End-of-Life Care in Taiwan: Single-Center Retrospective Study of Modes of Death*

Abstract

Medical advances and the National Health Insurance coverage in Taiwan mean that mortality in the PICU is low. This study describes change in modes of death and end-of-life care in a single center, 2011-2017. SETTING: Multidisciplinary PICU in a tertiary referral Children's Hospital in Taiwan.PATIENTS: There were 316 deaths in PICU patients. INTERVENTIONS:Palliative care consultation in the PICU service occurred after the 2013 "Hospice Palliative Care Act" revision. MEASUREMENTS AND MAIN RESULTS:In the whole cohort, 22 of 316 patients (7%) were determined as "death by neurologic criteria". There were 94 of 316 patients (30%) who had an event needing cardiopulmonary resuscitation within 24 hours of death: 17 of these patients (17/94; 18%) died after failed cardiopulmonary resuscitation without a do-not-resuscitate order, and the other 77 of 94 patients (82%) had a do-not-resuscitate order after cardiopulmonary resuscitation. Overall, there were 200 of 316 patients (63%) who had a do-not-resuscitate order and were entered into the palliative program: 169 of 200 (85%) died after life-sustaining treatment was limited, and the other 31 of 200 (15%) died after life-sustaining treatment was withdrawn. From 2011 to 2017, the time-trend in end-of-life care showed the following associations: 1) a decrease in PICU mortality utilization rate, from 22% to 7% (p < 0.001); 2) a decrease in use of catecholamine infusions after do-not-resuscitate consent, from 87% to 47% (p = 0.001), in patients having limitation in life-sustaining treatment; and 3) an increase in withdrawal of life-sustaining treatment, from 4% to 31% (p < 0.001). CONCLUSIONS:In our practice in a single PICU-center in Taiwan, we have seen that the integration of a palliative care consultation service, developed after the revision of a national "Palliative Care Act, " was associated with increased willingness to accept withdrawal of life-sustaining treatment and a lowered PICU care intensity at the end-of-life.

End-of-life decisions and practices as viewed by health professionals in pediatric critical care: A European survey study

“… EU, European; NICU, neonatal intensive care unit; PICU, pediatric intensive care unit. For subgroup analysis, the Europe countries were classified into three European regions as in the ETHICUS study ( 9 ); northern (Ireland, Latvia, Lithuania, the Netherlands, Sweden, Finland and United Kingdom), central (Austria, Belgium, Germany, France, Luxembourg, Poland, and Switzerland), and southern (Bulgaria, Italy, Portugal, Spain, Greece, Turkey). *Results are expressed as number (%) and median (25th–75th percentiles).…”

“…Some studies have described the successful integration of paediatric palliative care teams into PIC to support the family and the care team. But their expertise is traditionally in non-PIC settings (9)(10)(11)(12), and delivering EOL in PIC remains the responsibility of the intensive care team.…”

“…There is growing international literature describing attitudes and barriers to delivering optimal EOL care in PIC ( 6 – 9 ). A combination of recent demographic changes and public and professional attitudes means that in some high-income countries, most children admitted to PIC have a life-limiting condition and represent a significant proportion of PIC deaths ( 10 ).…”

Palliative and Critical Care: Their Convergence in the Pediatric Intensive Care Unit

“…Systemic integration of PPC into CC practice will likely improve this situation. This is demonstrated in a retrospective study in Taiwan where a standardized approach to EOL care resulted in increased willingness to accept withdrawal of life-sustaining interventions and lowered PICU care intensity, such as PICU utilization and use of catecholamines infusion in patients with the DNR status (26).…”

What Taiwan Teaches Us: Palliative Care Should Be As Integral to the PICU As the Code Cart*

“…The study population was patients less than 18 years old who died in the PICU between 2011 and 2017. The authors' describe a standardized approach to end-of-life care, in which the palliative team and intensivists conduct "choice talk, optional talk, and decision talk" to guide families in decision making around advanced care planning, a framework previously described by Elwyn et al (1)(2)(3). The study included 316 patients for analysis.…”