Withdrawal of ventilation from the dying child

Objectives

To document the beliefs and practices of UK paediatric intensive care (PICU) consultant medical staff in withdrawing ventilatory support from children who are terminally ill, but not brain-dead. Whilst all dying children should be treated individually, there is little in the literature to guide doctors in the manner and sequence in which ventilation should be discontinued [1]. Better understanding of current clinical practice may help formulate a rational and compassionate approach to withdrawal of ventilation.

Design

Questionnaires were posted to ninety-three consultants involved in the day-to-day management of children in 19 paediatric and 14 mixed adult/ paediatric intensive care units in the UK. Questions related specifically to the withdrawal of ventilatory support from dying children beyond the neonatal age-group (1 month to 16 years). There were 73 respondents (78%).

Results

Thirty-one (42%) respondents preferred extubation to terminal weaning, including nine (12%) who continue paralysis during extubation. Of the latter group, four were paediatricians, and six had withdrawn ventilation from five or more dying children in the last year. Twenty-four (33%) respondents preferred terminal weaning, 14 of whom decreased the FiO₂ as the first step. Consultants who graduated after 1980 were no more likely to practice extubation than their older colleagues (P = 0.78, Fisher's exact test). Eighteen respondents (25%) gave no preference. Thirty-six (49%) used a higher than standard dose of sedative during the process of withdrawal.

Conclusion

Once a consensus has been reached that death is inevitable, and that further prolongation of life is not only futile but intolerable, then the principal concern of the doctor should be the comfort of the child and family. Withdrawal of ventilation should be carried out with dignity, humanity, and concluded as rapidly as possible. Extubation was the preferred method of withdrawal in our survey, with a significant minority of respondents who continue paralysis.