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Making decisions to withhold or withdraw treatment in the paediatric intensive care setting can be complex, emotive and morally challenging. The process draws on the expertise and experience of both the families and the medical teams, their understanding of the needs and (where possible) choices of the child, and a balance of trust between all parties to want to achieve the right outcome. It is important that all healthcare professionals caring for children, particularly those living with potentially life-limiting or life-threatening conditions, are aware of the processes involved so they can support patients and families with confidence and sensitivity. This paper explores the basic aspects of withholding and withdrawing interventions in the PICU with the aim of demonstrating the situations in which these decisions might be necessary. It explains the frameworks and considerations guiding the decision-making process and describes the practicalities of providing ongoing care through collaboration with hospital and community services. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether parent-initiated or doctor-initiated decisions about limiting life-sustaining treatment (LST) in neonatal care has consequences for how possible courses of action are presented.Method: Formal conversations (n = 27) between doctors and parents of critically ill babies from two level 3 neonatal intensive care units were audio or video recorded. Sequences of talk where decisions about limiting LST were presented were analysed using Conversation Analysis and coded using a Conversation Analytic informed coding framework. Relationships between codes were analysed using Fisher's exact test.Results: When parents initiated the decision point, doctors subsequently tended to refer to or list available options. When doctors initiated, they tended to use 'recommendations' or 'single-option' choice (conditional) formats (p=0.017) that did not include multiple treatment options. Parent initiations overwhelmingly concerned withdrawal, as opposed to withholding of LST (p=0.030).Conclusion: Aligning parents to the trajectory of the news about their baby's poor condition may influence how the doctor subsequently presents the decision to limit LST, and thereby the extent to which parents are invited to participate in shared decision-making.Practice Implications: Explicitly proposing treatment options may provide parents with opportunities to be involved in decisions for their critically ill babies, thereby fostering shared decision-making. [ABSTRACT FROM AUTHOR]

Objective Since the implementation of two French laws in 2002 and 2005 and the implementation of guidelines about End-of-Life (EoL) decisions, few studies concerning EoL practices in French intensive care units (ICUs) have been reported. This study was aimed at assessing compliance with recommendations and current legislation concerning EoL decisions. Method Prospective observational study based on 1-day audit conducted from January to May 2009 in 66 southern French ICUs. Results Six hundred and twenty-five patients were included (median age: 63 [52–76] years, median SAPS II: 46 [34–58]). The written designation of a surrogate decision-maker was reported for 87 (15%) patients. Advance directives were completed for only 4% of patients. The EoL decision-making process consisted in a multidisciplinary approach for 99 (47%) patients and was recorded in the medical chart for 63 (64%) cases. Families were informed about medical decisions in 58% of cases. This proportion was higher (87%) if a decision to forego life-sustaining therapy was made. EoL decisions consisted of withholding treatments for 72 (94%) patients and withdrawal of treatments for 5 (6%) patients. In the multivariate stepwise logistic regression, four variables were independently associated with a decision to forego life support: preexisting dependence on others ( P < 0.0001), advance directives ( P = 0.01), age ( P = 0.008) and the SAPS 2 score ( P = 0.009). Conclusion The major finding of the present study is the existence of a gap between the widely approved EoL recommendations made by scientific societies and the daily practice of southern French ICUs. Even if EoL decisions are mostly shared with relatives, their written documentation in medical charts remains insufficient. Concerning EoL practices, the withdrawal of treatment remains an uncommon decision. [ABSTRACT FROM AUTHOR]

Abstract: For the last 20 years or so, conflicts on life-support have become the object of widespread media coverage. By focusing public opinion on the alleged physicians’ unreasonable obstinacy, these publicized cases impact social debates on life-support. By these, they justify claims for the legalization of assisted suicide, specifically the practice of termination of life by lethal injection. Via a conducted survey of the various caretakers and families involved in this type of situation, we propose an analysis based on the different forms of unreasonable obstinacy. The reasonable or unreasonable nature of treatments can often be perceived differently by physicians, caretakers and families. At least 6 unreasonable obstinacy cases can be brought to light. Publicized cases always involve a conflict between the physicians in charge and the families who view the situation as unreasonable. Nonetheless, evidence shows that in these situations, the roles are often reversed, and the families are the ones demanding the use of unreasonable care. A typical example of this is a recent case that became the object of legal proceedings in France. As it turns out, the publicized filter does not reflect the true reality of cases involving unreasonable care. Specific procedures could aid in notifying the existence of such situations. The role of health care professionals (excluding physicians) appears to play an essential part in preventing these situations from happening. [Copyright &y& Elsevier]

Abstract: End-of-life decisions and the accompanying legal ramifications related thereto are important matters to be considered and understood by nurse practitioners (NPs). This article focuses on 3 potential legal issues: creating advance directives with patients and their families, withholding or withdrawal of life-sustaining treatment, and do-not-resuscitate orders. The article also discusses improving communication about end-of-life care, thereby avoiding any potential legal pitfalls. Additionally, a legal case summary is provided to illustrate the importance of documentation in the patient''s medical record, as well as an overview of advance care planning. [Copyright &y& Elsevier]

Frequently, ethical dilemmas for clinicians in ICU focus on the conflict between the sanctity of life principle and other important ethical principles, such as patient autonomy or quality of life. Therefore, this chapter seeks to reveal the ethical tension between the sanctity of life and other competing ethical obligations, clearly outlining how the law in reality is making decisions and what a clinician''s duties are in end of life issues. [Copyright &y& Elsevier]

Résumé: La décision de réanimation en médecine d’urgence peut paraître complexe pour les patients âgés. Comment décider au plus juste sans risque d’obstination déraisonnable ? À partir d’un cas clinique chez une personne très âgée, nous montrons comment une prise en charge optimale peut être décidée en conformité avec l’esprit de la loi. [Copyright &y& Elsevier]

The authors suggested that this is the responsibility of physicians who are following patients with chronic and/or terminal diseases to obtain advance directives from patients in case they would not be able to communicate. It has been established that there is a lack of advance directives among patients admitted in emergency departments, especially for those coming from nursing homes despite the fact that advance directives could be useful to guide emergency care [2]. [Extracted from the article]