Do not resuscitate orders and pediatric patients: the role of a clinical ethics committee in a developing country.

Abstract

No published information is currently available about formal "do not resuscitate" (DNR) orders for pediatric patients in developing countries, even though there has been extensive discussion of how to determine who should be involved. This article reports the experience of a clinical ethics committee that recommended DNR orders at a pediatric public hospital in Chile. The committee consisted of four permanent physician members and temporary members including clergymen, nurses, the head of the patient's hospital unit, and the attending physician. Attending physicians submitted cases to the committee on a voluntary basis, and the committee's recommendations were not binding. During the 1990-1993 study period the committee recommended issuing DNR orders for 16 of the 34 patients it evaluated. The hospital records of these 16 patients were retrospectively reviewed for information about the patient's age and diagnosis, the committee's specific recommendations, and the outcome of the case. It was found that the committee typically recommended specific measures to help the child's parents and attending staff in addition to the DNR order. The average patient age was 2 years and 2 months. Nearly all of the patients had chronic and multiple pathologies. In all cases the committee recommendations (taken by consensus) were followed by the attending physician with the consent of the patient's parents. Eleven of the 16 patients for whom DNR orders were issued died during the study period. The five others remained alive despite respiratory insufficiency, severe neurologic damage, or hepatic failure. In general the committee's recommendations appeared useful, providing stronger arguments for DNR decisions and suggesting further support measures for patients, their families, and the attending professionals. This finding supports the idea that clinical ethics committees can provide both valuable support and an opportunity to arrive at better decisions in the public hospitals of developing countries.