What question did this study set out to answer?

The aim is to determine how often terminal CPR occurs in the last 24 hours of life and to explore the factors influencing the decision to forgo it.

February 22, 2026

Palliative Care and Decision for Terminal Cardiopulmonary Resuscitation in the PICU: Single-Center, Retrospective, Mixed-Methods Analysis, 2013–2022

Key Points

The aim is to determine how often terminal CPR occurs in the last 24 hours of life and to explore the factors influencing the decision to forgo it.
Conducted a retrospective, mixed-methods analysis of children who died in the PICU from 2013 to 2022.
Analyzed the prevalence of tCPR and its association with prior pediatric palliative care consultation.
Used classification tree analysis to identify key factors related to tCPR decisions.
Performed qualitative analysis of provider notes to understand the decision-making process.
Total of 316 deaths out of 23,434 PICU admissions (1.35%).
74% of deaths involved one or more end-of-life events, significantly higher than the national average.
tCPR was performed in 8% of the sample after 24 hours of admission.
Pre-admission pediatric palliative care consultation occurred in 34% of cases and was linked to reduced occurrence of tCPR.

Abstract

Objectives: To quantify the prevalence of cardiopulmonary resuscitation (CPR) in the final 24 hours of life (terminal CPR tCPR) and characterize the decision to forego tCPR. Design: Retrospective, mixed-methods datasets. Setting: PICU in a United States, midwestern quaternary regional pediatrics-only healthcare system. Patients: All children and adolescents (age ≤ 26 yr) who died in the PICU (2013–2022). Interventions: None. Measurements and Main Results: Out of 23,434 admissions, there were 316 deaths (1.35%), consistent with the national PICU reference. In our population, 74% of deaths occurred with one or more end-of-life (EOL) events (i.e., limitation or nonescalation of life-sustaining therapies, discontinuation of nonbeneficial life-sustaining therapies, and altered code status), 9% greater than the national reference (65%; p = 0.001). Out of 234 deaths occurring after 24 hours of admission, tCPR occurred in 18 (8%). Pre-admission pediatric palliative care (PPC) consultation occurred in 80 of 234 cases (34%) and the factors associated with this involvement included baseline disability (assessed using Pediatric Overall Performance Category plus Pediatric Cerebral Performance Category), nontrauma designation, primary admission diagnosis, home medical equipment, not meeting death by neurologic criteria, and sex. In a classification tree analysis, pre-admission PPC exposure was the strongest contributor of the tCPR-related factors. Further thematic, qualitative analysis of provider progress notes in 19 cases identified elements specific to the process of deciding to forego tCPR. Conclusions: Our 10-year retrospective analysis of children dying in the PICU after 24 hours of admission identified pre-admission PPC exposure as a key factor associated with a reduced proportion of tCPR occurrence. The additional qualitative analysis of those choosing to forego tCPR showed that these families experienced EOL care through a temporally and emotionally dynamic decision-making process.

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Palliative Care and Decision for Terminal Cardiopulmonary Resuscitation in the PICU: Single-Center, Retrospective, Mixed-Methods Analysis, 2013–2022

Key Points

Abstract

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