Pediatric Critical Care Transport as a Conduit to Terminal Extubation at Home: A Case Series

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Abstract

Objectives: To present our single-center's experience with three palliative critical care transports home from the PICU for terminal extubation. Design: We performed a retrospective chart review of patients transported between January 1, 2012, and December 31, 2014. Setting: All cases were identified from our institutional pediatric transport database. Patients: Patients were terminally ill children unable to separate from mechanical ventilation in the PICU, who were transported home for terminal extubation and end-of-life care according to their families' wishes. Interventions: Patients underwent palliative care transport home for terminal extubation. Measurements and Main Results: The rate of palliative care transports home for terminal extubation during the study period was 2.6 per 100 deaths. The patients were 7 months, 6 years, and 18 years old and had complex chronic conditions. The transfer process was protocolized. The families were approached by the PICU staff during multidisciplinary goals-of-care meetings. Parental expectations were clarified, and home hospice care was arranged pretransfer. All transports were performed by our pediatric critical care transport team, and all terminal extubations were performed by physicians. All patients had unstable medical conditions and urgent needs for transport to comply with the families' wishes for withdrawal of life support and death at home. As such, all three cases presented similar logistic challenges, including establishing do-not-resuscitate status pretransport, having limited time to organize the transport, and coordinating home palliative care services with available community resources. Conclusions: Although a relatively infrequent practice in pediatric critical care, transport home for terminal extubation represents a feasible alternative for families seeking out-of-hospital end-of-life care for their critically ill technology-dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports to include patient screening tools, palliative care home discharge algorithms, transport protocols, and resource utilization and cost analyses.

Original languageEnglish (US)
Pages (from-to)e4-e8
JournalPediatric Critical Care Medicine
Volume18
Issue number1
DOIs
StatePublished - Jan 1 2017

Fingerprint

Critical Care
Palliative Care
Pediatrics
Terminal Care
Home Care Services
Patient Care Planning
Hospice Care
Terminally Ill
Program Development
Artificial Respiration
Critical Illness
Databases
Technology
Physicians
Costs and Cost Analysis

Keywords

  • critical care transport
  • death at home
  • palliative care
  • pediatric end-of-life
  • pediatric terminal extubation

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Critical Care and Intensive Care Medicine

Cite this

@article{efe068d563f640a99b1a7fa14b9b3bd8,
title = "Pediatric Critical Care Transport as a Conduit to Terminal Extubation at Home: A Case Series",
abstract = "Objectives: To present our single-center's experience with three palliative critical care transports home from the PICU for terminal extubation. Design: We performed a retrospective chart review of patients transported between January 1, 2012, and December 31, 2014. Setting: All cases were identified from our institutional pediatric transport database. Patients: Patients were terminally ill children unable to separate from mechanical ventilation in the PICU, who were transported home for terminal extubation and end-of-life care according to their families' wishes. Interventions: Patients underwent palliative care transport home for terminal extubation. Measurements and Main Results: The rate of palliative care transports home for terminal extubation during the study period was 2.6 per 100 deaths. The patients were 7 months, 6 years, and 18 years old and had complex chronic conditions. The transfer process was protocolized. The families were approached by the PICU staff during multidisciplinary goals-of-care meetings. Parental expectations were clarified, and home hospice care was arranged pretransfer. All transports were performed by our pediatric critical care transport team, and all terminal extubations were performed by physicians. All patients had unstable medical conditions and urgent needs for transport to comply with the families' wishes for withdrawal of life support and death at home. As such, all three cases presented similar logistic challenges, including establishing do-not-resuscitate status pretransport, having limited time to organize the transport, and coordinating home palliative care services with available community resources. Conclusions: Although a relatively infrequent practice in pediatric critical care, transport home for terminal extubation represents a feasible alternative for families seeking out-of-hospital end-of-life care for their critically ill technology-dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports to include patient screening tools, palliative care home discharge algorithms, transport protocols, and resource utilization and cost analyses.",
keywords = "critical care transport, death at home, palliative care, pediatric end-of-life, pediatric terminal extubation",
author = "Corina Noje and Meghan Bernier and Costabile, {Philomena M.} and Bruce Klein and Kudchadkar, {Sapna R}",
year = "2017",
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doi = "10.1097/PCC.0000000000000997",
language = "English (US)",
volume = "18",
pages = "e4--e8",
journal = "Pediatric Critical Care Medicine",
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T1 - Pediatric Critical Care Transport as a Conduit to Terminal Extubation at Home

