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Bayuo J, Baffour PK. Utilisation of palliative/ end-of-life care practice recommendations in the burn intensive care unit of a Ghanaian tertiary healthcare facility: An observational study. Burns 2024; 50:1632-1639. [PMID: 38582696 DOI: 10.1016/j.burns.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 03/06/2024] [Accepted: 03/10/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The need to integrate palliative/end-of-life care across healthcare systems is critical considering the increasing prevalence of health-related suffering. In burn care, however, a general lack of practice recommendations persists. Our burn unit developed practice recommendations to be implemented and this study aimed to examine the components of the practice recommendations that were utilised and aspects that were not to guide further training and collaborative efforts. METHODS We employed a prospective clinical observation approach and chart review to ascertain the utilisation of the recommendations over a 3-year period for all burn patients. We formulated a set of trigger parametres based on existing literature and burn care staff consultation in our unit. Additionally, a checklist based on the practice recommendations was created to record the observations and chart review findings. All records were entered into a secure form on Google Forms following which we employed descriptive statistics in the form of counts and percentages to analyse the data. RESULTS Of the 170 burn patients admitted, 66 (39%) persons died. Although several aspects of each practice recommendation were observed, post-bereavement support and collaboration across teams are still limited. Additionally, though the practice recommendations were comprehensive to support holistic care, a preponderance of delivering physical care was noted. The components of the practice recommendations that were not utilised include undertaking comprehensive assessment to identify and resolve patient needs (such as spiritual and psychosocial needs), supporting family members across the injury trajectory, involvement of a palliative care team member, and post-bereavement support for family members, and burn care staff. The components that were not utilised could have undoubtedly helped to achieve a comprehensive approach to care with greater family and palliative care input. CONCLUSION We find a great need to equip burn care staff with general palliative care skills. Also, ongoing collaboration/ partnership between the burn care and palliative care teams need to be strengthened. Active family engagement, identifying, and resolving other patient needs beyond the physical aspect also needs further attention to ensure a comprehensive approach to end of life care in the burn unit.
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Affiliation(s)
- Jonathan Bayuo
- Department of Nursing and Midwifery, Presbyterian University, Ghana; School of Nursing, The Hong Kong Polytechnic University, Hong Kong.
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2
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Orbay H, Corcos AC, Ziembicki JA, Egro FM. Challenges in the Management of Large Burns. Clin Plast Surg 2024; 51:319-327. [PMID: 38429052 DOI: 10.1016/j.cps.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Large burns provoke profound pathophysiological changes. Survival rates of patients with large burns have improved significantly with the advancement of critical care and adaptation of early excision protocols. Nevertheless, care of large burn wounds remains challenging secondary to limited donor sites, prolonged time to wound closure, and immunosuppression. The development of skin substitutes and new grafting techniques decreased time to wound closure. Individually, these methods have limited success, but a combination of them may yield more successful outcomes. Early identification of patients with likely poor prognosis should prompt goals of care discussion and involvement of a palliative care team when possible.
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Affiliation(s)
- Hakan Orbay
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alain C Corcos
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jenny A Ziembicki
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Francesco M Egro
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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3
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Bayuo J, Abu-Odah H, Koduah AO. Components, Models of Integration, and Outcomes Associated with Palliative/ end-of-Life Care Interventions in the Burn Unit: A Scoping Review. J Palliat Care 2023; 38:239-253. [PMID: 35603876 DOI: 10.1177/08258597221102735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To scope the literature to ascertain the components of palliative care (PC) interventions for burn patients, models of integration, and outcomes. Methods: Arksey and O'Malley scoping review design with narrative synthesis was employed and reported following the PRISMA-ScR guidelines. Primary studies reporting PC interventions in the burn unit were considered for inclusion. CINAHL via EBSCO, PubMed, EMBASE via OVID, Web of Science, and gray literature sources were searched from inception to June 2021. Results: Fifteen studies emerging from high-income settings were retained. Data were organized around three concepts: components of palliative/ end of life care in the burn unit; models of integration; and outcomes. The components of interventions based on the Robert Wood Johnson Foundation Critical Care End-of Life Group domains include decision-making, communication, symptom management and comfort care, spiritual support, and emotional and practical support for families. Consultative and integrative models were noted to be the strategies for integrating PC in the burn unit. The outcomes were varied with only few studies reporting healthcare staff related outcomes. Conclusion: PC may have the potential of improving end-of-life care in the burn unit albeit the limited studies and lack of standardized outcomes makes it difficult to draw stronger conclusions regarding what is likely to work best in the burn unit.
