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Crit Care Med. 2014 Sep;42(9):2101-8. doi: 10.1097/CCM.0000000000000498.

Epidemiology of death in the PICU at five U.S. teaching hospitals*.

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1Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA. 2Department of Anesthesia, Harvard Medical School, Boston, MA. 3Bronfenbrenner Center for Translational Research, College of Human Ecology, Cornell University, Ithaca, NY. 4Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, MA. 5Department of Psychiatry, Harvard Medical School, Boston, MA. 6Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, WA. 7Department of Pediatrics, University of Washington, Seattle, WA. 8Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA.



To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States.


Prospective case series.


Five U.S. teaching hospitals.


We concurrently identified 192 consecutive patients who died prior to discharge from the PICU. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures.




The overall mortality rate was 2.39% (range, 1.85-3.38%). One hundred thirty-three patients (70%) died following the withholding or withdrawal of life-sustaining treatments, 30 (16%) were diagnosed as brain dead, and 26 (14%) died following an unsuccessful resuscitation attempt. Fifty-seven percent of all deaths occurred within the first week of admission; these patients, who were more likely to have new onset illnesses or injuries, included the majority of those who died following unsuccessful cardiopulmonary resuscitation attempts or brain death diagnoses. Patients who died beyond 1-week length of stay in the PICU were more likely to have preexisting diagnoses, to be technology dependent prior to admission, and to have died following the withdrawal of life-sustaining treatment. Only 64% of the patients who died following the withholding or withdrawing of life support had a formal do-not-resuscitate order in place at the time of their death.


The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved. Death is largely characterized by two fairly distinct profiles that are associated with whether death occurs within or beyond 1-week length of stay. Decisions not to resuscitate are often made in the absence of a formal do-not-resuscitate order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.

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