T2 - A Case Series

AU - Noje, Corina

AU - Bernier, Meghan

AU - Costabile, Philomena M.

AU - Klein, Bruce

AU - Kudchadkar, Sapna R

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Objectives: To present our single-center's experience with three palliative critical care transports home from the PICU for terminal extubation. Design: We performed a retrospective chart review of patients transported between January 1, 2012, and December 31, 2014. Setting: All cases were identified from our institutional pediatric transport database. Patients: Patients were terminally ill children unable to separate from mechanical ventilation in the PICU, who were transported home for terminal extubation and end-of-life care according to their families' wishes. Interventions: Patients underwent palliative care transport home for terminal extubation. Measurements and Main Results: The rate of palliative care transports home for terminal extubation during the study period was 2.6 per 100 deaths. The patients were 7 months, 6 years, and 18 years old and had complex chronic conditions. The transfer process was protocolized. The families were approached by the PICU staff during multidisciplinary goals-of-care meetings. Parental expectations were clarified, and home hospice care was arranged pretransfer. All transports were performed by our pediatric critical care transport team, and all terminal extubations were performed by physicians. All patients had unstable medical conditions and urgent needs for transport to comply with the families' wishes for withdrawal of life support and death at home. As such, all three cases presented similar logistic challenges, including establishing do-not-resuscitate status pretransport, having limited time to organize the transport, and coordinating home palliative care services with available community resources. Conclusions: Although a relatively infrequent practice in pediatric critical care, transport home for terminal extubation represents a feasible alternative for families seeking out-of-hospital end-of-life care for their critically ill technology-dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports to include patient screening tools, palliative care home discharge algorithms, transport protocols, and resource utilization and cost analyses.

AB - Objectives: To present our single-center's experience with three palliative critical care transports home from the PICU for terminal extubation. Design: We performed a retrospective chart review of patients transported between January 1, 2012, and December 31, 2014. Setting: All cases were identified from our institutional pediatric transport database. Patients: Patients were terminally ill children unable to separate from mechanical ventilation in the PICU, who were transported home for terminal extubation and end-of-life care according to their families' wishes. Interventions: Patients underwent palliative care transport home for terminal extubation. Measurements and Main Results: The rate of palliative care transports home for terminal extubation during the study period was 2.6 per 100 deaths. The patients were 7 months, 6 years, and 18 years old and had complex chronic conditions. The transfer process was protocolized. The families were approached by the PICU staff during multidisciplinary goals-of-care meetings. Parental expectations were clarified, and home hospice care was arranged pretransfer. All transports were performed by our pediatric critical care transport team, and all terminal extubations were performed by physicians. All patients had unstable medical conditions and urgent needs for transport to comply with the families' wishes for withdrawal of life support and death at home. As such, all three cases presented similar logistic challenges, including establishing do-not-resuscitate status pretransport, having limited time to organize the transport, and coordinating home palliative care services with available community resources. Conclusions: Although a relatively infrequent practice in pediatric critical care, transport home for terminal extubation represents a feasible alternative for families seeking out-of-hospital end-of-life care for their critically ill technology-dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports to include patient screening tools, palliative care home discharge algorithms, transport protocols, and resource utilization and cost analyses.

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KW - death at home

KW - palliative care

KW - pediatric end-of-life

KW - pediatric terminal extubation

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