This study suggests that perhaps earlier more aggressive critical care interventions in the pediatric hematopoietic stem cell transplant patient with respiratory failure requiring invasive mechanical ventilation may offer an opportunity to improve outcomes.

Innovation: Establish formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers' moral distress and decreases length of stay for patients with lifethreatening illnesses.Evaluation: Pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls.Setting: Pediatric Intensive Care Unit in a quaternary care Children's Hospital. Participants: Physicians and nurses on staff in the unit.Patients: There were 60 patients in the interventional and 66 patients in the historical control group.Intervention: Over a year, weekly meetings (PEACE rounds) to establish goals of care for patients with longer than 10 days length of stay in the ICU. Results:Moral distress scores measured intermittently with the MDT fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall MDS-R scores were lower for respondents in all categories (non-significant), and on three specific items (significant). Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS (4.94 control vs 3.37 PEACE, p=0.015), a statistically significant increase in both code status changes DNR (11% control, 28% PEACE, p=0.013), and in-hospital death (9% control, 25% PEACE, p=0.015), with no change in patient 30 or 365 day mortality. Conclusion:The addition of a clinical ethicist and senior intensivist to weekly interprofessional team meetings facilitates difficult conversations regarding realistic goals of care. The PEACE