Logistics of Withdrawal of Life-Sustaining Therapies in PICU

Logistics of Withdrawal of Life-Sustaining Therapies in PICU Karen Dryden-Palmer, RN, MSN1,2; Cathy Haut, DNP, CPNP, FAANP3; Samantha Murphy, RN, MANP, PGDip Nursing Practice4; Patricia Moloney-Harmon, RN, MS, CCNS, FAAN5 Objectives: To describe practical considerations and approaches to best practices for end-of-life care for critically ill children and families in the PICU. Data Sources: Literature review, personal experience, and expert opinion. Study Selection: A sampling of the foundational and current evidence related to the withdrawal of life-sustaining therapies in the context of childhood critical illness and injury was accessed. Data Extraction: Moderated by the authors and supported by lived experience. Data Synthesis: Narrative review and experiential reflection. Conclusions: Consequences of childhood death in the PICU extend beyond the events of dying and death. In the context of withdrawal of life-sustaining therapies, achieving a quality death is impactful both in the immediate and in the longer term for family and for the team. An individualized approach to withdrawal of life-sustaining therapies that is informed by empiric and practical knowledge will ensure best care of the child and support the emotional well-being of child, family, and the team. Adherence to the principles of holistic and compassionate end-of-life care and an ongoing commitment to provide the best possible experience for withdrawal of lifesustaining therapies can achieve optimal end-of-life care in the most challenging of circumstances. (Pediatr Crit Care Med 2018; 19:S19–S25) 1 Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada. 2 Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada. 3 Mednax-Pediatrix Medical Group, Nemours AI Dupont Hospital for Children, Wilmington, DE. 4 Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia. 5 Children’s Services, Sinai Hospital of Baltimore, Baltimore, MD. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000001621 Pediatric Critical Care Medicine Key Words: dying and death; end-of-life; intensive care; limitations of therapies; pediatric critical care; withdrawal of life-sustaining therapies M ost deaths in hospitalized children occur in the PICU. Many of those deaths can be anticipated (1). Acceptance of the inevitability of the child’s death can lead to the active decision to influence the dying process by withdrawing life-sustaining therapies (WOLST). WOLST is the removal or discontinuation of life-sustaining treatments or technology. The accepted rationale for WOLST is that the ongoing use of life-sustaining interventions is of limited or no benefit to the child, is not aligned with the goals of care for a child, and is thought to prolong the process of dying in a way that is burdensome for the child and family (2–4). WOLST is distinguished from withholding (i.e., not starting) life-sustaining therapies, as discontinuation of these therapies is planned (1, 5, 6). We will focus this discussion on WOLST occurring in the PICU environment. WOLST occurring outside the critical care environment is addressed in “Compassionate Discharge from the PICU” in this supplement (7). In our experience, clinicians describe that WOLST “feels” unique and is experienced differently from other deaths in the PICU. Decisions for WOLST in children often follow a change in the direction of care and a change in the expected and hopedfor outcomes (8). Here, we describe practical considerations and share strategies for providing end-of-life (EOL) care to critically ill children and their families in the PICU as life-sustaining therapies are withdrawn. The term “family” is used to describe the child’s primary caregivers—this includes all relatives, legal, and other guardians (9). Figure 1 describes the essential element of and recognized standards for EOL care that frame our discussion (10). WOLST IN PICU Withdrawal of life-sustaining interventions involves careful consideration for the proactive inclusion of EOL care and decisions about when and how the withdrawal will occur. The child and family should be well prepared, the environment well organized, and care during and after WOLST carefully www.pccmjournal.org S19 Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited Dryden-Palmer et al Figure 1. Five core elements of end-of-life care (10). considered. Four phases of WOLST are described, exploration of preferences and feasibility, planning, enacting WOLST, and care after WOLST. These phases frame our approach to describing the guiding principles and practical interventions for compassionate EOL care. Examples of interventions for achieving individualized quality EOL care in each phase are summarized in Table 1. EXPLORING WOLST PREFERENCES AND FEASIBILITY Once a determination has been made to pursue compassionate WOLST, the ICU team should begin preparatory activities. The PICU team should clarify who is included as “family” as per the family’s own understanding and how they wish to be engaged in the process. Open and authentic support of the family’s decisions is important in order to demonstrate respect for family relationships and for parental authority. Clinicians must ensure adequate supports are matched to the family’s desired role in decision-making about the process of WOLST (3). Facilitating family presence, encouraging spiritual and emotional expression, and matching