Tan Gim H, Totapally Balagangadhar R, Torbati Dan, Wolfsdorf Jack
Division of Critical Care Medicine, Miami Children's Hospital, FL 33155, USA.
J Palliat Med. 2006 Apr;9(2):332-42. doi: 10.1089/jpm.2006.9.332.
To investigate clinical and demographic factors affecting the nature of end-of-life decisions and pediatric palliative care.
Charts of 236 expired children were retrospectively reviewed for presence of endof- life care (EOLC) discussions and spiritual support, the nature of EOLC decisions, and the degree of opioid analgesics (OA) and sedatives (SDT) administration.
Approximately 60% of patients had EOLC discussion, of whom 87.4% obtained an EOLC decision, mostly opting for withholding therapy (68.8%). Presence of EOLC discussion was associated with a longer hospital stay (univariate analyses: odds ratio [OR] = 1.9; p < 0.029), higher number of failed organs (OR = 2.5; p < 0.003), chronic illnesses (OR = 2.4; p < 0.002), spiritual support (OR = 1.8; p < 0.028) and respiratory diseases (OR = 3.1; p < 0.0006). Younger patients and those with higher number of failed organs were more likely to have withdrawal of therapy (OR = 10.9 and 6.0; p < 0.0001 and <0.002, respectively), whereas patients with chronic illness opted for withholding of therapy (OR = 3.1; p < 0.006). Spiritual support was associated with higher use of both OA and SDT (OR = 1.9 and 2.3; p < 0.014 and p < 0.005, respectively). Younger patients received less OA and SDT (OR = 0.2 and 0.4, respectively; p < 0.0001). Multivariate analyses showed that EOLC discussion is associated with higher use of OA and SDT (OR = 4.4 and 4.2; p < 0.00001 and p < 0.0001, respectively), whereas younger age is associated with withdrawal of therapy (OR = 8.3; p < 0.0005) and lower use of SDT (OR = 0.23; p < 0.0001).
Patterns of care at the end of life vary in children with differing clinical and demographic characteristics. Because EOLC discussions are associated with greater focus on palliative care, strategies to enhance EOLC communications for pediatric patients should be further evaluated.
探讨影响临终决策性质及儿科姑息治疗的临床和人口统计学因素。
对236例死亡儿童的病历进行回顾性分析，以了解临终关怀（EOLC）讨论及精神支持的存在情况、EOLC决策的性质以及阿片类镇痛药（OA）和镇静剂（SDT）的使用程度。
约60%的患者进行了EOLC讨论，其中87.4%做出了EOLC决策，大多选择停止治疗（68.8%）。EOLC讨论的存在与住院时间延长相关（单因素分析：比值比[OR]=1.9；p<0.029）、器官衰竭数量较多（OR=2.5；p<0.003）、慢性病（OR=2.4；p<0.002）、精神支持（OR=1.8；p<0.028）和呼吸系统疾病（OR=3.1；p<0.0006）。年龄较小的患者和器官衰竭数量较多的患者更有可能停止治疗（OR分别为10.9和6.0；p<0.0001和<0.002），而患有慢性病的患者选择停止治疗（OR=3.1；p<0.006）。精神支持与OA和SDT的更高使用相关（OR分别为1.9和2.3；p<0.014和p<0.005）。年龄较小的患者接受的OA和SDT较少（OR分别为0.2和0.4；p<0.0001）。多因素分析表明，EOLC讨论与OA和SDT的更高使用相关（OR分别为4.4和4.2；p<0.00001和p<0.0001），而年龄较小与停止治疗相关（OR=8.3；p<0.0005）以及SDT的较低使用相关（OR=0.23；p<0.0001）。
不同临床和人口统计学特征的儿童临终护理模式各不相同。由于EOLC讨论与对姑息治疗的更多关注相关，应进一步评估增强儿科患者EOLC沟通的策略。
