Palliative Care and Decision for Terminal Cardiopulmonary Resuscitation in the PICU: Single-Center, Retrospective, Mixed-Methods Analysis, 2013-2022.

OBJECTIVES

To quantify the prevalence of cardiopulmonary resuscitation (CPR) in the final 24 hours of life (terminal CPR [tCPR]) and characterize the decision to forego tCPR.

DESIGN

Retrospective, mixed-methods datasets.

SETTING

PICU in a United States, midwestern quaternary regional pediatrics-only healthcare system.

PATIENTS: All children and adolescents (age ≤ 26 yr) who died in the PICU (2013-2022).

INTERVENTIONS: None.

MEASUREMENTS AND MAIN

RESULTS

Out of 23,434 admissions, there were 316 deaths (1.35%), consistent with the national PICU reference. In our population, 74% of deaths occurred with one or more end-of-life (EOL) events (i.e., limitation or nonescalation of life-sustaining therapies, discontinuation of nonbeneficial life-sustaining therapies, and altered code status), 9% greater than the national reference (65%; p = 0.001). Out of 234 deaths occurring after 24 hours of admission, tCPR occurred in 18 (8%). Pre-admission pediatric palliative care (PPC) consultation occurred in 80 of 234 cases (34%) and the factors associated with this involvement included baseline disability (assessed using Pediatric Overall Performance Category plus Pediatric Cerebral Performance Category), nontrauma designation, primary admission diagnosis, home medical equipment, not meeting death by neurologic criteria, and sex. In a classification tree analysis, pre-admission PPC exposure was the strongest contributor of the tCPR-related factors. Further thematic, qualitative analysis of provider progress notes in 19 cases identified elements specific to the process of deciding to forego tCPR.

CONCLUSIONS

Our 10-year retrospective analysis of children dying in the PICU after 24 hours of admission identified pre-admission PPC exposure as a key factor associated with a reduced proportion of tCPR occurrence. The additional qualitative analysis of those choosing to forego tCPR showed that these families experienced EOL care through a temporally and emotionally dynamic decision-making process.