Ethical issues surrounding limitation and withdrawal of support in the pediatric intensive care unit

Death in the pediatric intensive care unit (PICU) is most frequently associ ated with limiting or withdrawal of life-sustaining medical treatment (LSMT ). The transition from cure to care occurs in stages With all parties needi ng to consider several ethical issues. This article reviews these issues, i ncluding the concept of futility, disproportionate burden, assent, and best interest while taking the reader through the shift in emphasis from cure t o care. Physicians may also be concerned with issues such as active and pas sive euthanasia, the "Baby Doe" regulations, and the question of prognostic certainty. Communication can be maximized to facilitate decisions regardin g LSMT. If conflicts arise there should be an established mechanism for con flict resolution that may include involving an ethics committee or, rarely, the judicial system. Once the decision has been made to remove LSMT the em phasis becomes comfort care. Palliative care and bereavement specialists ca n provide an invaluable service. Many families will inquire about organ don ation at the time limitation or withdrawal of LSMT. In order to increase or gan availability trained counselors need to talk to families, and instituti ons are evaluating non-heart-beating donor policies. Autopsies should be di scussed with the family in order to inform them of the potential benefits a nd address any concerns. TNO special topics regarding withdrawal of LSMT ar e child abuse and brain death. In the case of abuse, the discussion of limi ting or withdrawing LSMT can be complicated by two factors: the apparent co nflict of interest of the accused or convicted parent retaining guardianshi p, and the possibility of the defense lawyer arguing that the removal of LS MT was the cause of death. When a child is brain dead careful attention mus t be paid to language, for example, that "machines" are stopped rather than "life support."