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Affiliation(s)
- Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
| | - Hammoda Abu-Odah
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong
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4
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Reeder S, Cleland HJ, Gold M, Tracy LM. Exploring clinicians' decision-making processes about end-of-life care after burns: A qualitative interview study. Burns 2022; 49:595-606. [PMID: 36709087 DOI: 10.1016/j.burns.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/02/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Little is known about treatment decision-making experiences and how/why particular attitudes exist amongst specialist burn clinicians when faced with patients with potentially non-survivable burn injuries. This exploratory qualitative study aimed to understand clinicians' decision-making processes regarding end-of-life (EoL) care after a severe and potentially non-survivable burn injury. METHODS Eleven clinicians experienced in EoL decision-making were interviewed via telephone or video conferencing in June-August 2021. A thematic analysis was undertaken using a framework approach. RESULTS Decision-making about initiating EoL care was described as complex and multifactorial. On occasions when people presented with 'unsurvivable' injuries, decision-making was clear. Most clinicians used a multidisciplinary team approach to initiate EoL; variations existed on which professions were included in the decision-making process. Many clinicians reported using protocols or guidelines that could be personalised to each patient. The use of pathways/protocols might explain why clinicians did not report routine involvement of palliative care clinicians in EoL discussions. CONCLUSION The process of EoL decision-making for a patient with a potentially non-survivable burn injury was layered, complex, and tailored. Processes and approaches varied, although most used protocols to guide EoL decisions. Despite the reported complexity of EoL decision-making, palliative care teams were rarely involved or consulted.
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Affiliation(s)
- Sandra Reeder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; Central Clinical School, Monash University, Melbourne, VIC 3004, Australia
| | - Heather J Cleland
- Victorian Adult Burns Service, Alfred Hospital, Melbourne, VIC 3004, Australia
| | - Michelle Gold
- Palliative Care Service, Alfred Health, Melbourne, VIC 3004, Australia
| | - Lincoln M Tracy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
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5
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What do we know about experiencing end-of-life in burn intensive care units? A scoping review. Palliat Support Care 2022:1-17. [PMID: 36254708 DOI: 10.1017/s1478951522001389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this article is to review and synthesize the evidence on end-of-life in burn intensive care units. METHODS Systematic scoping review: Preferred Reporting Items for Systemic Reviews extension for Scoping Reviews was used as a reporting guideline. Searches were performed in 3 databases, with no time restriction and up to September 2021. RESULTS A total of 16,287 documents were identified; 18 were selected for analysis and synthesis. Three key themes emerged: (i) characteristics of the end-of-life in burn intensive care units, including end-of-life decisions, decision-making processes, causes, and trajectories of death; (ii) symptom control at the end-of-life in burn intensive care units focusing on patients' comfort; and (iii) concepts, models, and designs of the care provided to burned patients at the end-of-life, mainly care approaches, provision of care, and palliative care. SIGNIFICANCE OF RESULTS End-of-life care is a major step in the care provided to critically ill burned patients. Dying and death in burn intensive care units are often preceded by end-of-life decisions, namely forgoing treatment and do-not-attempt to resuscitate. Different dying trajectories were described, suggesting the possibility to develop further studies to identify triggers for palliative care referral. Symptom control was not described in detail. Palliative care was rarely involved in end-of-life care for these patients. This review highlights the need for early and high-quality palliative and end-of-life care in the trajectories of critically ill burned patients, leading to an improved perception of end-of-life in burn intensive care units. Further research is needed to study the best way to provide optimal end-of-life care and foster integrated palliative care in burn intensive care units.
