Variability in physician opinion on limiting pediatric life support

Objective. We conducted this study to investigate how physicians in a pedia tric intensive care unit (ICU) currently make decisions to withdraw and wit hhold life support. Consultation with the patient's primary caregiver often precedes decisions about withdrawal and limitation of life support in chro nically ill patients. In these scenarios, the patients primary caregiver wa s the pediatric oncologist. To evaluate the influence of subspecialty train ing, we compared the attitudes of the pediatric intensivists and the oncolo gists using scenarios describing critically ill oncology patients. Design. Cross-sectional survey. Each physician was randomly assigned 4 of 8 potential case scenarios. Setting. A total of 29 American pediatric ICUs. Participants. Pediatric intensive care and oncology attendings and fellows. Intervention. Systematic manipulation of patient characteristics in two hyp othetical case scenarios describing 6-year-old female oncology patients pre senting to the ICU after the institution of mechanical ventilator support f or acute respiratory failure. Cases I through 4 described a patient who, be fore admission, had a 99% projected 1-year probability of survival from her underlying cancer and suffered from severe neurologic disabilities. Cases 5 through 8 described a patient who was neurologically normal before admiss ion and had a <1% chance of surviving longer than 1 year because of her und erlying cancer. Each physician was randomly assigned 2 cases from cases 1 t hrough 4 and 2 cases from cases 5 through 8. Within each of these case scen arios, parental preferences (withdraw or advance support or look for guidan ce from the caregivers) and probability of survival (5% vs 40%) were manipu lated. Before distribution, the survey instrument was pilot-tested and unde rwent a rigorous assessment for clinical sensibility. Primary Outcome Measures. Physicians ratings of the importance of 10 factor s considered in the decision to withdraw life support, and their decisions about the appropriate level of care to provide. Respondents were offered fi ve management options representing five levels of care: 1) discontinue inot ropes and mechanical ventilation but continue comfort measures; 2) disconti nue inotropes and other maintenance therapy but continue mechanical ventila tion and comfort measures; 3) continue with current management but add no n ew therapeutic intervention; 4) continue with current management, add addit ional inotropes, change antibiotics and the like as needed, but do not star t dialysis; and 5) continue with full aggressive management and plan for di alysis if necessary. Respondents also were asked whether they would obtain an ethics consultation. Results. A total of 270 physicians responded to our survey (165 of 198 pote ntially eligible pediatric intensivists and 105 of 178 pediatric oncologist s for response rates of 83% and 59%, respectively). The respondents conside red the probability of ICU survival and the wishes of the parents regarding the aggressiveness of care most important in the decision to limit life-su pport interventions. No clinically important differences were found when th e responses of oncologists were compared with those of intensivists. In six of eight possible scenarios, the same level of intensity of care was chose n by less than half of all respondents. In three scenarios, greater than or equal to 10% of respondents chose full aggressive management as the most a ppropriate level of care, whereas another greater than or equal to 10% chos e comfort measures only when viewing the same scenario. The most significan t respondent factors affecting choices were professional status (attending vs fellow) and the self-rated importance of functional neurologic status. T he majority of respondents (83%) believed that the intensive care and the o ncology staff were usually in agreement at their institution about the leve l of intervention to recommend to the parents. Respondents reporting that t hey were more likely to withdraw life support than their colleagues were mo re likely to limit life-support interventions in the scenarios than those w ho reported that they were less likely to withdraw life support. At least 5 0% of respondents would request an ethics consult when 1) the probability o f acute survival was 40% and the parents wanted to withdraw support in the patient with neurologic disabilities and 2) when the probability of surviva l was 5% and the parents wanted to advance support in the patient with a <1 year life expectancy from her underlying cancer. Conclusions. Acute prognosis, parental wishes, and functional status are si gnificant determinants of limitations of life support for critically ill ch ildren. However, responses to these hypothetical patient scenarios reflect marked variability in decision-making across pediatric intensivists and onc ologists. The degree to which this variability in decision-making exists in actual patient care requires additional study. Variability in decisionmaki ng may lead to unnecessary suffering, lack of fairness when making decision s about neurologically handicapped individuals, and inappropriate use of sc arce resources in futile cases. Increased efforts should be directed at dev eloping clearer recommendations for limiting life support in critically ill children.