Objective. To evaluate the change over time of attitudes about withdrawal of care from hopelessly ill children among a cohort of pediatric residents.Design. Prospective data collection via surveys.Setting. A pediatric residency program in a children's hospital.Subjects. Pediatric residents beginning training in 1987 and 1988; 29 residents completed the study.Interventions. Study participants completed a structured case-oriented questionnaire yearly from June 1988 through the completion of their residency training. The withholding of vasoactive agents or cardiopulmonary resuscitation, and the withdrawal of intravenous fluids, nutrition, or mechanical ventilation were the specific therapeutic options presented for a patient in a persistent vegetative state. The effects of time (further training) and parental wishes on resident decisions were assessed.Measurements and main results. No resident wanted to provide intensive care to a child in a persistent vegetative state who was in respiratory failure; all residents would withhold vasoactive agents and CPR from such a child. At the conclusion of training, most (97%) would withdraw mechanical ventilation. A minority would withdraw intravenous (IV) fluids (41%) or nutrition (35%). Residents became more willing to withdraw IV fluids from these patients (0/16 vs 6/16; P = .03) and to withhold or withdraw therapies in general ( P = .03) over the course of their training. All of this change occurred over the first year of training. Parental wishes altered treatment plans for these patients significantly, both when parents desired additional treatment ( P .0001), and when parents wanted treatment stopped ( P = .04). The residents' level of training had no effect on responses to parents' therapeutic requests.Conclusion. Although exposure to level of care issues occurs throughout pediatric residency training, almost all changes in trainees' attitudes occur during the first year. Efforts to promote effective learning and coping should be concentrated in this period.
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机译：目的。要评估随时间推移在一群儿科住院患者中对绝望的患病儿童退出照料的态度的变化。设计。通过调查收集预期数据。儿童医院的儿科住院医师课程。儿科住院医师于1987年和1988年开始接受培训; 29位居民完成了研究。研究参与者从1988年6月开始，通过完成住院医师培训，每年完成一份针对个案的结构化问卷。对于处于持续性植物状态的患者，停用血管活性剂或进行心肺复苏以及撤回静脉输液，营养或机械通气是特定的治疗选择。评估了时间（进一步培训）和父母意愿对居民决定的影响，测量和主要结果。没有居民愿意为处于呼吸困难的持续性植物状态的儿童提供重症监护;所有居民都将从这样的孩子身上拒绝血管活性剂和心肺复苏术。培训结束时，大多数（97％）将撤回机械通气。少数将撤回静脉输液（41％）或营养（35％）。居民变得更愿意在训练过程中从这些患者中抽出静脉输液（0/16 vs 6/16; P = .03），并且总体上拒绝或退出治疗（P = .03）。所有这些更改都发生在培训的第一年。当父母希望进一步治疗时（P <.0001），以及父母希望停止治疗时（P = .04），父母的意愿都极大地改变了这些患者的治疗计划。居民的培训水平对父母对治疗要求的反应没有影响。尽管在整个儿科住院医师培训中均会遇到护理问题，但受训者态度的几乎所有变化都发生在第一年。在此期间，应集中精力进行有效的学习和应对。
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