the tone of care to the family and to the situation encourage trust and help to establish strong therapeutic connections prior to the acts of WOLST (10). Establishing a consistent group of familiar clinicians including the child’s primary team members can help to establish these important therapeutic relationships, offer extended support, and facilitate transparent information sharing (11). Revisiting family perceptions and their understanding during each phase can ensure that information has been effectively taken up. Careful and clear articulation of the steps in WOLST and how goals of care will be supported can help mitigate family concerns or feelings of inadequacy or abandonment of their child. Assisting the family to reflect on the child’s preferences is an important component of WOLST preparation. The PICU team should consider disclosure of the WOLST to the child, their siblings, and others early in this process, ensuring that the child has a voice in decision-making, either via surrogate S20 www.pccmjournal.org or directly from the child. The integration of siblings and extended family/friends should be addressed and resolved during this preparation phase. The PICU team can provide guidance and resources in this phase to address the child’s level of engagement and support the family in decisionmaking around this aspect of preparation. Where and when WOLST will take place are decisions to be considered in preparation. Responding to family consideration for timing and setting realistic expectations of the process for WOLST promotes a sense of shared purpose and supports the exploration of concerns. Ideally, timing of WOLST allows for desired family experiences or activities to occur in the context of the child’s condition. Family may wish to experience a religious or culturally relevant occasion together, take their child outside, or celebrate an important family milestone while their child is able to be involved and present. These activities contribute to the child’s legacy and the family’s story and support connectedness to their community (10). Open-ended question about who from the family will be present and what roles individual family members may play in the child’s care and death should be asked. There is no one best way to approach a child’s WOLST; thus, family’s needs and strengths can reflect a range of preferences. Understanding family preferences and maximizing opportunities to spend time with their child are key when there is some predictability in the situation. If the situation is evolving or timing is uncertain (e.g., a cardiac arrest may occur), the team should offer guidance about how WOLST will proceed, how family can be present to support their child, and how they can support one another. Some families may wish to participate in all care activities, others may wish to observe, and others may choose to be in a separate space during the withdrawal. Having a designated team member available to support family in whatever way they choose to be present is an important part of high quality care. Providing preemptive age appropriate explanations and support for siblings by child life specialists or social workers are recommended. Anticipatory guidance should be provided for all family members who will be present to explain about WOLST and how the child’s death may look, sound, smell, and feel like. Exploring with the family spiritual and cultural observances and how these can be integrated in the context of the PICU are essential. Pragmatic factors can make it difficult to meet these observances, and the PICU team may need to manage resource limitations, distance of family members, or the child’s evolving condition. We make it our practice however to explore each request, challenge our abilities to be creative, engage the organization’s resources, and provide clear explanations as to what August 2018 • Volume 19 • Number 8 (Suppl.) Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited Supplement TABLE 1. Phased Goals and Actions for Withdrawing Life-Sustaining Therapies in Pediatric Intensive Care Phases Exploring WOLST preferences and feasibility Guiding Principles Individualized care Respect for person and family integrity, culture and traditions Goal(s) Actions Assessment of family/child needs and exploration of preferences Clarify understanding of goals of care Set supportive and matched tone Explore family and child preferences for when, where, and who will be present for WOLST Anticipatory guidance of WOLST process Explore cultural and spiritual needs Surface concerns and questions, clarify misinformation Explore disclosure to child and others Invite the participation of spiritual advisor as per family and child preferences Explore organ and tissue donation preferences Anticipatory guidance Set expectations of process and the experience Provide anticipatory guidance about sights sounds, smells, physiologic changes/responses of the child; what to expect before during and after WOLST; potential parental physical and emotional responses Discuss and clarify roles of family and team members Discuss sibling needs and engagement—engage child life specialists Identify and activate resources (family, organization, external) Planning for WOLST Balance family preferences and practical considerations Balance privacy with access to support Flexible responsive plan of care Determine a time for WOLST that meets the family and child’s needs Establish