[Madira Maleba]

#89897

PICU is one of the space with ethical dilemma. This include withholding and withdrawing life-sustaining treatment, withdrawal of feeds and allowing certain patients to have natural death. IN all of this , I personally find withdrawal of life sustaining treatment more difficult than withholding treatment, more expecially withdrawal of ventilation knowing very well that the patient can die within minutes or hours of withdrawal. This is referred to as compassionate extubation. Surprisingly enough in my setting I also find that healthcare professionals working in the ward find it difficult to withhold treatment than withdrawing. As a results as a consultant working in ICU , I got many calls of request for ICU beds for patients where decision not to readmit in ICU were made. Just today, I got a call of a patient with inoperable brain tumour where the decision to stop chemo and radiotherapy was made by the team of treating professionals as the risk of continuing treatment outweighed the benefits. The patient was going to theatre for PEG so that he can be palliated and be fed at home. the anaesthetist requested an ICU bed and the ICU team we were able to enlightened them that the patient was not for ICU and that he should extubated. With few ICU beds (6 beds), ethical principle of distributive justice govern most of the decisions we take. Not so long we had a patient referred from hospital in Gauteng who was referred there by cardiology for a corrective surgical intervention of the VSD. Patient unfortunately developed CMV colitis with bowel necrosis and most of his bowel was resected. Patient was send back because it was decided there that the corrective surgery was not going to go ahead since the child had short bowel, not compatible with life (the child had been on TPN since the surgical intervention and could not tolerate oral treatment. The patient was referred so that firstly we can do compassionate extubation and secondly withdraw TPN. I should say that was the most difficult time especially because the child was alert, moving all limbs. With brain dead patient the decision to discontinue is a bit easier. NOT easy at all but a bit easier. I also find that using ethical principles for any ethical dilemma. It also help to make decision based on weighing the benefits and risk of continuing or discontinuing the life sustaining treatment. Also deciding on whether life is limited in quantity or quality or both helps the team make the decision. Each decision should be made by the team and the family but should be in the best interest of the child. in conclusion let me tell you about the case we currently have in PICU, 10 YEARS OLD WITH COMPLICATED PANSINUSITIS WITH SUBDURAL EMPYEMA, POSTERIOR FOSSA PUS COLLECTION AND MULTIPLE INFARCT AND BRAIN OEDEMA WITH SLIGHT HERNIATION. The patient had 6 craniotomies to evacuate the empyema and FESS and had EVD inserted and readjusted twice in theatre (in total the child had 7 theatre interventions). The problem is that they cannot access the posterior fossa collection. As a results pus keeps on recollecting. Patient is in ICU more than a month, intubated, persisting temperature spikes not responsding to antibiotics, with severe neurological fallout. The surgery team are still contemplating to take him to theatre but the PICU team think otherwise. WHAT are your thought?

[Sue Boucher]

#90349

I cannot imagine how these very hard decisions must weigh on you and the staff in your PICU, Madira. I do hope there is support for you and the staff by way of debriefing and opportunities to mourn the losses you experience so regularly. I hope that others do offer some thoughts on the dilemma you pose at the end of your post. It seems the PICU team is more emotionally invested in the quality of life of this child as they are more involved in their care.

[Ayesha Bibi Khan]

#90644

Hi, these situations are never easy to navigate and working in the ICU I agree that the hardest ones to withdraw care on are the ones who are completely neurologically intact. The thing that helps me with this process is the MDT/IDT meetings. When you reach a situation like this it is best to get all the teams involved into one room (or one Zoom meeting nowadays) and then hear each ones thought processes on the decisions they make and come to consensus. So in this case the neurosurgeons, anaesthetists, radiologists, paediatricians, intensivists, rehab teams (OT/PT/Speech), PPC and anyone else who has cared for the child. If the surgical team can come up with a reasonable surgical approach then its worth a try. If the surgeons say that they don’t think they can actually reach it but want to try then to reconsider first do no harm. Often time surgeons are keen to cut because its hard to stop. But as a team if you look at the bigger picture – whatever the decision is made will be one the team agreed on so the burden will not be one teams to bear and that makes it easier.
Hope that helps. Wishing the kiddie the best possible outcome, even if that means a kind end with closure for the family.

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