New and Lingering Controversies in Pediatric EOL Care

My wife is a pediatric emergency physician (done with fellowship in 2006!) and so I get the pleasure of perusing her Pediatrics journal when it is delivered to our mailbox monthly. Well the October 2005 Issue was particularly exciting because my wife was the lead author on the first paper. (Not a palliative med article)

But since anyone reading this blog is unlikely to be primarily concerned about the correlation between HSV and the signs of pediatric abuse, I will get to the 2 palliative medicine minded articles that were in this issue. I will focus here on one of them.

The first article highlighted 6 controversies in Pediatric EOL care and the knowledge of these issues from residents, attendings and nurses. Now in reading this I thought these are just as relevant in adult EOL care and I thought there could probably be more pediatric oriented EOL care issues than these. Here are the 6 issues.

1. Withholding versus withdrawing life support.
An assessment, from the child's perspective, of the burdens and benefits of offering or continuing treatment is what should count ethically, not whether a treatment has begun or not.

2. Medically supplied food and fluids.
Medically supplied nutrition and hydration are not ethically and legally required in all circumstances. They can be stopped or foregone, like all other medical interventions, when their burdens outweigh their benefits.

3. Use of opioids.
However, recent research suggests that, if the dosage has been titrated properly, then respiratory depression is rare even when opioids are used at very high levels.

4. Use of paralytic agents.
Their use should never be initiated during the withdrawal of life-sustaining treatments.

5. Brain death.
In all 50 states, death can be defined on the basis of neurologic criteria (complete cessation of brain function) as well as cardiac criteria, and permission of the family is not necessary for withdrawal of ventilatory support when either type of criteria is met.

6. The dead-donor rule.
Permanently unconscious patients are not allowed, by current ethical standards, to serve as organ donors.

I would think a more pediatric oriented EOL dilemma is the issue of autonomy and surrogate decision-making in the pediatric patient; especially for the tween to teenager ages.

They took these 6 issues and asked nurses, attendings and residents about them and found that many had concerns of conscience. Statements such as:

At times, I have acted against my conscience in
providing treatment to children in my care.

“Sometimes I feel we are saving children who should
not be saved.”

demonstrated that pediatric Hem/Onc attendings felt this less than critical care attendings (p=.0051). And over 50% of house officers and nurses agreed with these statements. But attendings agreed with these statements around 30% of the time. There are some more nuggets in this article, and it is a good read for contrasting what people say they know, and what they show they know.