Complex Care Physician Icahn School of Medicine at Mount Sinai New York, New York, United States
Background: Pediatric palliative care (PPC) services in the pediatric intensive care unit (PICU) lends to broader support for families, patients and clinicians in enhancing quality of life, minimizing suffering and helping families in communication and complex decision-making especially during end of life. Objective: To determine if PPC consultation is associated with an increase in end-of-life discussions and advanced decision-making, strengthening family support during a child's dying process. . Design/Methods: This is a retrospective chart review of patients who died in the PICU of a children's hospital and the presence and absence of PPC consults. The presence of goals of care (GOC), end-of-life (EOL) discussions, DNR/DNI order, MOLST completion, interdisciplinary support, withdrawal of life-sustaining therapies, hospice discussion, legacy/memory-building services were studied. Descriptive data included age at time of death, length of stay (LOS) in the PICU, gender, race, spiritual preference and diagnosis. Results: Data were collected from 167 charts from 2018-2022. Average age: 6.7 years (range: 2 days-27 years), average PICU LOS: 16.9 days (range: 2 days-358 days), 50% female, 31% mixed race, 26% Black, 25% White, 10% Asian, 7% unknown, and 25% Hispanic. Most (79%) spoke English as their main language, 15% Spanish, 6% other. Most (71%) had complex chronic conditions. In 92% of cases, a GOC discussion took place, 58% involved PPC. In 87% of cases, EOL planning took place, 58% involved PPC. Overall, 79% had a DNR order, 40% with a MOLST, 67% offered chaplaincy, 100% involved social work, 84% offered child life services, 17% had hospice consideration, 56% with legacy building , 53% had withdrawal of life-sustaining care, and 17% had pre-established relationships with the PPC team. For cases with PPC involvement (n=99), in GOC and EOL discussions (vs no PPC), metrics were: DNR (85% vs 69% respectively, p=0.03), MOLST (48% vs 27%, p=0.02), chaplaincy (71% vs. 60%, p=0.16), social work (100% vs. 100%, p=N/A), offered child life (91% vs 74%, p< 0.01), hospice discussion (24% vs. 7%, p< 0.01), legacy building (61% vs. 50%, p=0.18) and withdrawal of life-sustaining care (60% vs. 41%, p=0.03).
Conclusion(s): PPC in the PICU is associated with improved quality indicators - supporting families suffering through a highly difficult and harrowing experience of loss, through a multidisciplinary team effort. Next steps include expanding this study to other sites within the health system and looking at specific programs to measure system-wide effectiveness.