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6
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Tracy LM, Reeder S, Gold M, Cleland HJ. Burn Care Specialists' Views Towards End of Life Decision-Making in Patients with Severe Burn Injury: Findings from an Online Survey in Australia and New Zealand. J Burn Care Res 2022; 43:1322-1328. [PMID: 35255498 DOI: 10.1093/jbcr/irac030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Burn care clinicians are required to make critical decisions regarding the withholding and withdrawal of treatment in patients with severe and potentially non-survivable burn injuries. Little is known about how Australian and New Zealand burn care specialists approach decision-making for these patients. This study aimed to understand clinician beliefs, values, considerations, and difficulties regarding palliative and end of life care (EoL) discussions and decision-making following severe burn injury in Australian and New Zealand burn services. An online collected respondent and institutional demographic data, as well as information about training and involvement in palliative care/EoL decision-making discussions from nurses, surgeons, and intensivists in Australian and New Zealand hospitals with specialist burn services. Twenty-nine burns nurses, 26 burns surgeons, and 15 intensivists completed the survey. Respondents were predominantly female (64%) and had a median 15 years of experience in treating burn patients. All respondents received little training in EoL decision-making during their undergraduate education; intensivists reported receiving more on-the-job training. Specialist clinicians differed on who they felt should contribute to EoL discussions. Ninety percent of respondents reported injury severity as a key factor in their decision-making to withhold or withdraw treatment, but less than half reported considering age in their decision-making. Approximately two-thirds indicated a high probability of death or a poor predicted quality of life influenced their decision-making. The three cohorts of clinicians had similar views towards certain aspects of EoL decision-making. Qualitative research could provide detailed insights into the varying perspectives held by clinicians.
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Affiliation(s)
- Lincoln M Tracy
- School of Public Health and Preventive Medicine, Monash University, Melbourne VIC, Australia
| | - Sandra Reeder
- School of Public Health and Preventive Medicine, Monash University, Melbourne VIC, Australia.,Central Clinical School, Monash University, Melbourne VIC, Australia
| | - Michelle Gold
- Palliative Care Service, Alfred Health, Melbourne VIC, Australia
| | - Heather J Cleland
- Victorian Adult Burns Service, Alfred Hospital, Melbourne VIC, Australia
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7
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Tracy LM, Gold M, Reeder S, Cleland HJ. Treatment Decisions in Patients with Potentially Non-Survivable Burn Injury in Australia and New Zealand: A Registry-based Study. J Burn Care Res 2022; 44:675-684. [PMID: 35170735 PMCID: PMC10152993 DOI: 10.1093/jbcr/irac017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Indexed: 11/13/2022]
Abstract
Whilst burn-related mortality is rare in high-income countries, there are unique features related to prognostication that make examination of decision-making practices important to explore. Compared to other kinds of trauma, burn patients (even those with non-survivable injuries) may be relatively stable after injury initially. Complications or patient comorbidity may make it clear later in the clinical trajectory that ongoing treatment is futile. Burn care clinicians are therefore required to make decisions regarding the withholding or withdrawal of treatment in patients with potentially non-survivable burn injury. There is yet to be a comprehensive investigation of treatment decision practices following burn injury in Australia and New Zealand. Data for patients admitted to specialist burn services between July 2009 and June 2020 were obtained from the Burns Registry of Australia and New Zealand. Patients were grouped according to treatment decision: palliative management, active treatment withdrawn, and active treatment until death. Predictors of treatment initiation and withholding or withdrawing treatment within 24 hours were assessed using multilevel mixed-effects logistic regression. Descriptive comparisons between treatment groups were made. Of the 32,186 patients meeting study inclusion criteria, 327 (1.0%) died prior to discharge. Fifty-six patients were treated initially with palliative intent and 227 patients had active treatment initiated and later withdrawn. Increasing age and burn size reduced the odds of having active treatment initiated. We demonstrate differences in demographic and injury severity characteristics as well as end of life decision-making timing between different treatment pathways pursued for patients who die in-hospital. Our next step into the decision-making process is to gain a greater understanding of the clinician's perspective (e.g., through surveys and/or interviews).
