1057: Institutional and Temporal Practice Variation in Withdrawal of Life-Sustaining Treatment in Children

Introduction: Withdrawal of life-sustaining treatment (WLST) is the most common mode of death in pediatric intensive care units (PICUs), yet data on how WLST is operationalized remain limited. Prior studies have not adequately examined variability in WLST medical management practices for children across institutions or over time. We hypothesized that substantial institutional and temporal variation exists in WLST practices related to analgesic and sedative use, vasoactive medication discontinuation, neuromuscular blockade, and post-extubation respiratory support. Methods: We performed a secondary analysis of the multicenter DONATE study (2009-2021), which included 905 pediatric patients who died following WLST defined as terminal extubation. Data were abstracted from 9 U.S. tertiary-care PICUs and included medications and interventions administered before and after extubation. Site-level differences were assessed using chi-square or Fisher’s exact tests. Logistic regression was used to assess temporal trends. Results: Of 905 patients, 75.1% died within 1 hour of WLST. Opioids were administered in 79.7% (site range 68-89%, p< 0.001; no significant temporal trend); benzodiazepines in 56.0% (site range 41-66%, p< 0.001; decrease over time OR 0.95 per year, 95% CI 0.90-0.99, p=0.04); dexmedetomidine in 15.5% (site range 4-21%, p=0.002; increase over time OR 1.16 per year, 95% CI 1.05-1.27, p=0.004). Vasoactive infusions were discontinued in 88.1% of cases (site range 59-100%, p< 0.001; increase over time OR 1.15 per year, 95% CI 1.04-1.26, p=0.007). Neuromuscular blockade was used in 5.1% of patients (site range 0-13%, p< 0.001; increase over time OR 1.23 per year, 95% CI 1.08-1.40, p=0.002). Use of any post-extubation respiratory support was rare (5.5%) with no significant site or temporal variation. Conclusions: There is substantial institutional and temporal variability in WLST practices across US PICUs. These findings highlight a need for clearer guidance to reduce variability and support consistent, high-quality end-of-life care for critically ill children.