DeathandDying - The END: Pediatric Death and Dying Kevin M....

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Unformatted text preview: The END: Pediatric Death and Dying Kevin M. Creamer M.D. Pediatric Critical Care Walter Reed AMC The Kobeyashi Maru? How we deal with death is at least as important as how we deal with life Agenda Death statistics EOL training In practice, from Residents and families perspectives Modes of death CPR issues and outcomes Family presence / support DNR/ Withholding / Withdrawing support Spectrum Brain Death Organ Donation The tough stuff National Pediatric Data Roughly 80,000 pediatric deaths occur annually in US and Canada 2/3 infants, and 2/3 of these deaths occur in the 1 s t month 35,000 Pediatricians Limits exposure to <3 / year Sahler, 2000, Pediatrics Pediatric Residents Attitudes Over 200 residents surveyed Majority expressed discomfort toward issues of death and dying upon entering training that only somewhat improved over time Developed unplanned behaviors to create a safe emotional distance Parents perceived this distancing Desired physicians to communicate openly, share grief, and provide comfort and support Vazirani, CCM, 2000,Schowalter, J Ped, 1970, Harper, J Reprod Med, 1994 NARMC Pediatric Residents Surveyed 29 housestaff 12 reported no EOL training thus far 5 have discussed EOL issues in Continuity clinic 1 answered correctly regarding distinction between withdrawal and limitation of support POOR 1 Disagree SUPERIOR 5 Agree End of Life training: Almost Non-existent 1/3 of 115 medical residents never supervised during DNR discussion 76% All surgery residencies nationwide had one or no ethics lecture in entire curriculum of 300 nurses reported lack of understanding of advanced directives Tulsky, Arch Int Med, 1996, Downing, Am J Surg, 1997, Crego, Am J Crit Care,1998 More work to be done French PICU excluded 93.8% parents and 53.7% bedside nurses from EOL planning Parents informed of result in 18.7% of cases VA study >80% physicians unilaterally withheld or withdrew support (without knowledge or consent of patient/family) US survey found 92% of physicians but only 59% of nurses felt ethical issues were well discussed with the families 18% nurses reported that physicians were not at bedside at the time of withdrawal DeVictor, CCM,2001, Burns, CCM, 2001Asch, Am J Resp CCM, 1995 Looking Back at Death Family telephone interviews after 150 deaths revealed 19% wanted more information 30% complained about poor communication Many had persistent sleep, work, emotional issues 1to2-Year Follow-up found 46% report perceived conflict between family and medical staff Need for better space for family discussions reported by 27% Cuthbertson, CCM, 2000, Abbott, CCM, Mode of death in PICU 31% 26% 23% 20% Failed resuscitation Withdraw al of Care Limitation of Care Brain Death Duncan, CCM(A), 2001, Wall, Pediatrics,1997, Klopfenstein, J Peds H O, 2001 NICU study: Withdrawal 65%, Limit 8%, Full Tx 26%, Peds H/O review: DNR 64%, Full Tx 10%, died at home 40% Death in the PICU...
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DeathandDying - The END: Pediatric Death and Dying Kevin M....

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