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Affiliation(s)
- Lincoln M Tracy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michelle Gold
- Palliative Care Service, Alfred Health, Melbourne, Australia
| | - Sandra Reeder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Partners Academic Health Science Centre, Kanooka Grove Clayton, VIC, Australia
| | - Heather J Cleland
- Victorian Adult Burns Service, Alfred Hospital, Melbourne VIC, Australia
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8
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Carmichael H, Brackett H, Scott MC, Dines MM, Mather SE, Smith TM, Duffy PS, Wiktor AJ, Lambert Wagner A. Early Palliative Care Consultation in the Burn Unit: A Quality Improvement Initiative to Increase Utilization. J Burn Care Res 2021; 42:1128-1135. [PMID: 34302472 DOI: 10.1093/jbcr/irab140] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite significant morbidity and mortality for major burns, palliative care consultation (PCC) is underutilized in this population. The purpose of this study is to examine the impact of a protocol using recommended "triggers" for PCC at a single academic burn center. This is a retrospective review of patient deaths over a four-year period. Use of life-sustaining treatments, comfort care (de-escalation of one or more life-sustaining treatments) and do not attempt resuscitation (DNAR) orders were determined. Use of PCC was compared during periods before and after a protocol establishing recommended triggers for early (<72 hrs of admission) PCC was instituted in 2019. A total of 33 patient deaths were reviewed. Most patients were male (n=28, 85%) and median age was 62 years [IQR 42-72]. Median revised Baux score was 112 [IQR 81-133]. Many patients had life-sustaining interventions such as intubation, dialysis, or cardiopulmonary resuscitation, often prior to admission. Amongst patients who survived >24 hrs, 67% (n=14/21) had PCC. Frequency of PCC increased after protocol development, with 100% vs. 36% of these patients having PCC before death (p=0.004). However, even during the later period, less than half of patients had early PCC despite meeting criteria at admission. In conclusion, initiation of life-sustaining measures in severely injured burn patients occurs prior to or early during hospitalization. Thus, value-based early goals of care discussions are valuable to prevent interventions that do not align with patient values and assist with de-escalation of life-sustaining treatment. In this small sample, we found that while there was increasing use of PCC overall after developing a protocol of recommended triggers for consultation, many patients who met criteria at admission did not receive early PCC. Further research is needed to elucidate reasons why providers may be resistant to PCC.
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Affiliation(s)
| | - Hareklia Brackett
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine.,Palliative Care Service, University of Colorado Hospital
| | - Maurice C Scott
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine.,Palliative Care Service, University of Colorado Hospital
| | | | - Sarah E Mather
- Department of Spiritual Care Services, University of Colorado Hospital
| | - Tyler M Smith
- Department of Surgery, University of Colorado School of Medicine
| | - Patrick S Duffy
- Department of Surgery, University of Colorado School of Medicine
| | - Arek J Wiktor
- Department of Surgery, University of Colorado School of Medicine
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9
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Ota RK, Johnson MB, Pickering TA, Garner WL, Gillenwater TJ, Yenikomshian HA. The Impact of No Next of Kin Decision Makers on End-of-Life Care. J Burn Care Res 2021; 42:9-13. [PMID: 33037435 DOI: 10.1093/jbcr/iraa165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
For critically ill burn patients without a next of kin, the medical team is tasked with becoming the surrogate decision maker. This poses ethical and legal challenges for burn providers. Despite this frequent problem, there has been no investigation of how the presence of a next of kin affects treatment in burn patients. To evaluate this relationship, a retrospective chart review was performed on a cohort of patients who died during the acute phase of their burn care. Variables collected included age, gender, length of stay, total body surface area, course of treatment, and presence of a next of kin. In total, 67 patients met the inclusion criteria. Of these patients, 14 (21%) did not have a next of kin involved in medical decisions. Patients without a next of kin were significantly younger (P = .02), more likely to be homeless (P < .01), had higher total body surface area burns (P = .008), had shorter length of stay (P < .001), and were five times less likely to receive comfort care (P = .01). Differences in gender and ethnicity were not statistically significant. We report that patients without a next of kin present to participate in medical decisions are transitioned to comfort care less often despite having a higher burden of injury. This disparity in standard of care demonstrates a need for a cultural shift in burn care to prevent the suffering of these marginalized patients. Burn providers should be empowered to reduce suffering when no decision maker is present.
