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G51 HAS MODERN MEDICINE DESKILLED THE GENERAL PAEDIATRICIAN IN DIAGNOSING DEATH?

T. Vince, M. B. Schindler, M. B. Kenny, C. M. Pierce, M. J. Peters, A. J. Petros. Paediatric & Neonatal ICU (PICU/NICU), Hospital for Sick Children, Great Ormond St Hospital London WC1N 3JH

Introduction: Following a prolonged out of hospital arrest (OHA) or period with fixed dilated pupils (FDP), a child will have undergone potentially irreversible brainstem damage or death. The prognosis for these cases is hopeless and ICU admission futile. Previous studies provide good evidence for limiting paediatric resuscitation1,2 but are they followed in clinical practice?

Method: Retrospective case note review of all PICU/NICU admissions (Jan 1995–Dec 2002) to identify cases of OHA and FDP. Hopeless cases were identified using a criteria specific definition.3 Outcome variables included survival or neurological status at ICU discharge.

Results: In the study period, the admission rate for hopeless cases has increased sixfold. In total, 146 cases were admitted with histories of OHA (n = 86) or FDP (n = 60). After 63 were excluded, 83 (42OHA/41FDP) cases were deemed hopeless. Of the 42 OHA cases, 37 (88%) died on ICU. Four of the five survivors were discharged in vegetative states. All 41 hopeless FDP cases died on ICU. Of the 63 excluded cases, 46% died. A total of 107 (73%) children died, of which 44% fulfilled brainstem criteria and a further 19% had care withdrawn on the basis of other neurological tests. 56% died before formal withdrawal of care; the remaining 15% had care withdrawn in anticipation of death.

Conclusion: Referrals for hopeless cases to PICU are rising. Such admissions bring false hope and undue trauma to families while denying beds to more appropriate cases. DGH paediatricians are not comfortable with withdrawal of care in the DGH setting. Reasons for this may include shortened SpR training, centralisation of PICU services, and fear of criticism. …

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