The pediatric intensive care unit (PICU) is a specialized ward that provides special care to critically/terminally ill children who require assisted ventilation and hemodynamic monitoring. Various studies have reported mortality rates in PICU ranging from 2.6% to 45.5%, based on the quality, region, and kind of patients of their settings.^1,2 In a series from Mexico, a mortality rate of 18% was found in their PICU.³ Pediatric intensive care workers are almost always interested in the physical, social, and mental dimensions of death in the PICU, but not as much in the religious/spiritual dimension of death. Nonetheless, many cultures and religions have the concept of an afterlife, and they also maintain the idea of a judgement of good and bad deeds in one’s life (Heaven, Hell, Karma).⁴ Herein, we discuss the position of children after death, to attract attention to the religious/spiritual dimension of death.

Timely conversations about death as a possible outcome of PICU are an important part of high-quality intensive care. Informed conversations require preparation to provide the best available objective information. This information should include the distillation of local experience, the patients’ clinical trajectory, the potential impact(s) of alternate treatments, the description of possible modes of death, and an acknowledgement of the extent of uncertainty.⁵ In another study, most parents described social workers/chaplain interactions as helpful (81.3% and 72.2%, respectively) in PICU. Parents described social workers/chaplain roles as related to emotional, spiritual, instrumental, and holistic support.⁶ Robinson et al.⁷ studied matters of spirituality at the end of life in the PICU from the parents’ perspective. They found that spiritual/religious themes were included in the responses of 73% of parents to questions about what had been most helpful to them and what advice they would offer to others in a similar situation. Four explicitly spiritual/religious themes emerged: prayer, faith, access to and care from clergy, and belief in the transcendent quality of the parent-child relationship that endures beyond death.⁷

The death of a child is recognized as a uniquely traumatic experience for a parent. The care delivered to a child and family surrounding death can have a lasting effect on the grieving process. A wide range of challenges facing children, parents, and staff are highlighted, although the facilitation of transferring children to their homes or hospice for withdrawal of intensive care and continuing end-of-life care are supported. Keeping a child in hospital for end-of-life care results in them being in an unfamiliar environment, and it deprives them from contact with family, friends and pets. It has been suggested that within contemporary society, dying at home has become an indicator of high-quality end-of-life care. Despite this, the proportion of children dying at home remains low.⁸

All parents in all geographies and all cultures of the world wonder about the fate of their children after their death. Allah, the Most Merciful of the Merciful, will return children who die before reaching the age of 15 years, that is, the age of puberty, once more to the embrace of their fathers and mothers, in a manner appropriate to Paradise. They will be most beautifully adorned and lovable, in the form of the children of Paradise, known as immortal youths.⁹ We believe that this comforting news should be given to parents whose children have died in PICU, and parents should be spiritually/religiously supported by clergy.

REFERENCES

1. Hajidavalu FS, Sadeghizadeh A. Mortality rate and risk factors in pediatric intensive care unit of Imam Hossein Children’s Hospital in Isfahan: A prospective cross‑sectional study. Adv Biomed Res 2023; 12: 92. https://doi.org/10.4103/abr.abr_371_21
2. Daher AH, Al-Ammouri I, Ghanem N, Abu Zahra M, Al-Zayadneh E, Al-Iede M. All-cause mortality in a pediatric intensive care unit at a teaching hospital in Amman, Jordan. Pediatr Int 2021; 64 (1): e14940. https://doi.org/0.1111/ped.14940
3. Camarena-Vielma L, Lona-Reyes JC, Vázquez-Bojórquez MS, et al. Implementation of the pediatric index of mortality 3 and the pediatric sequential organ failure assessment in an intensive care unit in Mexico. Arch Argent Pediatr. 2022; 120 (5): 332-335. https://doi.org/10.5546/aap.2022.eng.332
4. Death. From Wikipedia, the free encyclopedia. 2024. [Internet]. [citado el 22 Mar 2024]. Disponible en: https://en.wikipedia.org/wiki/Death
5. Gilleland JC, Parshuram CS. Discussing death as a possible outcome of PICU care. Pediatr Crit Care Med 2018; 19 (8S Suppl 2): S4-S9. https://doi.org/10.1097/PCC.0000000000001557
6. Michelson KN, Patel R, Haber-Barker N, Emanuel L, Frader J. End-of-life care decisions in the PICU: roles professionals play. Pediatr Crit Care Med 2013; 14 (1): e34-44. https://doi.org/10.1097/PCC.0b013e31826e7408
7. Robinson MR, Thiel MM, Backus MM, Meyer EC. Matters of spirituality at the end of life in the pediatric intensive care unit. Pediatrics 2006; 118 (3): e719-e729. https://doi.org/10.1542/peds.2005-2298
8. Howes C. Caring until the end: a systematic literature review exploring paediatric intensive care unit end-of-life care. Nurs Crit Care 2015; 20 (1): 41-51. https://doi.org/10.1111/nicc.12123
9. Nursi BS. From the Risale-i Nur Collection. The Words. The thirty-second word.  Istanbul: Söz. 2012. [Internet]. [citado el 22 Mar 2024]. Disponible en: http://www.erisale.com/index.jsp?locale=en#content.en.201.678