Prevalence of questioning regarding life-sustaining treatment and time utilisation by forgoing treatment in francophone PICUs

Abstract

Purpose: Our goal is to assess the prevalence of questioning about the appropriateness of initiating or maintaining life-sustaining treatments (LST) in French-speaking paediatric intensive care units (PICUs) and to evaluate time utilisation related to decision-making processes (DMP).

Methods: 18-month, multicentre, prospective, descriptive, observational study in 15 French-speaking PICUs.

Results: Among the 5,602 children admitted, 410 died (7.3%), including 175 after forgoing LST (42.7% of deaths). LST was questioned in 308 children (5.5%) with a prevalence of 13.3 per 100 patient-days. More than 30% of children survived despite the appropriateness of LST being questioned (23% despite a decision to forgo treatment). Median caregiver time spent on making and presenting the decisions was 11 h per child.

Conclusions: In this study, on any given day in each 10-bed PICU, there was more than one child for whom a DMP was underway. Of children, 23% survived despite a decision to forgo LST being made, which underlines the need to elaborate a care plan for these children. Also, DMP represented a large amount of staff time that is undervalued but necessary to ensure optimal palliative practice in PICU.

Figure 1

Study flow chart 1 Defined as the record of a date of initiation of a decision-making process. 2 Defined as the record, prior to the terminal event, of at least one choice by PICU staff among four possible options: full medical intervention, DNR, withholding LST, withdrawing LST, associated with the record of the corresponding date. 3 Defined as the record of a date of initiation of a decision-making process but the absence of data concerning decision-making process. 4 Defined as the record of at least a decision with the corresponding date but the absence of data concerning decision-making meeting or bedside discussion 5 Defined as the record of an anticipated decision regarding LST and the record of a decision-making meeting.