Death in children with malignancy may result from refractory disease or acute complications during therapy. In this population, little is known about the medical interventions received in the last week of life from the overall cohort of children who die from cancer or related complications as inpatients. Perceptions of under- or over-treatment can cause distress among families and staff, yet the prevalence of do not attempt resuscitation (DNAR) orders, use of CPR, and other supportive therapies remains poorly described.
We describe the inpatient medical management of children with cancer during the last week of life with a focus on code status and use of CPR, conducting a 10-year single-institution retrospective chart review of all inpatient pediatric oncology deaths (n=344). In this cohort, 51% of deaths occurred in the ICU; 86% had evidence of disease with 20% receiving chemotherapy 7 days prior to death. Patients receiving therapeutic chemo were less likely to have a DNAR (OR = 0.331; P = 0.0081) while patients on palliative chemo were more likely to have a DNAR (OR= 14; P = 0.022). For the 51 children without any DNAR at death, 32 (63%) did not receive CPR due to parental agreement. Older patients (> 7 years) were more likely to have a DNAR (OR=2.764, P= 0.0023). In the total cohort, 20% ever received CPR, with 12% receiving CPR only at death. For CPR at death, 51% were thought to have a potentially reversible cause of arrest. Death in the ICU (OR=17.2, P< 0.0001) or history of ICU admission (OR= 4.637, P= 0.0022) was associated with an increased likelihood of CPR. Lack of a formal DNAR does not appear to be a risk factor for potentially non-beneficial CPR at the end of life. Further analysis is needed to better understand other factors that impact DNAR and CPR decisions.
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Liza-Marie Johnson, MD MPH MSB HEC-C
Belinda Mandrell, PhD RN CPNP
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