Matteo Fontana and his collaborators have just published an interesting paper evaluating modes of death in the PICU and NICU at my hospital, Annie Janvier is, of course, the senior author (Fontana MS, Farrell C, Gauvin F, Lacroix J, Janvier A: Modes of death in pediatrics: Differences in the ethical approach in neonatal and pediatric patients. The Journal of pediatrics 2013). They defined modes of death using the same schema that Annie has published previously (with Eduard Verhagen): as follows (1) children who died because admission to an ICU was withheld; (2) children who died despite active cardiopulmonary resuscitation (CPR); (3) children who died while receiving mechanical ventilation, without active CPR; (4) children who died after withdrawal or withholding of LSI who were extremely sick and expected to die and (5) children who died after withdrawal and withholding LSI of infants who were stable, because of prediction of a poor quality of life.
In both units the proportion of patients who died during CPR was low. There was in contrast a very large difference in the proportion of patients who died during on-going intensive care, but without CPR (51% of deaths in the PICU and 5% in the NICU), and in the proportion who died after withdrawing or withholding intensive care for quality of life reasons (16% of deaths in the PICU and 53% in the NICU).
Why is this? Why do we frequently redirect care in the NICU when usually all we have are indications of increased probability of impairments, with an enormous amount of uncertainty, while in the PICU, even when the children are known to already have the same sort of impairments, intensive care continues to the very end? Maybe we have something to learn from each other.
I note that there will be an editorial accompanying this article when it is published, I guess I will be re-blogging at that point!