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Affiliation(s)
- Ryan K Ota
- Keck School of Medicine, University of Sothern California, Los Angeles
| | - Maxwell B Johnson
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - Trevor A Pickering
- Department of Preventive Medicine, Keck School of Medicine, University of Sothern California, Los Angeles
| | - Warren L Garner
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - T Justin Gillenwater
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
| | - Haig A Yenikomshian
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, California
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10
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den Hollander D, Albertyn R, Ambler J. Palliation, end-of-life care and burns; practical issues, spiritual care and care of the family - A narrative review II. Afr J Emerg Med 2020; 10:256-260. [PMID: 33299759 PMCID: PMC7700979 DOI: 10.1016/j.afjem.2020.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 12/03/2022] Open
Abstract
Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. This second article discusses practical issues around palliative care for burn patients, such as pain and fluid management, withdrawal of ventilator support and wound care, as well as spiritual and family issues. This paper forms part two, of two narrative reviews on the topic of palliation, end-of-life care and burns. The first part considered concepts, decision-making and communication. It was published in volume 10, issue 2, June 2020, pages 95–98. Mortality of burns presented to a burns unit in Africa is about 10%. Resources in Africa to manage burn patients are scarce and patients with massive burns may not be offered curative burn care. There are no guidelines for palliative care in burn patients.
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Affiliation(s)
- Daan den Hollander
- Burns Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- Department of Surgery, University of KwaZulu Natal, South Africa
- Corresponding author at: Red Cross Memorial Children's Hospital, Cape Town, South Africa.
| | - Rene Albertyn
- Red Cross Memorial Children's Hospital, Cape Town, South Africa
| | - Julia Ambler
- Palliative Care Practitioner, Department of Paediatrics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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den Hollander D, Albertyn R, Amber J. Palliation, end-of-life care and burns; concepts, decision-making and communication - A narrative review. Afr J Emerg Med 2020; 10:95-98. [PMID: 32612916 PMCID: PMC7320205 DOI: 10.1016/j.afjem.2020.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 12/03/2022] Open
Abstract
Palliative care is the turn from cure as the priority of care to symptom relief and comfort care. Although very little is published in the burn literature on palliative care, guidelines can be gleaned from the general literature on palliative care, particularly for acute surgical and critical care patients. Palliative care may be started because of futility, on request of the patient, or because of limited resources. The SPIKES acronym is a useful guide to avoid errors in communication with terminal patients and their relatives.
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Affiliation(s)
- Daan den Hollander
- Burns Unit Inkosi Albert Luthuli Central Hospital, Durban, South Africa
- Department of Surgery, University of KwaZulu Natal, South Africa
| | - Rene Albertyn
- Red Cross Memorial Children's Hospital, South Africa
| | - Julia Amber
- Palliative Care Practitioner, Department of Pediatrics, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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12
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Bayuo J, Bristowe K, Harding R, Agyei FB, Agbeko AE, Agbenorku P, Baffour PK, Allotey G, Hoyte-Williams PE. The Role of Palliative Care in Burns: A Scoping Review. J Pain Symptom Manage 2020; 59:1089-1108. [PMID: 31733355 DOI: 10.1016/j.jpainsymman.2019.11.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Patients with severe burns may face distressing symptoms with a high risk of mortality as a result of their injury. The role of palliative care in burns management remains unclear. OBJECTIVE To appraise the literature on the role of palliative care in burns management. METHODS We used scoping review with searches in 12 databases from their inception to August 2019. The citation retrieval and retention are reported in a PRISMA statement. FINDINGS 39 papers comprising of 30 primary studies (26 from high-income and four from middle-income countries), four reviews, two editorials, two guidelines, and one expert board review document were retained in the review. Palliative care is used synonymously with comfort and end-of-life care in burns literature. Comfort care is mostly initiated when active treatment is withheld (early deaths) or withdrawn (late deaths), limiting its overall benefits to burn patients, their families, and health care professionals. Futility decisions are usually complex and challenging, particularly for patients in the late death category, and it is unclear if these decisions result in timely commencement of comfort care measures. Three comfort care pathways were identified, but it remained unclear how these pathways evaluated "good death" or supported the family which creates the need for the development of other evidence-based guidelines. CONCLUSION Palliative care is applicable in burns management, but its current role is mostly confined to the end-of-life period, suggesting that it is not been fully integrated in the management process. Evidence-based guidelines are needed to support the integration and delivery of palliative care in the burn patient population.
