Division of Bioethics and Palliative Care, Seattle Children's Hospital and University of Washington (A Trowbridge), Seattle, Wash.
Pediatric Advanced Care Team, The Children's Hospital of Philadelphia (T Bamat, E McConathey, C Feudtner, and JK Walter), Philadelphia, Pa.
Acad Pediatr. 2020 Jan-Feb;20(1):81-88. doi: 10.1016/j.acap.2019.07.008. Epub 2019 Jul 31.
Pediatric residents are expected to be competent in end-of-life (EOL) care. We aimed to quantify pediatric resident exposure to patient deaths, and the context of these exposures.
Retrospective chart review of all deceased patients at one children's hospital over 3 years collected patient demographics, time, and location of death. Mode of death was determined after chart review. Each death was cross-referenced with pediatric resident call schedules to determine residents involved within 48 hours of death. Descriptive statistics are presented.
Of 579 patients who died during the study period, 46% had resident involvement. Most deaths occurred in the NICU (30% of all deaths); however, resident exposure to EOL care most commonly occurred in the PICU (52% of resident exposures) and were after withdrawals of life-sustaining therapy (41%), followed by nonescalation (31%) and failed resuscitation (15%). During their postgraduate year (PGY)-1, <1% of residents encountered a patient death. During PGY-2 and PGY-3, 96% and 78%, respectively, of residents encountered at least 1 death. During PGY-2, residents encountered a mean of 3.5 patient deaths (range 0-12); during PGY-3, residents encountered a mean of 1.4 deaths (range 0-5). Residents observed for their full 3-year residency encountered a mean of 5.6 deaths (range 2-10).
Pediatric residents have limited but variable exposure to EOL care, with most exposures in the ICU after withdrawal of life-sustaining technology. Educators should consider how to optimize EOL education with limited clinical exposure, and design resident support and education with these variable exposures in mind.
儿科住院医师应具备临终关怀能力。我们旨在量化儿科住院医师接触患者死亡的情况及其接触背景。
对一家儿童医院 3 年内所有死亡患者的病历进行回顾性分析，收集患者人口统计学、死亡时间和地点。通过病历回顾确定死亡模式。将每例死亡与儿科住院医师值班表进行交叉核对，以确定在死亡后 48 小时内参与的住院医师。采用描述性统计方法进行分析。
在研究期间死亡的 579 名患者中，有 46%的患者有住院医师参与。大多数死亡发生在新生儿重症监护病房（NICU）（占所有死亡人数的 30%）；然而，住院医师接触临终关怀最常见的是在儿科重症监护病房（PICU）（占住院医师接触的 52%），并且是在停止生命支持治疗（41%）之后，其次是不升级（31%）和复苏失败（15%）。在住院医师第一年（PGY-1）期间，<1%的住院医师遇到过患者死亡。在 PGY-2 和 PGY-3 期间，分别有 96%和 78%的住院医师遇到过至少 1 例死亡。在 PGY-2 期间，住院医师平均遇到 3.5 例患者死亡（范围为 0-12）；在 PGY-3 期间，住院医师平均遇到 1.4 例死亡（范围为 0-5）。在整个 3 年住院医师培训期间观察到的住院医师平均遇到 5.6 例死亡（范围为 2-10）。
儿科住院医师接触临终关怀的机会有限，但变化较大，大多数接触发生在 ICU 中，在停止生命支持技术后。教育者应考虑如何在有限的临床接触的情况下优化临终关怀教育，并根据这些变化的接触情况为住院医师提供支持和教育。
