Do-not-resuscitate orders in a children's hospital

Abstract

Objectives: a) To quantify the use of do-not-resuscitate orders in a tertiary care children's hospital; and b) to characterize the circumstances in which such orders are written.

Design: Retrospective chart review.

Setting: University teaching hospital.

Patients: All inpatients who died in an urban children's hospital over a 1-yr period of time.

Interventions: None.

Measurements and main results: The hospital records of 54 of 69 patients who died were reviewed. Eighty-two percent of patient deaths occurred in the ICU; 13% of patient deaths occurred in the operating room, and 5% occurred in a medical ward. Other findings included the following: 25 (46%) of 54 patients died after attempted cardiopulmonary resuscitation; 13 (24%) patients were brain dead; and 16 (30%) died with a do-not-resuscitate order in effect. Age was associated with resuscitation status: do-not-resuscitate orders were written for five (21%) of 22 infants (< 1 yr of age); seven (50%) of 14 children (1 to 11 yrs of age); and four (80%) of five adolescents who died (p < .002). Fifteen of 16 do-not-resuscitate orders were written for patients who were in the ICU, where they remained until death. Findings in patients when the do-not-resuscitate orders were written were as follows: 15 ICU patients were receiving mechanical ventilation; 14 (95%) of 15 were receiving inotropic agents; 12 (80%) of 15 patients were receiving narcotic analgesics; and one (6%) patient was being dialyzed. At least one therapeutic modality was withdrawn in 7 (44%) of 16 patients. Do-not-resuscitate orders followed documented conferences with physicians and family members in 13 (81%) of 16 cases. These discussions were initiated by physicians in 12 (92%) of 13 cases.

Conclusions: Do-not-resuscitate orders in pediatric patients are written more often in older than younger hospitalized children who die. Most do-not-resuscitate orders are written for patients who are receiving aggressive medical therapy in the ICU.