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Affiliation(s)
- Jonathan Bayuo
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Agogo, Ghana; School of Nursing, The Hong Kong Polytechnic University, Hong Kong.
| | - Katherine Bristowe
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, United Kingdom
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, Kings College, London, United Kingdom
| | - Frank Bediako Agyei
- Department of Nursing, Faculty of Health and Medical Sciences, Presbyterian University College, Agogo, Ghana
| | | | - Pius Agbenorku
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Prince Kyei Baffour
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Gabriel Allotey
- Burns Intensive Care Unit, Plastics and Reconstructive Surgical Unit, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Paa Ekow Hoyte-Williams
- Plastics, Burns and Reconstructive Surgical Division, Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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13
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Bartley CN, Atwell K, Cairns B, Charles A. Predictors of withdrawal of life support after burn injury. Burns 2018; 45:322-327. [PMID: 30442381 DOI: 10.1016/j.burns.2018.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/05/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center. METHODS We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS. RESULTS 8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18-3.48; p=0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08-1.52; p=0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06-1.12; p<0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07-1.51; p<0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05-5.78; p=0.038) was also found in patients with inhalation injury. CONCLUSION The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored.
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Affiliation(s)
- Colleen N Bartley
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Kenisha Atwell
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States.
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Pompermaier L, Steinvall I, Elmasry M, Thorfinn J, Sjöberg F. Burned patients who die from causes other than the burn affect the model used to predict mortality: a national exploratory study. Burns 2018; 44:280-287. [DOI: 10.1016/j.burns.2017.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/09/2017] [Accepted: 07/14/2017] [Indexed: 11/25/2022]
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Vercler CJ, Hultman CS. Ethics in the Setting of Burned Patients. Clin Plast Surg 2017; 44:903-909. [PMID: 28888315 DOI: 10.1016/j.cps.2017.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This article considers multiple ethical principles in the context of patients with burns. It explores the application of these principles to burn care and the impact on medical decision making, through several clinical vignettes.
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Affiliation(s)
- Christian J Vercler
- Section of Plastic Surgery, Department of Surgery, University of Michigan, 1540 East Hospital Drive, Suite 4-730, Ann Arbor, MI 48109, USA.
| | - Charles Scott Hultman
- Division of Plastic Surgery, University of North Carolina Aesthetic, Laser, and Burn Reconstruction Center, NC Jaycee Burn Center, University of North Carolina at Chapel Hill, Suite 7038, Burnett-Womack, Chapel Hill, NC 27599, USA
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Clinical differences between major burns patients deemed survivable and non-survivable on admission. Injury 2015; 46:870-3. [PMID: 25707879 DOI: 10.1016/j.injury.2015.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/16/2014] [Accepted: 01/02/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Despite advances in burn care, there is still a group of patients with serious burn injury who fail to respond to therapies or for whom active treatments are unsuccessful. As the demographic and causative factors of burn related mortality may differ between treating units and countries, we aimed to investigate clinical aspects of patients that die whose injuries are considered either survivable or non-survivable on admission. METHODS A retrospective 11-year medical record review (2000-2011) of patients admitted to the Victorian Adult Burns Service (VABS), Melbourne, Australia, with a fatal burn injury was undertaken. Patient characteristics such as age, gender, total body surface area (TBSA%) burned, type and site of burn, hospital length of stay, receipt of burn care treatments and when withdrawal of care (WOC) took place were identified using hospital databases. For the purposes of categorization, two categories of patients were defined retrospectively. 'Early WOC' patients were those for whom a decision was made within the first 24h following admission that a patient injury was likely non-survivable, or that survival was incompatible with a meaningful quality of life. 'Late WOC' patients were those patients for whom a decision was made within the first 24h following admission that a patient injury was survivable and potentially compatible with a meaningful quality of life. RESULTS In a study analyzing 70 patients, the average TBSA% burned in the 'Early WOC' group (n=43) was significantly higher with the 'Late WOC' cohort (n=27) (85% vs. 45%; p=0.001) compared. A higher incidence of accelerant use (60% vs. 35%; p=0.07) and facial burns (74% vs. 44%; p=0.02) was found in the 'Early WOC' patients. In the 'Late WOC' group, 92.6% of patients required mechanical ventilation and 78.6% of patients underwent operative intervention (median surgical time 9.25h, inter-quartile range 6.5-18.5). CONCLUSION A number of clinical differences in major burn patients can be observed at admission between patients for whom a decision is made as to whether an injury is survivable or non-survivable. These differences may influence the degree of therapeutic aggression or conservatism as determined by the treating clinical team. As a matter of maintaining standards amongst the burns community, reporting mortality data such as this may also provide a benchmark by which other burns units can assess their own data regarding end-of-life decision-making.
