PM2021: Modes of Death in a Quaternary Level Pediatric Intensive Care Unit Within a Safety Net Hospital

Background: Advances in Pediatric Critical Care have led to widespread availability and utilization of highly specialized and invasive technological support for seriously ill children. Though most critically ill children benefit from this mechanical support, there are times when an exceedingly poor outcome or death are unavoidable. In these cases, goals of care can be augmented to provide a dignified death via limitation or withdrawal of artificial life sustaining therapies versus the perceived difficult experience of failed resuscitation. There is paucity of evidence on how factors such as ethnicity and race impact decision making at end of life in the Pediatric Intensive care Unit (PICU).

Methods: A retrospective chart review was conducted for all deaths in PICU from January 2010 to January 2020. MOD were categorized into failed resuscitation (FR), limitation of technology (LOT), withdrawal of technology (WOT) or brain death (BD). Failed resuscitation was defined as initiation of CPR without return of spontaneous circulation. LOT was defined as placement of a DNI/DNR order or documented decision not to escalate therapies during clinical deterioration. WOT was defined as active de-escalation of technologies with death being the expected outcome. For patients with more than one documented end of life (EOL) decision, MOD was defined as the one closest to expiration.

Results: A total of 238 deaths were documented. A remarkable representation of minorities was observed with 86 (37.2%) African American, 84 (36.4%) Hispanic, 42 (18%) White, 14 (6%) Afro-Caribbean, and 7 (2.9%) Asian. MOD frequencies were FR 33 (13.9%), LOT 109 (45.8%), WOT 65 (27.3%), and BD 31 (13%). Combination of LOT and WOT modes showed a frequency of 174 (73.1%).

Conclusion: MOD in our PICU correlate with recent studies showing a strong tendency toward LOT/WOT at pediatric EOL. In critical care, the approach to discussions about EOL preferences will differ for patients with chronic vs acute illness. The dynamic nature of this discussion highlights the potential impact that a skilled palliative care approach can have. There may be variability in MOD by demographic factors such as ethnicity and race. To provide compassionate, informed and culturally sensitive care at EOL, it is imperative that we explore this further. Awareness of potential differences may also help identify possible bias and aid in provision of ethical and equitable care for all critically ill pediatric patients.