LIMITATIONS AND WITHDRAWALS OF MEDICAL INTERVENTION IN PEDIATRIC CRITICAL CARE

Objective.-To investigate the use and implementation in pediatric inte nsive care units (PICUs) of three levels of restriction of medical int ervention: 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 an d unit coordination. Main Outcome Measures.-Profiles of children under going restrictions of medical interventions including the influence of chronic disease, the justifications for restrictions, and description of implementation practices. Patients.-All pediatric admissions under going restrictions (n = 119) drawn from 5415 consecutive PICU admissio ns. Results.-A total of 94 (79%) of the restriction patients died duri ng the PICU course, representing 38% of all deaths. A total of 73 rest rictions (61%) resulted from acute disease, most involving the central nervous system or respiratory system. Restrictions were evenly divide d between DNR (39%), additional limitations of medical intervention be yond DNR (27%), and withdrawals of medical intervention (34%). Surviva l decreased with increasing levels of restriction from 35% of DNR pati ents to 9% of patients with additional limitations and 2% of withdrawa l patients. Imminent death was cited as the justification for restrict ions in 70% of cases, no relational potential was cited in 22%, and ex cessive burden was cited in 8%. Conclusions.-Restrictions of medical i ntervention were used in all PICUs surveyed. Although severe chronic d isease was common among restriction patients, acute disease was the pr edominant event precipitating placement of restrictions. Imminent deat h, not quality of life or excessive burden, was the most common justif ication.