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Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med 2015; 41:1572-85. [DOI: 10.1007/s00134-015-3810-5] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/07/2015] [Indexed: 12/01/2022]
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Duhamel P, Suberbielle C, Grimbert P, Leclerc T, Jacquelinet C, Audry B, Bargues L, Charron D, Bey E, Lantieri L, Hivelin M. Anti-HLA sensitization in extensively burned patients: extent, associated factors, and reduction in potential access to vascularized composite allotransplantation. Transpl Int 2015; 28:582-93. [PMID: 25683513 DOI: 10.1111/tri.12540] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/03/2014] [Accepted: 02/06/2015] [Indexed: 12/21/2022]
Abstract
Extensively burned patients receive iterative blood transfusions and skin allografts that often lead to HLA sensitization, and potentially impede access to vascularized composite allotransplantation (VCA). In this retrospective, single-center study, anti-HLA sensitization was measured by single-antigen-flow bead analysis in patients with deep, second- and third-degree burns over ≥40% total body surface area (TBSA). Association of HLA sensitization with blood transfusions, skin allografts, and pregnancies was analyzed by bivariate analysis. The eligibility for transplantation was assessed using calculated panel reactive antibodies (cPRA). Twenty-nine patients aged 32 ± 14 years, including 11 women, presented with a mean burned TBSA of 54 ± 11%. Fifteen patients received skin allografts, comprising those who received cryopreserved (n = 3) or glycerol-preserved (n = 7) allografts, or both (n = 5). An average 36 ± 13 packed red blood cell (PRBC) units were transfused per patient. In sera samples collected 38 ± 13 months after the burns, all patients except one presented with anti-HLA antibodies, of which 13 patients (45%) had complement-fixing antibodies. Eighteen patients (62%) were considered highly sensitized (cPRA≥85%). Cryopreserved, but not glycerol-preserved skin allografts, history of pregnancy, and number of PRBC units were associated with HLA sensitization. Extensively burned patients may become highly HLA sensitized during acute care and hence not qualify for VCA. Alternatives to skin allografts might help preserve their later access to VCA.
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Affiliation(s)
- Patrick Duhamel
- Service de Chirurgie Plastique, Centre de Traitement des Brûlés, Hôpital d'Instruction des Armées Percy, Clamart Cedex, France
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Metaxa V, Lavrentieva A. End-of-life decisions in Burn Intensive Care Units - An International Survey. Burns 2014; 41:53-7. [PMID: 25017109 DOI: 10.1016/j.burns.2014.05.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 05/25/2014] [Accepted: 05/28/2014] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Burn victims and their families are faced with an unexpected, life changing injury, and they don't have the necessary time to adjust to the trauma. Even though there is extensive literature exploring the attitudes of intensive care physicians on forgoing life-sustaining treatment, little is known about end-of-life practices in specialised burn intensive care units (ICUs). The aim of this study was to evaluate physician beliefs, values, considerations and difficulties in end-of-life decisions in burn ICUs. METHODS Two hundred and fifty questionnaires were distributed via electronic mail to burn specialists, randomly selected from the directories of the 45(th) annual meeting of American Burn Association and the 15(th) European Burns Association Congresses. RESULTS A moral difference between withdrawing and withholding was stated by 73% of physicians, with withholding being viewed as more preferable (42% vs 37%). Primary reasons given by physicians for the decision to withhold/withdraw the treatment were the patient's medical condition/high probability of death (68%), unresponsiveness to therapy (68%), severity of burn (78%) and poor outcome in terms of quality of life (44%). Vasopressors (85%), blood products (68%) and renal replacement therapy (85%) were the common modalities withheld/withdrawn. Almost 50% involved the patients in the end-of-life decisions and 66% involved the family. CONCLUSIONS In this first international study on end-of-life attitudes, burn ICU physicians clearly distinguish between withhold and withdrawal decisions, with the majority preferring the former. In contrast to general ICUs, treatment limitation accounts only for the minority of the deaths.
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Affiliation(s)
- Victoria Metaxa
- Consultant in Critical Care and Major Trauma, Critical Care Units, King's College Hospital, London SE5 9RS, UK.
| | - Athina Lavrentieva
- Consultant in Critical Care Papanikolaou Hospital, Burn ICU, Thessaloniki, Greece.
