The experience of caring for a child who dies in the PICU is multifaceted. Grief, rather than moral distress, was the dominant psychological response of caregivers. Future research could focus on enhancing communication and emotional support.

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There is significant variation in both the frequency and time to tracheostomy between the studied PICUs for patients requiring prolonged mechanical ventilation; among those who received a tracheostomy, the majority did so after two or more weeks of mechanical ventilation. Future studies examining tracheostomy benefits, disadvantages, outcomes, and resource utilization of this patient subgroup are indicated.

WHAT'S KNOWN ON THIS SUBJECT:Studies from the 1990s demonstrated limitation of end-of-life support in 30% to 58% of US PICU deaths. Little has been published from the United States since that time. More-recent publications from Australia showed limitation in 74% to 84% of deaths. WHAT THIS STUDY ADDS:The authors address a gap in the literature by describing recent end-of-life support practices in 30 PICUs across the United States. abstract OBJECTIVE: Our purpose was to examine alterations in end-of-life support in a multiinstitutional sample of PICUs. METHODS:This was a retrospective, descriptive study. Variables collected included end-of-life support category, race, length of stay, operative status, reason for admission, and Pediatric Index of Mortality 2 score, as well as the number of ICU beds and the presence of trainees. RESULTS:There were 1745 deaths at 35 institutions between January 1, 2004, and September 30, 2005. Of those, 1263 had complete data and were analyzed. The end-of-life support category distribution was as follows: brain death, 296 (23%); do not resuscitate, 205 (16%); limitation of support, 36 (3%); withdrawal of support, 579 (46%); no limitation, 124 (10%); no advance directives, 23 (2%). For further analyses, end-of-life support categories were grouped as limitation (ie, do not resuscitate, limitation of support, or withdrawal of support) versus no limitation (ie, no limitation or no advance directive). Brain death was not included in further analyses. The majority of deaths were in the limitation group (n ϭ 820 [85%]), and 12 (40%) of 30 institutions had 100% of deaths in this group. There were significant differences between institutions (P Ͻ .001). Decisions for limitation were seen less frequently in the black race (112 [76%] of 147 deaths; P ϭ .037) and in institutions with no trainees (56 [69%] of 81 deaths; P Ͻ .001). CONCLUSIONS:

Objective To describe the teaching and evaluation modalities utilized by pediatric critical care medicine (PCCM) training programs in the areas of professionalism and communication. Design Cross sectional national survey. Setting PCCM fellowship programs. Subjects PCCM program directors. Interventions None. Measurements and Main Results Survey response rate was 67% of program directors in the United States, representing educators for 73% of current PCCM fellows. Respondents had a median of 4 years experience, with a median of 7 fellows and 12 teaching faculty in his/her program. Faculty role modeling or direct observation with feedback were the most common modalities used to teach communication. However, 6 of the 8 (75%) required elements of communication evaluated were not specifically taught by all programs. Faculty role modeling was the most commonly utilized technique to teach professionalism in 44% of the content areas evaluated, and didactics were the technique utilized in 44% of other professionalism content areas. Thirteen of the 16 required elements of professionalism (81%) were not taught by all programs. Evaluations by members of the healthcare team were used for assessment for both competencies. The use of a specific teaching technique was not related to program size, program director experience, or training in medical education. Conclusions A wide range of techniques are currently utilized within PCCM to teach communication and professionalism, but there are a number of required elements that are not specifically taught by fellowship programs. These areas of deficiency represent opportunities for future investigation and improved education in the important competencies of communication and professionalism.