timing of actions Design communication plan Determine environment and roles for WOLST Select a room or space for WOLST Provide guidance for what to do if one feels overwhelmed/unwell Identify space outside of the child’s room for family Plan provider presence/access Maintain level of care Plan for contingencies in child’s condition Plan for ongoing care and symptom management Engage palliative care specialists Design monitoring plan Determine actions should a condition change occur and the child deteriorates prior to WOLST Determine a plan for survival to transition from PICU Support meaning making for the child and family Action spiritual, cultural, and family rituals Discuss how to say goodbye (legacy-building activities) (see Fig. 2) Plan cultural and family rituals that will be a part of the WOLST procedure (e.g.) obtaining a large bed, so family can lay close to the child (Continued) Pediatric Critical Care Medicine www.pccmjournal.org S21 Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited Dryden-Palmer et al TABLE 1. (Continued). Phased Goals and Actions for Withdrawing Life-Sustaining Therapies in Pediatric Intensive Care Phases Guiding Principles Carrying out WOLST Best care of child and family Goal(s) Actions Plan for comfort, safety, and wellbeing of child and family throughout process Implement monitoring plan Support family presence as per family preferences Dress the child in his/her own clothing, use familiar hygiene products, assist family members to hold and connect with their child Provide privacy while remaining accessible—interval check-ins Designate a team member to assist with flow of visitors and to enforce safe use of the allotted space Respond promptly for changes in child’s condition/ needs Provide information and interpretation of child’s condition and responses Maintain open communication Implement communication plan Implement care and symptom management plan Provide familiar care givers Frequently reassess child and family needs and address any concerns arising Inclusive approaches to addressing concerns/clinical challenges Engage family in care as per their preference Support family care giving/roles Frequently reassess child and family needs and address any concerns arising Ensure space is available for larger groups and for those who wish to be near, however not present in the child’s room Provide support for emotional distress After WOLST Best care of child and family Maintain supportive environment up to and after death Continue supportive care and symptom management for child Frequently assess child’s condition adapt plan of care accordingly Provide guidance/interpretations of the sights sounds, smells, physiologic changes/responses of the child Facilitate family members to meet their personal needs (rest/food) Provide positive reinforcement of family role and impact on child Honor family culture and traditions Engage family in after death care/ decision-making Provide support for and facilitate after death rituals Transition family and support bereavement Support meaning making for the child and family Provide guidance about next steps Provide anticipatory information Ensure family has team contact information Initiate referrals for after care as needed WOLST = withdrawing life-sustaining therapies. can and cannot be accomplished. In cases where family preferences are not realized, sincere attempts to accommodate these wishes can reassure the family that they were heard, understood, and advocated well for themselves and their child (12). Exploration of organ and tissue donation preferences (legislated in some jurisdictions) may be initiated in this phase and may potentially influence other planning decisions (timing and place of WOLST for donation after circulatory death) (13, 14). S22 www.pccmjournal.org PLANNING FOR WOLST WOLST requires careful planning, ongoing assessment, adaptation and continuity of care extending beyond the actions of the withdrawal itself. Planning should always consider each potential trajectory for the child including an immediate death and the potential for longer survival. The involvement of palliative care specialists is advisable before withdrawal if it seems likely that the child will survive long enough to consider PICU discharge (7, 15). August 2018 • Volume 19 • Number 8 (Suppl.) Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited Supplement chaplaincy), seeking creative ways to connect family (internet contact with remote family), and following through with deferred requests after the child’s death (creating legacy items after death) are ways of providing quality EOL care within a potentially restricted timeframe (18). Figure 2 lists a sample of these activities that can be helpful for families anticipating or experiencing bereavement (19, 20). It is not surprising that the PICU environment designed to deliver constant and intense monitoring can also pose challenges for WOLST. Barriers to family presence may include the available space, workflow, and organizational policy. Physical space for family at the child’s bedside, availability of facilities to house larger famFigure 2. The creation of memories and mementos can be an important and enduring part of end of life care. ily groups on or near the unit, The figure includes list of potential items and activities that may be incorporated into care in the PICU. organizational policies related to visitor admittance to the Specific