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de Decker L, Annweiler C, Launay C, Fantino B, Beauchet O. Do not resuscitate orders and aging: impact of multimorbidity on the decision-making process. J Nutr Health Aging 2014; 18:330-5. [PMID: 24626763 DOI: 10.1007/s12603-014-0023-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The "Do Not Resuscitate" orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related multimorbidity may influence the DNR decision-making process. Our objective was to perform a systematic review and meta-analysis of published data examining the relationship between DNR orders and multimorbidity in older patients. METHODS A systematic Medline and Cochrane literature search limited to human studies published in English and French was conducted on August 2012, with no date limits, using the following Medical Subject Heading terms: "resuscitation orders" OR "do-not-resuscitate" combined with "aged, 80 and over" combined with "comorbidities" OR "chronic diseases". RESULTS Of the 65 selected studies, 22 met the selection criteria for inclusion in the qualitative analysis. DNR orders were positively associated with multimorbidity in 21 studies (95%). The meta-analysis included 7 studies with a total of 27,707 participants and 5065 DNR orders. It confirmed that multimorbidity were associated with DNR orders (summary OR = 1.25 [95% CI: 1.19-1.33]). The relationship between DNR orders and multimorbidity differed according to the nature of morbidities; the summary OR for DNR orders was 1.15 (95% CI: 1.07-1.23) for cognitive impairment, OR=2.58 (95% CI: 2.08-3.20) for cancer, OR=1.07 (95% CI: 0.92-1.24) for heart diseases (i.e., coronary heart disease or congestive heart failure), and OR=1.97 (95% CI: 1.61-2.40) for stroke. CONCLUSIONS This systematic review and meta-analysis showed that DNR orders are positively associated with multimorbidity, and especially with three morbidities, which are cognitive impairment, cancer and stroke.
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Affiliation(s)
- L de Decker
- Olivier Beauchet, MD, PhD; Department of Neuroscience, Division of Geriatric Medicine, Angers University Hospital, 49933 Angers cedex 9, France; E-mail: ; Phone: ++33 2 41 35 45 27; Fax: ++33 2 41 35 48 94
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Medical futility and the burns patient. Burns 2013; 39:851-5. [PMID: 23523220 DOI: 10.1016/j.burns.2013.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 12/19/2012] [Accepted: 02/06/2013] [Indexed: 11/21/2022]
Abstract
Since its inception in the 1980s 'futility' has been a controversial concept. The history of this concept, its definition and application to burns care are discussed from the perspective of a burn surgeon. Although introduced as an objective (value-free) criterion, futility proves impossible to objectivate and judgements about the value of human life always play a role. The roles of the patient, the doctor, the 'politician' and society at large in futility-decisions are discussed.
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Abstract
Despite many advances in modern burn care, deaths still occur in the burn intensive care unit. For patients with severe burns, providers may advocate to withdraw life support early during hospitalization when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Our regional burn center has implemented a stepwise withdrawal protocol since 2001 in an effort to standardize symptoms palliation at the end of life. In this study, the authors evaluated the frequency of early withdrawal and the protocol impact on end-of-life processes of care in burn patients who died within 72 hours of hospitalization. A 13-year review of all burn patients aged ≥18 years admitted to our burn center to identify all patients who died within 72 hours of hospitalization was performed. Patients were dichotomized to the periods before (1995 to mid-2001) and after implementation of standardized withdrawal protocol (mid-2001 to 2007). Descriptive analyses were performed to compare end-of-life care processes between the two periods. A total of 4374 adult patients with acute burns were admitted during the 13-year study period, of which 252 (6%) died during hospitalization. Of the patients who died within 72 hours, 106 (84%) had withdrawal of life support compared with 20 (16%) who died with ongoing life support. Higher mean TBSA distinguished patients who died by withdrawal (61 vs 48%, P = .06). Since mid-2001, all 61 patients who had life support withdrawn were by protocol. Implementation of the protocol has led to more frequent use of opioid infusion (98 vs 87%, P = .07) and benzodiazepine infusion (95 vs 49%, P < .01), without hastening time to death (median 5.0 vs 5.5 hours, P = .70). The large majority of early burn deaths at our regional center occur via withdrawal of life support. Implementation of a protocolized withdrawal has resulted in more consistent provision of analgesia and sedation without hastening death. Burn centers should consider using a protocol for withdrawal of life support to improve consistency in end-of-life symptoms palliation.
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