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Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered fxor tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.

Parental priorities and recommendations offer simple yet compelling guidance to improve pediatric end-of-life clinical practice and research.

Parents place the highest priorities on quality of life, likelihood of improvement, and perception of their child's pain when considering withdrawal of life support. Parents make such decisions and garner psychosocial support in the context of a social network that changes over time and includes healthcare professionals, family, and friends.

The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.

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Objective To determine the epidemiology of death in pediatric intensive care units (PICUs) at 5 geographically diverse teaching hospitals across the United States. Design, Setting, and Patients In the PICUs of five teaching hospitals across the United States, we prospectively identified 192 consecutive patients who died prior to PICU discharge. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures. Interventions None Measurements and Main Results The overall mortality rate was 2.39% (range 1.85% to 3.38%). 133 (70%) patients 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 CPR attempts or brain death diagnoses. Patients who died beyond one week length-of-stay in the PICU were more likely to have pre-existing 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 DNR order in place at the time of their death. Conclusions 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 one week length-of-stay. Decisions not to resuscitate are often made in the absence of a formal DNR order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.