comfort interventions such as the presence of others area, age restrictions for visitors, and control of access to care and spiritual/cultural observances are important choices to be areas can all influence the team’s ability to maximize family honored when planning for WOLST (16). Evidence indicates presence (21). These same environmental factors can make preparents’ preference a shared approach to decision-making, serving privacy for the child and family and other children in and despite the intense emotions, parents actively participate the same care areas difficult. Shared rooms and areas designed in decision-making in order to protect their child from sufferto optimize patient observation limit private spaces for famiing during the dying process (17). Throughout the decision- lies anticipating WOLST. Others in the immediate areas may making processes, the PICU team should work to ensure that be unintentionally exposed to the grieving family’s experience. families do not perceive that they are alone in making these Organizational restrictions, such as the use of cameras and decisions and that adequate supports are matched to the famvideos in shared spaces, may interfere with memory-making ily’s desired role in the process (3). activities. The PICU team must be creative in order to define a Control of the timing of the child’s death can be achieved in private space for the child and family. Simple strategies include some contexts of WOLST. Time can be experienced differently the use of privacy curtains, mobile wall barriers, posting signs to between parents and clinicians with family being orientated to limit unnecessary entry into the room, and attention to reducthe moment and the critical care team taking on a future-ori- ing sound interruptions (22). Moving a child to a more priented stance (8). Approaches to building a timeline for WOLST vate space is an option and may mitigate some of these issues; may often vary among persons, teams, local practice, and pro- however, a move may have negative connotations for families. cess; however, engaging the child and family whenever possible Family may prefer to remain in a familiar room, or they may be is essential. Fear of extending the child’s suffering can influence concerned about being isolated from the team or other families. timing for WOLST. Reassurance of the child’s comfort and dig- Some PICUs have preferred or designated rooms for EOL care. nity is the goal of each action and decision. These rooms have features to support family comfort, sibling There are also situations where there is little time to develop presence, religious and spiritual rituals, and many have relaxed a plan with the family, such as when the child’s clinical con- visiting protocols. Consideration to the space must also be given in terms of dition is evolving and withdrawal may occur in a short timewhat might be required to continue PICU support should the frame. In these contexts, skillfully eliciting immediate needs child survive after WOLST. Preemptive explanations about (parental and sibling presence, important rituals like baptism/ prayers), providing assurances that the child’s needs are being what care will look like in the new area including access to the met, immediate activation of supportive resources (child life, team, orientation of the family to the room, and assurance Pediatric Critical Care Medicine www.pccmjournal.org S23 Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited Dryden-Palmer et al about the continuation of the same level of care should be provided prior to moving the child. Sometimes family preference is to return to a familiar ward area or to return home for WOLST, and in these cases, compassionate PICU discharge is pursued (7). It can be difficult to balance a relaxing of organizational restrictions for family presence for one child while maintaining policy with other children and families in the area. Similarly, it is often challenging to protect other children and families from noticing the change in the dying child’s direction of care. Responding to questions from other families or aware patients can be challenging. Respecting and protecting the privacy of the dying child are imperative when responding. This respect should be coupled with sensitivity to the concerns and fears of others who may be impacted by exposure to WOLST activities and address their unique needs for support. Meticulous communication with the dying child's family and working through the anticipated and unanticipated clinical needs of the child provide important support and reinforce the team’s continued engagement (3). A plan of care for the child addressing symptom management, ongoing medical care, responses to potential complications or events related to WOLST should be created and shared among the team and family (23). Ready access to medication and interventions that support the child’s comfort before beginning WOLST is important in order to expedite responses to the child’s changing needs. Monitoring plans should be congruent with the goals of care. Legacy-building activities and any cultural and family rituals in this plan, especially any that will be a part of, or concurrent to the WOLST (e.g., prayers or blessings), are designed in this phase (18). PICU teams should review and revise the plan frequently and ensure flexibility to modify approaches as WOLST proceeds and the child’s clinical condition progresses. In