Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital

被引：3

作者：

Siegel, Bryan ^{[1
,2
]}

Taylor, Lisa S. ^{[3
]}

Alizadeh, Faraz ^{[1
,2
]}

Barreto, Jessica A. ^{[1
,2
]}

Daniel, Dennis ^{[1
,4
,5
]}

Alexander, Peta M. A. ^{[1
,2
]}

Lipsitz, Stuart ^{[2
,5
]}

Moynihan, Katie ^{[1
,2
,6
]}

机构：

[1] Harvard Med Sch, Dept Pediat, Boston, MA 02115 USA

[2] Boston Childrens Hosp, Dept Cardiol, Boston, MA 02115 USA

[3] Boston Childrens Hosp, Off Eth, Boston, MA USA

[4] Boston Childrens Hosp, Dept Anesthesia & Crit Care, Boston, MA USA

[5] Brigham & Womens Hosp, Div Gen Internal Med, Boston, MA USA

[6] Univ Sydney, Childrens Hosp Westmead, Fac Med & Hlth, Clin Sch, Sydney, NSW, Australia

来源：

PEDIATRIC CRITICAL CARE MEDICINE | 2024年 / 25卷 / 04期

关键词：

clinical ethics support; end-of-life care; ethics consultation; extracorporeal membrane oxygenation; LENGTH-OF-STAY; HEALTH DISPARITIES; DECISION-MAKING; MORAL DISTRESS; EXPERIENCE; DILEMMAS; CARE; PICU; END;

D O I：

10.1097/PCC.0000000000003422

中图分类号：

R4 [临床医学];

学科分类号：

1002 ; 100602 ;

摘要：

OBJECTIVE: To examine characteristics associated with formal ethics consultation (EC) referral in pediatric extracorporeal membrane oxygenation (ECMO) cases, and document ethical issues presented. DESIGN: Retrospective cohort study using mixed methods. SETTING: Single-center quaternary pediatric hospital. PATIENTS: Patients supported on ECMO (January 2012 to December 2021). INTERVENTIONS: We compared clinical variables among ECMO patients according to the presence of EC. We defined optimal cutoffs for EC based on run duration, ICU length of stay (LOS), and sum of procedures or complications. To identify independent explanatory variables for EC, we used a forward stepwise selection multivariable logistic regression model. EC records were thematically characterized into ethical issues. MEASUREMENTS AND MAIN RESULTS:Of 601 ECMO patients and 225 patients with EC in 10 years, 27 ECMO patients received EC (4.5% of ECMO patients, 12% of all ECs). On univariate analysis, use of EC vs. not was associated with multiple ECMO runs, more complications/procedures, longer ICU LOS and ECMO duration, cardiac admissions, decannulation outcome, and higher mortality. Cutoffs for EC were ICU LOS >52 days, run duration >160 hours, and >6 complications/procedures. Independent associations with EC included these three cutoffs and older age. The model showed good discrimination (area under the curve 0.88 [0.83, 0.93]) and fit. The most common primary ethical issues were related to end-of-life, ECMO discontinuation, and treatment decision-making. Moral distress was cited in 22 of 27 cases (82%). CONCLUSION: EC was used in 4.5% of our pediatric ECMO cases, with most ethical issues related to end-of-life care or ECMO discontinuation. Older age, longer ICU LOS, prolonged runs, and multiple procedures/complications were associated with greater odds for EC requests. These data highlight our single-center experience of ECMO-associated ethical dilemmas. Historical referral patterns may guide a supported decision-making framework. Future work will need to include quality improvement projects for timely EC, with evaluation of impacts on relevant endpoints.

引用

页码：301 / 311

页数：11