Decision making and end-of-life care in critically ill children

Objectives: 1) To comment on the medical literature on decision making rega rding end-of-life therapy, 2) to analyze the data on disagreement about suc h therapy, including palliative care, and withholding and withdrawal practi ces for critically ill children in the pediatric intensive care unit (PICU) , and 3) to make some general recommendations. Data sources and study selec tion: All papers published in peer-reviewed journals, and all chapters on e nd-of-life therapy, or on conflict between parents and caregivers about end -of-life decisions in the PICU were retrieved. Results: We found three case series, three systematic descriptive studies, two qualitative studies, fou r surveys, and many legal opinions, editorials, reviews, guidelines, and bo ok chapters. The main determinants of end-of-life decisions are the child's age, premorbid cognitive condition and functional status, pain or discomfo rt, probability of survival, and quality of life. Risk factors in persisten t conflict between parents and caregivers about end-of-life care include a grave underlying condition or an unexpected and severe event. Conclusion: M aking decisions about end-of-life care is a frequent event in the PICU. Chi ldren may need both intensive care and palliative care concurrently at diff erent stages of their illness. Disagreements are more likely to be resolved if the root cause of the conflict is better understood.