<p><strong>OBJECTIVES: </strong>To characterize patterns of surgery among pediatric patients during terminal hospitalizations in children's hospitals.</p>

<p><strong>METHODS: </strong>We reviewed patients ≤20 years of age who died among 4 424 886 hospitalizations from January 2013-December 2019 within 49 US children's hospitals in the Pediatric Health Information System database. Surgical procedures, identified by International Classification of Diseases procedure codes, were classified by type and purpose. Descriptive statistics characterized procedures, and hypothesis testing determined if undergoing surgery varied by patient age, race and ethnicity, or the presence of chronic complex conditions (CCCs).</p>

<p><strong>RESULTS: </strong>Among 33 693 terminal hospitalizations, the majority (n = 30 440, 90.3%) of children were admitted for nontraumatic causes. Of these children, 15 142 (49.7%) underwent surgery during the hospitalization, with the percentage declining over time (P &lt; .001). When surgical procedures were classified according to likely purpose, the most common were to insert or address hardware or catheters (31%), explore or aid in diagnosis (14%), attempt to rescue patient from mortality (13%), or obtain a biopsy (13%). Specific CCC types were associated with undergoing surgery. Surgery during terminal hospitalization was less likely among Hispanic children (47.8%; P &lt; .001), increasingly less likely as patient age increased, and more so for Black, Asian American, and Hispanic patients compared with white patients (P &lt; .001).</p>

<p><strong>CONCLUSIONS: </strong>Nearly half of children undergo surgery during their terminal hospitalization, and accordingly, pediatric surgical care is an important aspect of end-of-life care in hospital settings. Differences observed across race and ethnicity categories of patients may reflect different preferences for and access to nonhospital-based palliative, hospice, and end-of-life care.</p>

<p><strong>CONTEXT: </strong>Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period is limited.</p>

<p><strong>OBJECTIVES: </strong>Evaluate perioperative management of DNR orders at a tertiary care children's hospital.</p>

<p><strong>METHODS: </strong>We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from 2/1/2016 - 8/1/2017. Using standardized case report forms, we abstracted the following from physician notes: (A) patient/family wishes with respect to the DNR, (B) whether pre-operative DNRs were continued, modified, or suspended during the perioperative period, and (C) whether life threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision making in the perioperative period.</p>

<p><strong>RESULTS: </strong>Twenty-three patients aged six days to 17 years had a DNR in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures, and suspended for fifteen (51%). Three children (13%) suffered life threatening events. We identified four time points where systematic reconsideration should be documented in the medical record, recommended personnel, and important discussion points at each time point.</p>

<p><strong>CONCLUSION: </strong>Opportunities exist to improve how DNR orders are managed during the perioperative period.</p>

<p>Palliative care is now a core component of pediatric care for children and families who are confronting serious illness with a low likelihood of survival. Pediatric surgeons, in partnership with pediatric palliative care teams, can play a pivotal role in assuring that these patients receive the highest possible quality of care. This article outlines a variety of definitions and conceptual frameworks, describes decision-making strategies and communication techniques, addresses issues of interdisciplinary collaboration and personal self-awareness, and illustrates these points through a series of case vignettes, all of which can help the pediatric surgeon perform the core tasks of pediatric palliative care.</p>

<p><strong>OBJECTIVE: </strong>Describe variability in admission, discharge, and occupancy patterns for surgical patients at a large children's hospital and assess the relationship between scheduled admissions and occupancy.</p>

<p><strong>BACKGROUND: </strong>High hospital occupancy degrades quality of care and access, whereas low levels of occupancy use hospital resources inefficiently. Variability in scheduling patients for surgical procedures may affect occupancy and be amenable to alteration.</p>

<p><strong>METHODS: </strong>This is a retrospective administrative data analysis that took place at 1 urban, tertiary-care children's hospital. A total of 8552 surgical patients hospitalized from July 1, 2009, to June 30, 2010, were included in the analysis, and admission-discharge-transfer data for 1 fiscal year were abstracted for analysis of admission and occupancy patterns.</p>

<p><strong>RESULTS: </strong>Among 6257 surgical admissions for non-intensive care unit (ICU) patients, 49% were emergent and 51% were scheduled. Variation in admission volume by day of week was more than 3 times higher for scheduled admissions than for emergent admissions. For non-ICU surgical patients with length of stay 7 days or less (97%), Mondays and Tuesdays generated 42% of scheduled patient occupancy time. Thursdays and Fridays often had high occupancy of surgical patients (&gt;90% of designated beds filled), whereas Saturdays, Sundays, and Mondays were often at low occupancy for those beds (&lt;80% filled). Only 20% of all days in the year had designated non-ICU surgery beds with occupancy between 80% and 95%.</p>

<p><strong>CONCLUSIONS: </strong>Scheduled admissions contribute significantly to variability in occupancy. Predictable patterns of admissions lead to high occupancy on some days and unused capacity on others, with few days being at an optimal level of occupancy. These predictable patterns suggest opportunities to improve hospital operations with changes in scheduled admission patterns, which present a different problem than random demand.</p>