Sudhir Mishra

ARI Control Programme: Results in Hospitalized Children

One hundred cases of pneumonia with chest indrawing were treated according to the treatment protocol of the ARI control programme. The majority of children were > 2 months old (85 per cent) with male predominance (61 per cent). All cases with severe pneumonia survived. A mortality rate of 7.7 per cent was seen in cases of very severe pneumonia. Three children in the severe pneumonia group deteriorated on benzyl penicillin to very severe pneumonia but subsequently improved on chloramphenicol. Six patients were treated as cases of Staphylococcal pneumonia and one of them died. Thirteen children (21.3 per cent) in the severe pneumonia group required oxygen for breathing rates > 70 per minute. Seventy-four per cent in the very severe pneumonia group required administration of IV fluids. Blood counts did not prove to be of help in differentiating the children at risk of dying. There was no significant difference in roentgenographic findings in the two groups. Congestive cardiac failure was the most common complication, seen in 33.3 per cent of cases of the very severe pneumonia group. The duration of stay was significantly less in cases of severe pneumonia (4.21 +/- 1.59 days) as compared to very severe pneumonia (9.35 +/- 2.39 days). The data from this study suggest that the treatment protocol for the ARI control programme for hospitalized children is reasonably effective and can be implemented in small hospitals.

End-of-life care: Consensus statement by Indian Academy of Pediatrics

JustificationThe right to life has been accepted as one of the fundamental rights in our constitution. Resuscitation is a procedure performed for all patients suffering from cardiac or respiratory arrest irrespective of the clinical condition. There are no legal guidelines defining process to be adopted in situations where resuscitation is unlikely to be useful. There are no guidelines on withdrawal of care or end of life (EOL) decisions, accepted by the Government, judiciary, professionals, academicians or the community.ProcessA National Consultative meet was organized by Indian Medico-Legal and Ethics Association and the Medico-legal group of Indian Academy of Pediatrics (IAP) to formulate the guidelines on ‘Do Not Resuscitate’ (DNR), and ‘End of Life Support’. The meeting was organized on 30th May, 2014 at Ram Manohar Lohia Hospital, New Delhi. The meeting involved professionals from legal and various medical fields as well as administrators, and members from Medical Council of India.ObjectivesTo frame the guidelines related to EOL care issues and withdrawal or with-holding treatment in situations where outcome of continued treatment is expected to be poor in terms of ultimate survival or quality of life.Recommendations(i) DNR or end of life care should not be activated till consensus is achieved between treating team and the next of kin; (ii) Consensus within health care team (including nurses) needs to be achieved before discussion with family members; (iii) Discussion should involve the family members–next of kin and other persons who can influence decisions; (iv) If family members want to include their family physician or a prominent person from the community, it should be encouraged. Similarly if family members want a particular member of treating team, he/she should be included; (v) Treating doctors should have all the facts of the case including investigations available with them before discussion; (vi) Unit in-charge or treating doctor should be responsible for achieving consensus and should initiate the discussion; (vii) After presenting the facts of the cases, family members should be encouraged to ask questions and clear doubts (if any); (viii) At the end of discussion, a summary of the discussion should be prepared and signed by the next of kin and the unit in-charge or treating doctors; (ix) DNR orders should be reviewed in the event of unexpected improvement or on request of next of kin. Same should be documented; (x) DNR orders remain valid during transport.