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A paper from the Great Ormond Street Hospital for Children in London (Padmanabhan Ramnarayan and colleagues. Journal of Medical Ethics 2007;33:255–60) has raised the question of whether too many children who are terminally ill with chronic conditions are being admitted to intensive care units (ICUs) in the final acute phase of their illness and die there.
A total of 1127 children died in the hospital during a 7‐year period (1997–2004). Of these, 650 were aged <1 year, 407 were aged 1–14 years and 70 were aged 15–18 years. The chief diagnostic categories were congenital malformations (22%), perinatal conditions (18%), cardiovascular diseases (15%) and neoplasms (12%). Death occurred on the ICUs in 86% of cases and there was a significant trend with 80% of deaths on ICUs in 1997–98 and 91% in 2003–04. Among the 161 children who died outside the ICU, 51 (32%) died on the oncology, cardiology or neurology wards, but most had been transferred from an ICU having spent, on average, 12 days there. The proportion of ICU admissions that were from within the hospital increased from 15% in 1998 to 25% in 2004. A larger proportion of children with neoplasms died on the hospital wards (43% compared with 15% of children who died of congenital malformations).
The strong implication is that too many children are dying in ICUs when they and their families would be better served if the children were allowed a more dignified and peaceful death elsewhere. Without individual case analysis it is not possible to judge how many children were admitted to ICUs without hope of useful recovery. Some of the children must have been previously well and admitted with acute illnesses, but the categories of injury, poisoning and infection accounted for only 12% of deaths. There is no information about how many children left hospital to die at home or in a hospice or were not admitted in the terminal stages of their illness. The Great Ormond Street Hospital is not a typical children's hospital and practice may differ elsewhere. The authors of this paper suggest it might be useful to establish a multidisciplinary combined paediatric intensive care/palliative care team to oversee end‐of‐life provision.