Publication
Timing of Do-Not-Resuscitate Order Establishment Varies by Illness Trajectory and Clinical Context in Children Receiving Palliative Care: A Retrospective Cohort Study
Javadi S, Espiritu I, Leung T, Karam O, Siegel L, Espiritu I, Siegel L · Cureus · 2026
Background Do-not-resuscitate (DNR) orders in pediatrics are frequently analyzed as static outcomes, although they emerge through a longitudinal process shaped by evolving illness trajectories and repeated clinical encounters. Our primary objectives were to characterize the time from the first pediatric palliative care (PPC) consultation to formal DNR order establishment and to identify associated clinical factors. Secondary objectives were to describe longitudinal changes in DNR status and withdrawal of life-sustaining therapy. Methodology We conducted a retrospective cohort study of 371 children who received hospital-based PPC consultation at a quaternary children’s hospital in the United States between December 2011 and December 2016. The descriptive cohort included all 371 patients. Time-to-event analyses included 351 patients with an ascertainable event time and no DNR order before the first PPC consultation. Kaplan-Meier methods and multivariable Cox proportional hazards models were used, with follow-up extending across subsequent hospitalizations. Results Among 371 patients (median age = 2.4 years; 49.1% female), 115 (31.0%) had a documented DNR order. In the time-to-event cohort, 95 patients established a DNR order. DNR-free survival differed by diagnosis category (log-rank p = 0.003). Life-limiting illness without a realistic hope of cure was associated with a higher hazard of DNR establishment (adjusted hazard ratio (adjHR) = 2.10, 95% confidence interval (CI) = 1.14-3.86, p = 0.017). Symptom management consultations were associated with a lower hazard (adjHR = 0.08, 95% CI = 0.02-0.35, p < 0.001). Other hospital-based settings were associated with a higher hazard than the pediatric intensive care unit (adjHR = 5.85, 95% CI = 1.74-19.69, p = 0.004), although this estimate was based on six patients and three events. Religious affiliation was not associated with time to DNR. Among patients with a DNR order, 54 of 115 (47.0%) underwent withdrawal of life-sustaining therapy. Conclusions Formal DNR order establishment among children receiving palliative care was longitudinal and associated with illness trajectory and consultation context. DNR order establishment and withdrawal of life-sustaining therapy were distinct outcomes. Estimates from sparse subgroups require cautious interpretation.
Synced from the TRENDS in Pediatric Palliative Care Zotero library, curated by The Siden Research Team. ICPCN does not host or verify the full text.