our experience, careful communication and check-ins coordinated through a central/core leader on the child’s team are efficient mechanisms to achieve this. CARRYING OUT WOLST When moving to WOLST, goals for care shift to providing comfort and symptom management for the child and emotional support for the child and family. Areas of action include the child’s physical care, managing the environment, supporting the emotional needs of child and family, and reassessing for impact of the interventions. Plans for managing the child’s symptoms (pain, anxiety, and dyspnea) are acted on in this phase. Considerations for nonpharmacologic comfort interventions, such as music, massage, holding, or other comforting activities that the child responds to, are essential. Acting on the communication and monitoring plans and delivering the required care (e.g., suctioning or infusions) are ongoing in this phase. Families need to observe that removal of life-sustaining therapies is grounded in best care and not abandonment or surrendering the child to death. Providers should anticipate and take action related to the specific procedures for each child’s WOLST (extubation, S24 www.pccmjournal.org decannulation) and minimize exposure to distressing or unpleasant sensory experiences. The PICU team leads in managing the care space and monitoring family presence to ensure the child’s safety and security. When family is present during WOLST, providers should remain alert for signals that the family is becoming overwhelmed. If possible, arranging for alternative space away from the child for parents, siblings, or other family members to take a break can be helpful. Supporting the family to be as present with their child as they desire and respecting family roles and cultural expectations are goals during WOLST (22). Family questions should be encouraged to address any misconceptions. Parents should be supported to connect to their child in whatever capacity they wish and are able (21). They should have explanations of what the child may hear or experience, and parents should be told of the positive impact they have on their child. The family should be aware of available resources and have easy access to these. If extreme distress is experienced, it can be managed with the addition of social work, crisis support, and spiritual support or activating community resources. If time permits and the family desires, active legacy building can be pursued in this phase. Many PICUs have legacy programs to create tangible memory items (hand and foot casts, prints, locks of hair, photos, arm bands). It is also important to remain aware of the experience and needs of providers. WOLST is challenging to coordinate, demanding of individuals, and emotionally fatiguing. AFTER WOLST After WOLST has taken place, ongoing adaptations to meeting the child’s physiologic needs in the dying process and activating ongoing support for family become the focus (24, 25). When WOLST results in the child’s continued survival for an uncertain length of time, the action plans designed during the WOLST should be continued. Palliative care specialist, if not already involved, should be consulted to facilitate transition if the child is expected to survive to require care outside of the PICU setting. The timing of transitioning the dying child to the ward, hospice, or home should be considered as aligned with the preparatory and planning discussions for each individual child (26). When WOLST results in the child’s immediate or approaching death, the PICU teams should facilitate family, spiritual, or cultural rituals requested for the time of death. It is very important that the time of death is marked, and the condolences of the team and individual clinicians be shared with the family (27). PICU providers should work with the family to engage them in the child’s after death care according to their desires and preferences and arrange for them to spend time with the child after death if they wish to (10). Information and guidance about next steps in terms of their child’s body care, funeral planning, autopsy, and release of the child’s remains should be provided (21). Ensure that family has contact information for key members of the PICU team prior to leaving the hospital (28, 29). August 2018 • Volume 19 • Number 8 (Suppl.) Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited Supplement CONCLUSIONS The experience of childhood death deeply impacts the family and may result in complicated grief (30, 31). Consequences for the child, family, and providers extend beyond the events of dying and death. Emphasis in the PICU is often placed on the short-term issues and needs of the child and family in the context of WOLST, but successfully implementing a quality death is impactful both in the immediate and in the longer term for family and for the team. An individualized approach to WOLST that is informed by empiric and experiential knowledge will alleviate physical and emotional suffering and support spiritual health for all parties. There are no established best ways to navigate the discrete elements of WOLST (family presence, approaches to decision-making, sibling engagement). However, taking an interest in exploring preferences and making a firm commitment to providing the best possible experience for the child and family can achieve optimal EOL care in the most challenging of circumstances. Care that provides the right skills