Calling It: Pediatric Intensivists’ Decision to End a Code

Introduction: The decision to end resuscitation attempts during a pediatric code and declare death is a low-frequency, high-impact event. Guidelines specify pediatric code initiation, but the process by which intensivists decide to end resuscitation attempts is not well described. This study aims to establish the relative importance of clinical and contextual factors that pediatric intensivists consider in their process of deciding when to conclude a pediatric code event.


Methods: A survey was developed to score the importance of clinical and contextual factors when considering ending a code using a Likert scale and was distributed to US pediatric intensivists via the Pediatric Acute Lung Injury and Sepsis Investigators listerv. Survey responses were summarized descriptively and compared between groups using linear models based on sex, experience, and primary practice environment.


Results: 179 participants responded. Participant experience skewed towards early career intensivists and those practicing in primary PICU units. There were a similar number of male and female participants. The two factors most frequently indicated as being “extremely important” or “very important” by participants were related to duration of arrest ("down time prior to initiation of CPR" (90%) and "total duration of CPR" (81%)). "Patient's insurance status" and "personal religious and spiritual beliefs" were reported as “not at all important” by most participants. Female intensivists reported prioritizing the “presence of a caregiver” in their decision making more than their male counterparts (p=0.0005). More experienced intensivists reported greater prioritization of location of arrest (“in hospital vs. out of hospital”), “perceived prognosis prior to arrest”, and “presence of a caregiver” more than their less experienced counterparts (all p≤0.01). There were no significant differences between primary practice environments.


Conclusions: Intensivists weigh a range of factors when deciding when to stop resuscitation and declare death. "Down time prior to initiation of CPR" was most important and "patient insurance status" and individual "religious and spiritual beliefs" were the least important. These trends warrant further exploration with a qualitative approach to better understand the nuances of this high-stakes decision making.