Impact of a pediatric palliative care team on limitations of care for inpatients at a free-standing, tertiary-care children’s hospital

Abstract

Objectives * Understand the role of pediatric palliative care in end-of-life discussions. * Identify further opportunities for do-not-resuscitate (DNR) research and analysis of advanced care planning in pediatrics. Original Research Background. Discussions surrounding limitations of care can invoke controversy, confusion, and anxiety in both healthcare professionals and families. Some literature exists regarding the impact of pediatric palliative care teams on ICU admission, cost, and family satisfaction. Limited information, however, is available regarding the factors involved in end-of-life decisions. Understanding these factors may improve the process of evaluating and placing limitation-of care orders in children. Research Objectives. Our study aims to analyze the timing of DNR order placement prior to death in pediatric patients. We also aim to further delineate the specialty of the ordering physician, demographic data, and location of death. Methods. We present a retrospective review of 471 deaths between 1/2009 and 10/2014. The palliative care team was established in September, 2011. For those patients who had a DNR order in place, we analyzed patient and physician characteristics as well as DNR order timing. Results. The location of death of 49% of patients who had a DNR in place was in an ICU setting. The death rate in the ICU was not statistically different following initiation of the palliative care team (PCT) (p=0.53). The overall DNR rate increased following initiation of the PCT from 30.8% to 39.2% (p=0.05). The PCT was consulted in 77% of deaths and ordered the DNR in 60% of children. Conclusion. Our results emphasize the important role of the palliative care team during end-of-life discussions in children. The palliative care team met with more than three quarters of families prior to death, and they placed the DNR order in more than half of these instances. The initiation of the palliative care team was associated with a large increase in overall DNR rates. Implications for Research, Policy or Practice. Additional studies are needed in pediatrics to further delineate the timing of palliative care consultation in the patient’s overall course of illness, demographic and cultural influences, and specific patient conditions, such as tracheostomy dependence.