;;89:961-963.
4 +
Smedira NG, Evans BH, Grais LS, et al.  Withholding and withdrawal of life support from the critically ill. N Engl J Med . 1990;;322:309-315.
5 +
Whitelaw A.  Death as an option in neonatal intensive care. Lancet . 1986;;2:328-331.
6 +
Zimmerman JE, Knaus WA, Sharpe SM, et al.  The use and implications of do-not-resuscitate orders in intensive care units. JAMA . 1986;;255:351-356.
7 +
Wanzer SH, Federman DD, Adelstein SJ, et al.  The physician's responsibility toward hopelessly ill patients. N Engl J Med . 1989;;320:844-849.
8 +
Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying . Briarcliff Manor, NY: Hastings Center; 1987;.
9 +
Nelson LJ, Nelson RM.  Ethics and the provision of futile, harmful, or burdensome treatment to children. Crit Care Med . 1992;;20:427-433.
10 +
Task Force on Ethics of the Society of Critical Care Medicine.  Consensus report on the ethics of forgoing life-sustaining treatments in the critically ill. Crit Care Med . 1990;;18:1435-1438.
11 +
American College of Physicians.  American College of Physicians ethics manual, part 2: the physician and society; research; life-sustaining treatment; other issues. Ann Intern Med . 1989;;111:327-335.
12 +
Council on Ethical and Judicial Affairs, American Medical Association. Code of Medical Ethics, Current Opinions . Chicago, Ill: American Medical Association; 1992;.
13 +
US Dept of Health and Human Services. Child Abuse Amendments of 1984. May 15, 1985.
14 +
Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M.  Impact of quality-of-care factors on pediatric intensive care unit mortality. JAMA . 1994;;272:941-946.
15 +
Pollack MM, Ruttimann UE, Getson PR.  Accurate prediction of the outcome of pediatric intensive care: a new quantitative method. N Engl J Med . 1987;;316:134-139.
16 +
Adams FH, Emmanouilides GC, Riemenschneider TA, eds. Heart Disease in Infants, Children and Adolescents . 4th ed. Baltimore, Md: Williams & Wilkins; 1989;.
17 +
Rudolph AM, ed. Pediatrics . 19th ed. New York, NY: Appleton-Century-Crofts; 1991;.
18 +
Behrman RE, Vaughn VC, eds. Nelson Textbook of Pediatrics . 13th ed. Philadelphia, Pa: WB Saunders Co; 1987;.
19 +
Smith DW. Recognizable Patterns of Human Malformation . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1982;.
20 +
Tomlinson T, Brody H.  Ethics and communication in do-not-resuscitate orders. N Engl J Med . 1988;;318:43-46.
21 +
Bedell SE, Pelle D, Maher PL, Cleary PD.  Do-not-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA . 1986;;256:233-237.
22 +
Jonsson PV, McNamee M, Campion EW.  The 'do not resuscitate' order: a profile of its changing use. Arch Intern Med . 1988;;148:2373-2375.
23 +
Arras JD.  Toward an ethic of ambiguity. Hastings Cent Rep . 1984;;14:25-33.
24 +
Lantos JD, Berger AC, Zucker AR.  Do-notresuscitate orders in a children's hospital. Crit Care Med . 1993;;21:52-55.
25 +
Haines IE, Zalcberg J, Buchanan JD.  Not-for-resuscitation orders in cancer patients: principles of decision-making. Med J Aust . 1990;;153:225-229.
26 +
Nelson LJ, Cranford RE.  Legal advice, moral paralysis and the death of Samuel Linares. Law Med Health Care . 1989;;17:316-324.
27 +
Jecker NS.  Knowing when to stop: the limits of medicine. Hastings Cent Rep . 1991;;21:5-8.
28 +
Schaffner KF, Snyder JV, Abramson NS, et al.  Philosophical, ethical and legal aspects of resuscitation medicine, III: discussion. Crit Care Med . 1988;;16:1069-1076.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Duff RS, Campbell AGM.  Moral and ethical dilemmas in the special care nursery. N Engl J Med . 1973;;289:890-894.
