L. M. Baumann1,2, K. Williams1,2, F. Abdullah1,2, R. J. Hendrickson3, T. A. Oyetunji1,2 3Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA 1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA
Introduction: There is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, despite the fact that invasive procedures are frequently performed in very high risk and critically ill children. There have been significant efforts in adult medicine to enhance discussions around end-of-life care, however, little is known about similar endeavors in the pediatric population.
Methods: A retrospective review of the National Surgical Quality Improvement Program Pediatric (NSQIP Pediatric) was performed. Patients <18 years old with ASA class 3 or greater who underwent elective operation in 2012-2013 were identified and included for analysis. Demographic factors, principal diagnosis, associated conditions, DNR status and mortality were extracted. Descriptive analysis was performed using Stata 11.
Results: A total of 114,395 records were initially identified, with 20,164 patients meeting the inclusion criteria. 91.6% of patients were ASA III, 8.3% ASA IV, and 0.1% ASA V. Less than 1% (0.18%) of all patients had a signed DNR order prior to operation. Of severely ill patients defined by ASA IV, only 1 out of a hundred were DNR status. There were no differences in gender, race, ethnicity or surgical department of patients with and without a DNR order. Of those children who died within 30 days of operation, 11.1% were DNR status. Notably, 17.1% of children who died within this period had multiple operations performed prior to expiring.
Conclusion: The rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even amongst severely ill children where systemic disease is a “constant threat to life”. It is unclear if this is due to physician hesitancy or parents’ unwillingness to make this difficult decision. Regardless, well-informed end-of-life care and DNR status discussions in a patient focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of any DNR discussion will also allow better tracking and benchmarking.