The Little Prince and his Rose: Comparisons Between Modes of Death in the Nicu and the Picu

Abstract

Background: 80% of pediatric deaths occur in ICUs, the majority because life sustaining treatments (LST) are withdrawn (WD) or withheld (WH). Most end-of-life studies do not make the distinction between WD LST from moribund children and WD/WH LST from physiologically stable children for quality-of-life considerations. Objective: Compare modes of death in the PICU and the NICU. Design/Methods: Chart review: all deaths in the delivery room (DR), the NICU and the PICU at Ste-Justine Hospital (Montreal, Canada) over 2 y (2008-09). Results: NICU deaths (n=77), average GA = 34wks (43% <29wks), average BW = 1765g; average day of life at death = 15. 1y Dx: 36% congenital malformation (13% heart); 13% asphyxia; 9% resp insufficiency; 9% IVH, 9% NEC. PICU deaths (n=68), Age: 41% <1y old, 35% 1-10y; 24% >10y. 60% had pre-existing serious conditions that contributed to their death. Average days in PICU before death: 13 days. 1ry Dx: congenital malformation 29% (heart 25%), trauma 10%, neoplasia 7%, intracranial hemorrhage 7%, infection 6%. (Table presented) Dying on the respirator was the most common way to die in the PICU and the least common in the NICU. Withdrawal of LST for quality-of-life considerations was the most common cause of death in the NICU (53% in the NICU vs 16% in PICU). This difference would be even more striking if DR deaths were included (22 deaths followed WH NICU, of which 11/22 = prems at 23-25wks GA). Unstable physiology at time of death was much more common in the PICU (82% vs 47% in NICU). The average length of PICU stay was 13 d in these patients (16% of them <48h) vs 18 d for NICU pts. 58% of unstable deaths in the PICU occured in children with preexisting medical conditions. Conclusions: Modes of death are strikingly different in the NICU and the PICU. A greater proportion of deaths with stable physiology in the NICU may suggest: 1. That neonatologists & parents are more inclined to WD or WH life sustaining treatments before babies reach unstable physiology; 2. That PICU physicians & parents are more inclined to WD life sustaining treatments when children become unstable; and 3. That parents & physicians are more willing to WD or WH life sustaining treatments for neonates for QOL considerations, as compared to older children.