2 +
Faber-Langendoen K, Bartels DM.  Process of forgoing life-sustaining treatment in a university hospital. Crit Care Med . 1992;;20:570-577.
3 +
Mink RB, Pollack MM.  Resuscitation and withdrawal of therapy in pediatric intensive care. Pediatrics . 1992;;89:961-963.
4 +
Smedira NG, Evans BH, Grais LS, et al.  Withholding and withdrawal of life support from the critically ill. N Engl J Med . 1990;;322:309-315.
5 +
Whitelaw A.  Death as an option in neonatal intensive care. Lancet . 1986;;2:328-331.
6 +
Zimmerman JE, Knaus WA, Sharpe SM, et al.  The use and implications of do-not-resuscitate orders in intensive care units. JAMA . 1986;;255:351-356.
7 +
Wanzer SH, Federman DD, Adelstein SJ, et al.  The physician's responsibility toward hopelessly ill patients. N Engl J Med . 1989;;320:844-849.
8 +
Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying . Briarcliff Manor, NY: Hastings Center; 1987;.
9 +
Nelson LJ, Nelson RM.  Ethics and the provision of futile, harmful, or burdensome treatment to children. Crit Care Med . 1992;;20:427-433.
10 +
Task Force on Ethics of the Society of Critical Care Medicine.  Consensus report on the ethics of forgoing life-sustaining treatments in the critically ill. Crit Care Med . 1990;;18:1435-1438.
11 +
American College of Physicians.  American College of Physicians ethics manual, part 2: the physician and society; research; life-sustaining treatment; other issues. Ann Intern Med . 1989;;111:327-335.
12 +
Council on Ethical and Judicial Affairs, American Medical Association. Code of Medical Ethics, Current Opinions . Chicago, Ill: American Medical Association; 1992;.
13 +
US Dept of Health and Human Services. Child Abuse Amendments of 1984. May 15, 1985.
14 +
Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M.  Impact of quality-of-care factors on pediatric intensive care unit mortality. JAMA . 1994;;272:941-946.
15 +
Pollack MM, Ruttimann UE, Getson PR.  Accurate prediction of the outcome of pediatric intensive care: a new quantitative method. N Engl J Med . 1987;;316:134-139.
16 +
Adams FH, Emmanouilides GC, Riemenschneider TA, eds. Heart Disease in Infants, Children and Adolescents . 4th ed. Baltimore, Md: Williams & Wilkins; 1989;.
17 +
Rudolph AM, ed. Pediatrics . 19th ed. New York, NY: Appleton-Century-Crofts; 1991;.
18 +
Behrman RE, Vaughn VC, eds. Nelson Textbook of Pediatrics . 13th ed. Philadelphia, Pa: WB Saunders Co; 1987;.
19 +
Smith DW. Recognizable Patterns of Human Malformation . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1982;.
20 +
Tomlinson T, Brody H.  Ethics and communication in do-not-resuscitate orders. N Engl J Med . 1988;;318:43-46.
21 +
Bedell SE, Pelle D, Maher PL, Cleary PD.  Do-not-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA . 1986;;256:233-237.
22 +
Jonsson PV, McNamee M, Campion EW.  The 'do not resuscitate' order: a profile of its changing use. Arch Intern Med . 1988;;148:2373-2375.
23 +
Arras JD.  Toward an ethic of ambiguity. Hastings Cent Rep . 1984;;14:25-33.
24 +
Lantos JD, Berger AC, Zucker AR.  Do-notresuscitate orders in a children's hospital. Crit Care Med . 1993;;21:52-55.
25 +
Haines IE, Zalcberg J, Buchanan JD.  Not-for-resuscitation orders in cancer patients: principles of decision-making. Med J Aust . 1990;;153:225-229.
26 +
Nelson LJ, Cranford RE.  Legal advice, moral paralysis and the death of Samuel Linares. Law Med Health Care . 1989;;17:316-324.
27 +
Jecker NS.  Knowing when to stop: the limits of medicine. Hastings Cent Rep . 1991;;21:5-8.
28 +
Schaffner KF, Snyder JV, Abramson NS, et al.  Philosophical, ethical and legal aspects of resuscitation medicine, III: discussion. Crit Care Med . 1988;;16:1069-1076.

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