at the right time, excellent transparent communication, compassion and flexibility are the hallmarks of well-executed WOLST. REFERENCES 1. Garros D, Rosychuk RJ, Cox PN: Circumstances surrounding end of life in a pediatric intensive care unit. Pediatrics 2003; 112:e371 2. Meert KL, Eggly S, Kavanaugh K, et al: Meaning making during parent-physician bereavement meetings after a child’s death. Health Psychol 2015; 34:453–461 3. Devictor D, Latour JM, Tissières P: Forgoing life-sustaining or deathprolonging therapy in the pediatric ICU. Pediatr Clin North Am 2008; 55:791–804, xiii 4. Burns JP, Sellers DE, Meyer EC, et al: Epidemiology of death in the PICU at five U.S. teaching hospitals*. Crit Care Med 2014; 42:2101–2108 5. Sands R, Manning JC, Vyas H, et al: Characteristics of deaths in paediatric intensive care: A 10-year study. Nurs Crit Care 2009; 14:235–240 6. Brosche TA: Death, dying, and the ICU nurse. Dimens Crit Care Nurs 2003; 22:173–179 7. Kang T, Hynson J: Compassionate discharges from the pediatric intensive care unit. Pediatr Crit Care Med 2018: In Press 8. Benner P, Hooper-Kyriakidis P, Stannard D: Clinical Wisdom and Interventions and Acute and Critical Care: A Thinking-in-Action Approach. New York, NY, Springer Publishing Company, 2011 9. Wright L, Leahey M: Nurses and Familes: A Guide to Family Assessment and Intervention. Fifth Edition. Philadelphia, PA, F.A. Davis, 2009 10. Meyer EC, Ritholz MD, Burns JP, et al: Improving the quality of endof-life care in the pediatric intensive care unit: Parents’ priorities and recommendations. Pediatrics 2006; 117:649–657 11. Larcher V, Craig F, Bhogal K, et al; Royal College of Paediatrics and Child Health: Making decisions to limit treatment in life-limiting and life-threatening conditions in children: A framework for practice. Arch Dis Child 2015; 100 Suppl 2:s3–23 Pediatric Critical Care Medicine 12. Macdonald ME, Liben S, Carnevale FA, et al: Parental perspectives on hospital staff members’ acts of kindness and commemoration after a child’s death. Pediatrics 2005; 116:884–890 13. Gilleland J, Parshuram C: Discussing death as a possible outcome of PICU care. Pediatr Crit Care Med 2018; In Press 14. Nakagawa T, Dryden-Palmer K, Parshuram CS, et al: Donation following neurologic and circulatory determination of death. death and dying supplement PCCM. Pediatr Crit Care Med 2018; In Press 15. Morrison W, Gauvin F: Integrating palliative care into the ICU: From core competency to consultative expertise (Invited contribution to the Supplement: Death and Dying in PICU). Pediatr Crit Care Med 2018; In Press 16. Gries CJ, Curtis JR, Wall RJ, et al: Family member satisfaction with end-of-life decision making in the ICU. Chest 2008; 133:704–712 17. de Vos MA, Bos AP, Plötz FB, et al: Talking with parents about end-oflife decisions for their children. Pediatrics 2015; 135:e465–e476 18. Meert KL, Thurston CS, Briller SH: The spiritual needs of parents at the time of their child’s death in the pediatric intensive care unit and during bereavement: A qualitative study. Pediatr Crit Care Med 2005; 6:420–427 19. Meert KL, Thurston CS, Thomas R: Parental coping and bereavement outcome after the death of a child in the pediatric intensive care unit. Pediatr Crit Care Med 2001; 2:324–328 20. Brooten D, Youngblut JM, Seagrave L, et al: Parent’s perceptions of health care providers actions around child ICU death: What helped, what did not. Am J Hosp Palliat Care 2013; 30:40–49 21. Meert KL, Briller SH, Schim SM, et al: Examining the needs of bereaved parents in the pediatric intensive care unit: A qualitative study. Death Stud 2009; 33:712–740 22. Meert KL, Briller SH, Schim SM, et al: Exploring parents’ environmental needs at the time of a child’s death in the pediatric intensive care unit. Pediatr Crit Care Med 2008; 9:623–628 23. Cohen MS, Prough DS: Reducing the Angst Associated with withdrawal of life-sustaining therapy. Crit Care Med 2016; 44:1241–1242 24. Butler AE, Hall H, Willetts G, et al: Family experience and PICU death: A Meta-synthesis. Pediatrics 2015; 136:e961–e973 25. McGraw SA, Truog RD, Solomon MZ, et al: “I was able to still be her mom”–parenting at end of life in the pediatric intensive care unit. Pediatr Crit Care Med 2012; 13:e350–e356 26. Widger K, Davies D, Rapoport A, et al: Pediatric palliative care in Canada in 2012: A cross-sectional descriptive study. CMAJ Open 2016; 4:E562–E568 27. Leash RM: Death notification: Practical guidelines for health care professionals. Crit Care Nurs Q 1996; 19:21–34 28. October T, Dryden-Palmer K, Meert K, et al: Death and dying in PICU supplement; caring for parents after the death of a child. Pediatr Crit Care Med 2018; In Press 29. Garstang J, Griffiths F, Sidebotham P: What do bereaved parents want from professionals after the sudden death of their child: A systematic review of the literature. BMC Pediatr 2014; 14:269 30. Rogers CH, Floyd FJ, Seltzer MM, et al: Long-term effects of the death of a child on parents’ adjustment in midlife. J Fam Psychol 2008; 22:203–211 31. Meert KL, Donaldson AE, Newth CJ, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network: Complicated grief and associated risk factors among parents following a child’s death in the pediatric intensive care unit. Arch Pediatr Adolesc Med 2010; 164:1045–1051 www.pccmjournal.org S25 Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Unauthorized reproduction of this article is prohibited