The decision making process regarding the withdrawal or withholding of potential life-saving treatments in a children's hospital

Karen Street, Richard Ashcroft, John Henderson and Alastair V Campbell

South West Deanery, Paediatrics and University of Bristol

Correspondence to:
Dr Karen Street, Knapp Cottage, Knapp Rd East, Thornbury BS35 2HJ. Phone: 01454 418877; E-mail: karen_street_khan{at}yahoo.co.uk

Objectives—To investigate the factors considered by staff, and the practicalities involved in the decision making process regarding the withdrawal or withholding of potential life-sustaining treatment in a children's hospital. To compare our current practice with that recommended by the Royal College of Paediatrics and Child Health (RCPCH) guidelines, published in 1997.

Design—A prospective, observational study using self-reported questionnaires.

Setting—Tertiary paediatric hospital.

Patients and participants—Consecutive patients identified during a six-month period, about whom a formal discussion took place between medical staff, nursing staff and family regarding the withholding or withdrawal of potentially life-sustaining treatments. The primary physician and primary nurse involved in the discussion were identified.

Method—Two questionnaires completed independently by the primary physician and nurse.

Results—Twenty-two patients were identified (median age 1 year; range 1 day—34 years). In 20 cases treatment was withdrawn or withheld, in two cases treatment was continued. Nursing staff considered family wishes and family perceptions of patient suffering as significantly more important factors in decision making than medical staff, who considered prognostic factors as most important. In only two cases were the patient's expressed wishes apparently available. In most cases staff considered the patient's best interests were served and the process would not be enhanced by the involvement of an independent ethics committee. The exceptions were those cases in which treatment was continued following disagreement between parties.

Conclusions—Our current practice is consistent with that recommended by the RCPCH. The contribution of the patient, provision of staff counselling and general practitioner (GP) involvement were identified as areas for improvement.

Key Words: Withdrawal • limitation • life-sustaining • therapy • treatment

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