Withdrawal of Enteral Nutrition and Intravenous Hydration in Pediatric Palliative Care

1Children's National Medical Center, Washington, DC

Meeting: Hospital Medicine 2007, May 23-25, Dallas, Texas

Abstract number: 116

Case Presentation:

A 5‐month‐old girl presented to the emergency room with lethargy and respiratory depression. She had multiple injuries consistent with inflicted trauma, including massive intracranial injury, lacerated liver, ruptured bladder, fractured femur, and facial bruising. Within 24 hours of presentation, she had progressive cerebral edema, and an EEG showed no brain activity. Based on the extent of her injuries and her poor prognosis, her mother decided to withdraw care including intravenous fluids and feeds, to initiate a DNR order, and to pursue palliative care. Morphine and Ativan IV were provided for pain and agitation. After 3 weeks without hydration or feeds, she continued to survive and had no significant signs of dehydration on exam. She began to have slightly increased activity, so her mother decided to restart intravenous fluids and feeds for comfort. She tolerated this without event, and her mother subsequently resumed full medical care.

Discussion:

Severely injured and/or terminally ill patients who transition to palliative care require special consideration by pediatric hospitalists. Because of insufficient pediatric hospice care, children who no longer meet criteria for intensive care are often cared for in an acute care setting until an adequate placement is found. Withdrawal of feeding/hydration, as highlighted in this case, is one of the most difficult issues to address in pediatric palliative care. Ethically and legally, withdrawal of feeding/hydration is appropriate when the burden of such an intervention outweighs its benefit. There has been little research about the potential burden of feeding/hydration of children near the end of life. Areviewof the patient's records showed that IV medications provided approximately 25% of her maintenance fluid requirement, whereas in adults this amount of fluid would have been insignificant. Therefore, she would have been more likely to die from starvation than dehydration. Moreover, the physiologic process of starvation in children has not been well studied. Consequently, when discussing withdrawal of feeding and hydration with parents, there is little information to offer them regarding the child's expected clinical course and time to death. Providing nourishment is fundamental to parenting. To withhold such care is a very difficult decision for parents to make and a hard task for health care providers to undertake.

Conclusions:

Increasingly, pediatric hospitalists are faced with the challenge of caring for patients whose parents have opted to pursue palliative care. However, there is little research about palliative care of children to guide pediatric hospitalists in this process. Future research efforts should be directed at understanding the physiologic, clinical, and psychological ramifications of withholding or withdrawing feeding and hydration in order to properly prepare parents for these decisions.

Author Disclosure:

J. Ehrhardt, None; N. Shah, None; K. L. Smith, None.

To cite this abstract:

Ehrhardt J, Shah N, Smith K. Withdrawal of Enteral Nutrition and Intravenous Hydration in Pediatric Palliative Care. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 116. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/withdrawal-of-enteral-nutrition-and-intravenous-hydration-in-pediatric-palliative-care/. Accessed November 12, 2019.

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