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October 26, 1994

Limitations and Withdrawals of Medical Intervention in Pediatric Critical Care

Author Affiliations

From the Department of Critical Care Medicine (Drs Levetown and Pollack), the Center for Health Services and Clinical Research, Children's Research Institute (Dr Pollack), and the Department of Pediatrics (Dr Cuerdon), Children's National Medical Center, Washington, DC; the Departments of Anesthesiology and Pediatrics (Drs Pollack and Cuerdon), Pediatrics (Dr Ruttimann), and Health Care Sciences (Dr Glover), The George Washington University School of Medicine, Washington, DC; and the National Institute on Alcohol Abuse and Alcoholism, the National Institutes of Health (Dr Ruttimann), Bethesda, Md. Dr Levetown is now with the Department of Pediatrics, University of Texas Medical Branch at Galveston. Dr Glover is a philosopher in residence with the Children's National Medical Center.

JAMA. 1994;272(16):1271-1275. doi:10.1001/jama.1994.03520160055043

Objective.  —To investigate the use and implementation in pediatric intensive care units (PICUs) of three levels of restriction of medical intervention: do not resuscitate (DNR), additional limitations of medical interventions beyond DNR, and withdrawal of care.

Design.  —Consecutive patients admitted between December 1989 and January 1992.

Setting.  —A total of 16 PICUs randomly selected to represent variability in size, teaching status, and presence or absence of a pediatric intensivist and unit coordination.

Main Outcome Measures.  —Profiles of children undergoing restrictions of medical interventions including the influence of chronic disease, the justifications for restrictions, and description of implementation practices.

Patients.  —All pediatric admissions undergoing restrictions (n=119) drawn from 5415 consecutive PICU admissions.

Results.  —A total of 94 (79%) of the restriction patients died during the PICU course, representing 38% of all deaths. A total of 73 restrictions (61%) resulted from acute disease, most involving the central nervous system or respiratory system. Restrictions were evenly divided between DNR (39%), additional limitations of medical intervention beyond DNR (27%), and withdrawals of medical intervention (34%). Survival decreased with increasing levels of restriction from 35% of DNR patients to 9% of patients with additional limitations and 2% of withdrawal patients. Imminent death was cited as the justification for restrictions in 70% of cases, no relational potential was cited in 22%, and excessive burden was cited in 8%.

Conclusions.  —Restrictions of medical intervention were used in all PICUs surveyed. Although severe chronic disease was common among restriction patients, acute disease was the predominant event precipitating placement of restrictions. Imminent death, not quality of life or excessive burden, was the most common justification.(JAMA. 1994;272:1271-1275)